Every finding on record at Renaissance Home Healthcare Services, Inc

A recertification survey for Emergency Preparedness was conducted by the Michigan Department of Licensing and Regulatory Affairs, on 12/2/24 through 12/5/24 at: Renaissance Home Healthcare Services 30445 Northwestern Hwy, Suite 120 Farmington Hills, MI 48334 At the survey's conclusion, the agency was found to be in compliance with the requirements for the Conditions of Participation at 42 CFR §484.102, Emergency Preparedness.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 12/2/24 through 12/5/24 at: Renaissance Home Healthcare Services 30445 Northwestern Highway, Suite 120 Farmington Hills, MI 48334 This agency has no additional branch locations. The agency had no active patients at the time of the survey. There were no home visits. Seven discharge records were reviewed. At the conclusion of the survey, Renaissance Home Healthcare Services was not in compliance with the Conditions of Participation for Home Health Agencies at: 42 CFR Part 484.

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, the agency failed to ensure safety precautions were included on the plan of care for 1 (P-5) of 7 records reviewed, and failed to ensure the plan of care included parameters to notify the physician for 4 (P-2, 3, 6, 7) of 7 records reviewed, resulting in the potential for poor patient outcomes and no assurance the physician is notified of vital signs or excessive pain ratings. Findings include: P-2: This patient was admitted to home care on 9/27/24 with diagnoses of type 2 diabetes with high blood sugars, high blood pressure, and abnormal gait. The patient received skilled nursing and physical therapy services. During record review on 12/2/24, it was noted that the 9/27/24 plan of care failed to include parameters to notify the physician regarding the patient's blood sugar readings, blood pressure, and pain. The findings were reviewed with and acknowledged by the administrator (Admin-A) during an interview on 12/5/24 at 10:00 a.m. P-3: This patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia (high concentration of fats or lipids in the blood), high blood pressure, and generalized anxiety disorder. The patient received skilled nursing and physical therapy services. During record review on 12/2/24, it was noted that the 9/27/24 plan of care failed to include parameters to notify the physician regarding the patient's blood pressure. Agency Policy – Care Plan Management and Evaluation (III-16, no date). Assessment and Reassessment Guidelines. Use of Standards of Practice: Each disciplines standards of practice will be referenced for decision-making regarding patient care. Agency will use the following standard ranges for physician contact when parameters are out of range… P-5: This 65-year-old patient was admitted to home care on 7/31/24 with diagnoses of acute bronchitis, peripheral vascular disease, and debility. The patient received skilled nursing services. A review of the patient’s medication list indicates the patient takes a blood thinner, Plavix. During record review on 12/3/24, it was noted that the plan of care failed to include bleeding precautions. P-6: This 86-year-old patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia, hypertension, and abnormal gait. The patient received skilled nursing and physical therapy services. During record review on 12/2/24, it was noted that the plan of care failed to include parameters for reporting vital signs or pain levels to the physician. P-7: This 68-year-old patient was admitted to home care on 9/27/24 with diagnoses of chronic obstructive pulmonary disease (COPD), and essential hypertension. The patient received skilled nursing and physical therapy services. During record review on 12/2/24, it was noted that the plan of care failed to include parameters for reporting vital signs or pain levels to the physician. These findings were reviewed and acknowledged by the administrator/director of nursing on 12/5/24 at 9:45 a.m.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included accurate physical therapy notes for 1 (P-6) of 7 records reviewed, resulting in the potential for the lack of continuity of care. Findings include: P-6: This 86-year-old patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia, hypertension, and abnormal gait. During record review on 12/2/24, it was noted that the physical therapists discharge summary, dated 11/12/24, states “patient goes to dialysis 3 days a week.” There was no evidence the patient received dialysis in the start of care assessment, or in the Face-to-Face encounter signed by the patient’s physician on 9/26/24. This finding was reviewed and acknowledged by the administrator/director of nursing on 12/5/24 at 9:45 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 ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-1: This patient was admitted to home care on 8/9/24 with diagnoses of right foot surgical incision due to fracture, high blood pressure, and pain to the right ankle and joints. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/21/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-2: This patient was admitted to home care on 9/27/24 with diagnoses of type 2 diabetes with high blood sugars, high blood pressure, and abnormal gait. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/12/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-3: This patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia (high concentration of fats or lipids in the blood), high blood pressure, and generalized anxiety disorder. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/12/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-4: This patient was admitted to home care on 3/8/24 with diagnoses of high blood pressure, right shoulder pain, and abnormal gait. During record review on 12/3/24, it was noted that the patient was discharged from agency services on 7/2/24. The discharge summary was signed by the physician and dated 7/11/24. This is nine days after the patient was discharged. There was no evidence to indicate when the discharge summary was sent to the physician. The findings were reviewed with and acknowledged by the administrator (Admin-A) during an interview on 12/5/24 at 10:00 a.m. P-5: This 65-year-old patient was admitted to home care on 7/31/24 with diagnoses of acute bronchitis, peripheral vascular disease, and debility. During record review on 12/3/24, it was noted that the patient was discharged from agency services on 11/14/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-6: This 86-year-old patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia, hypertension, and abnormal gait. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/12/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-7: This 68-year-old patient was admitted to home care on 9/27/24 with diagnoses of chronic obstructive pulmonary disease (COPD), and essential hypertension. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/12/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. These findings were reviewed and acknowledged by the administrator/director of nursing on 12/5/24 at 9:45 a.m.

On 12/14/21 through 12/16/21, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Renaissance Home HealthCare Services. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 12/14/21 through 12/16/21 at: Renaissance Home HealthCare Services 30445 Northwestern Hwy, Suite 120 Farmington Hills, MI 48334 This agency has no branch sites. Records Reviewed: 7 records without home visits, for a total of 7 records reviewed. There were no active patients during the survey. 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.

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, it was determined the agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required in 7 of 7 sampled records reviewed (MR's #1, 2, 3, 4, 5, 6 and 7), resulting in the potential for harmful medication effects for all patients serviced by this Agency. Findings include: MR#1: The Start of Care (SOC) was dated 5/4/20. The Plan of Care (POC) identified diagnoses of Chronic Bronchitis, Urinary Incontinence and Allergic Rhinitis. During record review on 12/14/21, section M2001 of the "Comprehensive Assessment" dated 5/4/20, completed by the Registered Nurse (RN), documented "Yes – Issues found during review." The comment section regarding “Describe problems found during review” was left blank. The agency failed to document the medication issues that were found during review. MR#2: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath and Hypertension. During record review on 12/14/21, section M2001 of the "Comprehensive Assessment" dated 12/2/18, completed by the RN, documented "Yes – Issues found during review." The comment section regarding “Describe problems found during review” was left blank. The agency failed to document the medication issues that were found during review. MR#3: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Age-Related Physical Debility, Hypertension, Osteoarthritis of Hip. During record review on 12/15/21, section M2001 of the "Comprehensive Assessment" dated 12/2/18, completed by the RN, documented "Yes – Issues found during review." The comment section regarding “Describe problems found during review” was left blank. The agency failed to document the medication issues that were found during review. MR#4: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Abnormalities of Gait, Wernicke’s Encephalopathy and Hypertension. During record review on 12/15/21, section M2001 of the "Comprehensive Assessment" dated 12/2/18, completed by the RN, documented "Yes – Issues found during review." The comment section regarding “Describe problems found during review” was left blank. The agency failed to document the medication issues that were found during review. MR#5: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Plasma Cell Leukemia and Hypertension. During record review on 12/15/21, section M2001 of the "Comprehensive Assessment" dated 12/2/18, completed by the RN, documented "Yes – Issues found during review." The comment section regarding “Describe problems found during review” was left blank. The agency failed to document the medication issues that were found during review. MR#6: The Start of Care (SOC) was dated 10/9/18. The Plan of Care (POC) identified diagnoses of Cerebrovascular Accident (CVA), Hypertension and Other Muscle Spasm. During record review on 12/15/21, section M2001 of the "Comprehensive Assessment" dated 10/9/18, completed by the RN, documented "Yes – Issues found during review." The comment section regarding “Describe problems found during review” was left blank. The agency failed to document the medication issues that were found during review. MR#7: The Start of Care (SOC) was dated 5/1/18. The Plan of Care (POC) identified diagnoses of Cerebrovascular Accident (CVA), Peripheral Vascular Disease and Hypertension. During record review on 12/16/21, section M2001 of the "Comprehensive Assessment" dated 5/1/18, completed by the RN, documented "Yes – Issues found during review." The comment section regarding “Describe problems found during review” was left blank. The agency failed to document the medication issues that were found during review. Admin#1 was questioned on 12/16/21 at 12:45 pm and confirmed the findings stating, "We need to work on our start of care medication documentation."

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 that the Agency failed to provide care and services in accordance with the plan of care in 5 (MR's # 1, 2, 3, 4 and 6) of 7 records reviewed for provision of services, from a total of 7 records reviewed, resulting in the potential for decline in physical functioning and unmet care needs. Findings include: MR#1: The Start of Care (SOC) was dated 5/4/20. The Plan of Care (POC) identified diagnoses of Chronic Bronchitis, Urinary Incontinence and Allergic Rhinitis. The POC ordered the Physical Therapist (PT) at a frequency of 2w6 (2 visits per week for 6 weeks). During record review on 12/14/21, it was noted that the agency only completed one visit for week 3 and there was no change of frequency order. The agency failed to attempt to reschedule the missed visits to meet the ordered POC. MR#2: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath and Hypertension. The POC ordered the PT at a frequency of 2w8. During record review on 12/14/21, it was noted that the PT documented "Missed Visit" on 12/27/18 and 1/10/19. The agency failed to attempt to reschedule the missed visits to meet the ordered POC. MR#3: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Age-Related Physical Debility, Hypertension, Osteoarthritis of Hip. The POC ordered Skilled Nursing (SN) 2w1, 1w8 and PT 2w7. During record review on 12/15/21, it was noted that the SN documented "Missed Visit" on 12/29/18 and the PT documented “Missed Visit” on 12/27/18 and 12/29/18. The agency failed to attempt to reschedule the missed visits to meet the ordered POC. MR#4: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Abnormalities of Gait, Wernicke’s Encephalopathy and Hypertension. The POC ordered SN 2w1, 1w8 and PT 2w7. During record review on 12/15/21, it was noted that the SN documented "Missed Visit" on 12/29/18 and the PT documented “Missed Visit” on 12/27/18 and 12/29/18. The agency failed to attempt to reschedule the missed visits to meet the ordered POC. MR#6: The Start of Care (SOC) was dated 10/9/18. The Plan of Care (POC) identified diagnoses of Cerebrovascular Accident (CVA), Hypertension and Other Muscle Spasm. The POC ordered SN 2w1, 1w8 and PT 2w8. During record review on 12/15/21, it was noted the SN documented "Missed Visit" on 11/23/18 and 12/26/18, and the PT documented “Missed Visit” on 11/20/18 and 11/21/18. The agency failed to attempt to reschedule the missed visits to meet the ordered POC. Admin#1 was questioned on 12/16/21 at 12:50 am and confirmed the findings stating, "We did not meet our ordered frequencies.

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 ensure a discharge summary was complete, that provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 7 (MR# 1, 2, 3, 4, 5, 6 and 7), of 7 closed records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: MR#1: The Start of Care (SOC) was dated 5/4/20. The Plan of Care (POC) identified diagnoses of Chronic Bronchitis, Urinary Incontinence and Allergic Rhinitis. The Physical Therapist (PT) completed a discharge OASIS (outcome and assessment information set) on 6/25/20. During record review on 12/14/21, 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. MR#2: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath and Hypertension. The Registered Nurse (RN) completed a discharge OASIS on 3/9/19. During record review on 12/14/21, 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. MR#3: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Age-Related Physical Debility, Hypertension, Osteoarthritis of Hip. The RN completed a discharge OASIS on 3/9/19. During record review on 12/15/21, 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. MR#4: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Abnormalities of Gait, Wernicke’s Encephalopathy and Hypertension. The RN completed a discharge OASIS on 3/9/19. During record review on 12/15/21, 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. MR#5: The Start of Care (SOC) was dated 12/2/18. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Plasma Cell Leukemia and Hypertension. The RN completed a discharge OASIS on 3/9/19. During record review on 12/15/21, 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. MR#6: The Start of Care (SOC) was dated 10/9/18. The Plan of Care (POC) identified diagnoses of Cerebrovascular Accident (CVA), Hypertension and Other Muscle Spasm. The RN completed a discharge OASIS on 1/16/19. During record review on 12/15/21, 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. MR#7: The Start of Care (SOC) was dated 5/1/18. The Plan of Care (POC) identified diagnoses of Cerebrovascular Accident (CVA), Peripheral Vascular Disease and Hypertension. The RN completed a discharge OASIS on 7/9/18. During record review on 12/16/21, 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. Admin#1 was questioned on 12/16/21 at 12:55 pm and confirmed the findings stating, "We need to work on how we process our discharge summary’s."