Every finding on record at Platinum Care Home Services, Inc

This was a standard survey, the requirements for Emergency Preparedness were not reviewed. Platinum Care Home Health Services 25572 Shoehnerr Rd. Warren, MI 48089 The agency does not operate any extension sites or subunits. COVID-19 vaccination requirements were reviewed on site. For this survey 4 home visits with record reviews, 3 active records without a home visit, and 3 discharged records were reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/17/22 through 10/20/22 at: Platinum Care Home Health Services 25572 Shoenherr Rd. Warren, MI 48089 The agency did not have any extension sites or subunits. COVID-19 vaccination requirements were reviewed on site. For this survey 4 home visits with record reviews, 3 active records without a home visit, and 3 discharged records were reviewed. At the conclusion of the survey the agency was found to be out of compliance with standard level deficiencies for the conditions of participation for home health agencies at: 42 CFR Part 484.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure patients were informed of the Administrator's name during the initial evaluation visit for 4 of 4 (MR# 3, 4, 8, 9) joint surveyor home visits, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect the quality of care for the agency's 161 current patients. Findings include: The agency's documentation provided to patients at the time of admission was reviewed on 10/17/22 at 3:30 p.m. Review of the loose-leaf flyers and the booklet titled, Patient Orientation for Home Health Care, revealed that the documentation failed to inform the patient of the Administrator's name. Page 15 of the booklet directed the patient to contact the Privacy Official if there were any complaints. The findings were confirmed while observing the agency's paperwork left in the homes during the joint surveyor home visits (MR#3, 4, 8, 9) conducted on 10/18/22 and 10/19/22. The findings were reviewed with and acknowledged by the administrator (Adm) and the director of nursing (DON) during an interview on 10/20/22 at 11:55 a.m.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to advise patients of the names, addresses and telephone numbers of Federally funded and State funded entities that serve the areas where the patients reside for 4 of 4 (MR# 3, 4, 8, 9) joint surveyor home visits, resulting in a lack of information regarding available resources which has the potential to negatively affect the quality of care for the agency's 161 current patients. Findings include: On 10/17/22 at 3:30 p.m., the contents of the agency's admission folder were reviewed. The folder failed to include documentation of the names, addresses and phone numbers for the following Federally funded and State funded agencies: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. During joint surveyor home visits (MR# 3, 4, 8, 9) with agency staff on 10/18/22 and 10/19/22, it was observed that the patient's folder from the agency failed to contain the required information for the State and Federally funded agencies. The finding was reviewed with and confirmed by the administrator (Adm) and the director of nursing (DON) during an interview on 10/20/22 at 11:55 a.m.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 2 of 8 (MR# 6, 8) records reviewed with skilled nursing starts of care, resulting in a delay in determining the immediate care and support needs for these patients. Findings include: MR#6: This 83-year-old patient was admitted to home care on 8/23/22 with diagnoses of left femur fracture and left sided weakness. During record review on 10/19/22, it was noted the referral for home care was fax stamped on 8/16/22 at 3:28 p.m. The fax referral cover letter from the rehabilitation center documented that the patient would be discharged on 8/19/22. The initial assessment visit was conducted by the registered nurse on 8/23/22, which is 4 days after the agency was made aware of the patient's discharge to home. There was no documentation to indicate the patient's discharge from the rehabilitation center was delayed and no documentation to indicate the patient had requested a delay in home care services. The findings were reviewed with and acknowledged by the administrator (Adm) and the director of nursing (DON) during an interview on 10/20/22 at 11:55 a.m. MR#8: This 81-year-old patient was admitted to home care on 9/23/22 with diagnoses of stroke, muscle weakness, high blood pressure, and dementia. During record review on 10/18/22, it was noted the referral for home care was fax stamped on 9/16/22 at 3:37 p.m. The initial assessment visit was conducted by the registered nurse on 9/23/22, which is 7 days after the agency received the referral. There was no documentation to indicate the patient had requested a delay in home care services. The findings were reviewed with and acknowledged by Adm and the DON during an interview on 10/20/22 at 11:55 a.m.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 1 of 10 records reviewed (MR# 1) out of a total of 10 records reviewed, resulting in the potential for negative patient outcomes. Findings include: MR#1: The start of care was 5/16/22 with diagnoses that included hypertension, diabetes, and heart failure. During record review on 10/17/22, it was discovered that no baseline blood sugar was documented on the start of care (SOC) comprehensive assessment. The SOC comprehensive assessment also documented "no history" under the endocrine assessment section with a diagnosis of diabetes mellitus. During an interview on 10/20/22 at 11:10 a.m., the administrator (Adm) and the director of nursing (DON) acknowledged the above findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 2 of 2 (MR# 4, 7) records reviewed with therapy only services, from a total of 10 records reviewed. This deficient practice results in the potential for unrecognized adverse effects due to medications that could affect all agency patients. Findings include: MR#4: This patient was admitted to the agency on 9/27/22, with diagnoses of osteoarthritis and cervicalgia. During record review on 10/19/22, it was noted that the medication review was acknowledged and signed by physical therapy (PT). There was no documented evidence the patient's medications had been reviewed by a skilled nurse. During an interview on 10/20/22 at 11:10 a.m., the administrator (Adm) and the director of nursing (DON) acknowledged the above findings. MR#7: This patient was admitted to the agency on 9/24/22 with diagnoses of aftercare following a left knee joint replacement. During record review on 10/18/22, it was noted that the medication review was acknowledged and signed by a physical therapist. There was no documented evidence the patient's medications had been reviewed by a registered nurse. The finding was reviewed with and acknowledged by Adm and DON during an interview on 10/20/22 at 11:55 a.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 5 of 10 (MR#s 1, 2, 6, 7, 8) records reviewed, from a total of 10 records reviewed, resulting in the potential for unmet patient care needs. Findings include: MR#1: The start of care was 5/16/22 with diagnoses that included hypertension, diabetes, and heart failure. During record review on 10/17/22, it was discovered that the SN goals on the POC were not measurable. One example stated, "Patient will demonstrate increased endurance by 5 weeks." another stated, "Patient will demonstrate proper body mechanics by 5 weeks." It was unclear as to how these goals could be objectively measured to indicate progress toward goals. MR#2: The start of care was 5/16/22 with diagnoses that included hypertension, A-fib, and heart failure. During record review on 10/17/22, it was discovered that only 1 of 11 SN goals on the POC were measurable. The POC had no documented parameters for congestive heart failure, including weights, measurements, or when to call the physician. During an interview on 10/20/22 at 11:10 a.m., the administrator (Adm) and the director of nursing (DON) acknowledged the above findings. MR#6: This 83-year-old patient was admitted to home care on 8/23/22 with diagnoses of left femur fracture and left sided weakness. During record review on 10/19/22, it was noted that the 8/23/22 POC listed the following SN goals: patient will demonstrate energy conservation techniques, demonstrate increased endurance, increased activity tolerance, and demonstrate safe use of assistive devices. There was no indication as to how each of these goals would be measured to determine readiness for discharge from skilled nursing care. The findings were reviewed with and acknowledged by Adm and DON during an interview on 10/20/22 at 11:55 a.m. MR#7: This patient was admitted to home care on 9/24/22 with diagnoses of aftercare following a left knee joint replacement on 9/23/22. During record review on 10/18/22, it was noted that the patient received physical therapy (PT) services. The comprehensive assessment completed by the physical therapist on 9/24/22, indicates that the patient rated left knee pain at 8 on a scale of 0-10. The PT also documented that the patient complains of significant pain and stiffness, but the patient is aware this is normal and is to be expected after surgery. A review of the 9/24/22 plan of care indicates that the PT failed to include goals related to the patient's post-operative "significant pain." The findings were reviewed with and acknowledged by Adm and DON during an interview on 10/20/22 at 11:55 a.m. MR#8: This 81-year-old patient was admitted to home care on 9/23/22 with diagnoses of stroke, muscle weakness, high blood pressure, and dementia. During record review on 10/18/22, it was noted that the 9/23/22 POC listed the following SN goals: bowel status will be within normal limits for patient, increased activity tolerance, and demonstrate safe use of assistive devices. There was no indication as to how each of these goals would be measured to determine readiness for discharge from skilled nursing care. The findings were reviewed with and acknowledged by Adm and DON during an interview on 10/20/22 at 11:55 a.m.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to notify the physician of plan of care (POC) changes, for 1 of 3 records (MR# 5) with home health aide (HHa) services provided, from a total sample of 10 records reviewed, resulting in the potential for unmet patient care needs. Findings include: MR#5: The start of care (SOC) was dated 7/26/22 with diagnoses of hypertension, heart failure, and chronic kidney disease. During record review on 10/20/22, it was discovered that HHa services were ordered on the POC and were refused by the patient. There was no documentation in the record that the physician was notified of the change in ordered services. During an interview on 10/20/22 at 11:10 a.m., the administrator (Adm) and the director of nursing (DON) acknowledged the above findings.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained completed visit notes for 1 of 8 (MR #6) records reviewed with skilled nursing care, resulting in a lack of information for the physician and all agency staff caring for this patient. Findings include: MR#6: This 83-year-old patient was admitted to home care on 8/23/22 with diagnoses of left femur fracture and left sided weakness. During record review on 10/19/22, it was noted that the skilled nursing note dated 8/25/22 was incomplete. The following areas of the visit note were blank of information: cardiopulmonary, genitourinary, gastrointestinal, neurological/endocrine, musculoskeletal, interventions, goals, and coordination of care. The findings were reviewed with and acknowledged by the administrator (Adm) and the director of nursing (DON) during an interview on 10/20/22 at 11:55 a.m.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include discharge summaries in the patient record that summarized the care provided and failed to document submission to the physician in 3 of 4 records (MR #'s 1, 2, 7) that were discharged from a total of 10 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: MR#1: The start of care was 5/16/22 with diagnoses that included hypertension, diabetes, and heart failure. During record review on 10/17/22, it was discovered that the discharge summary only summarized the care provided by physical therapy (PT). The summary did not include a summary of the care provided by skilled nursing (SN) or home health aide (HHa). MR#2: The start of care was 5/16/22 with diagnoses that included hypertension, A-fib, and heart failure. During record review on 10/17/22, it was discovered that the discharge summary only summarized the care provided by PT. The summary did not include a summary of the care provided by skilled nursing (SN), occupational therapy (OT), or home health aide (HHa). During an interview on 10/20/22 at 11:10 a.m., the administrator (Adm) and the director of nursing (DON) acknowledged the above findings. MR#7: This patient was admitted to home care on 9/24/22 and a discharge OASIS (outcome and assessment information set) was completed by the physical therapist on 10/8/22. During record review on 10/18/22, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. The findings were reviewed with and acknowledged by Adm and DON during an interview on 10/20/22 at 11:55 a.m. Adm replied that the discharge summary will be going out soon and it was probably in the works.