Every finding on record at Reverence Home Health and Hospice, LLC

The following standard level deficiencies were identified at A Medicare authorized complaint (MI00061621) investigation conducted by the Michigan Department of Licensing and Regulatory Affairs on 2/22/22 at: Ascension At Home 5445 Ali Drive, Dept. 500 Grand Blanc, MI Allegation: It was alleged the facility failed to provide contracted services and care to the patient in accordance with the Physician's orders - Substantiated.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure that all complaints and their resolutions were were documented, resulting in the potential for unidentified, unaddressed, unresolved patient/family concerns and the potential for the provision of substandard care for all past patients, and the 388 patients currently serviced by this agency. Findings include: On 2/22/22 at 9/10 a.m., the Administrator (Adm #1) was asked for permission to review the Agency's complaint log. At 11:02 a.m., Adm #1 presented a document titled "QI Event Report". The report was for the requested dates that included 12/1/21 to 2/22/22. It was further noted that the document was blank. During the review, Adm #1 stated, "I know what you're going to say. My Quality person already talked to me about it." When queried about the lack of documented complaints, Adm #1 reported, "I don't log the complaints. I mean, I do take the calls, but if a patient says, for example, "I want a new nurse", I just get them a new nurse. I don't write it down. I guess this is an opportunity for improvement." The Agency failed to ensure that all complaints and their resolutions were were documented

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 Comprehensive Assessment visit was made on the Physician - ordered start of care date for 1 (MR #1) of 1 patient who required Intravenous Antibiotic Therapy, on a specified start date, for a Joint Infection, from a total of 3 sampled records reviewed, resulting in potential for the delay in healing and the worsening and spread of infection. Findings include: Policy: "Admission of Patients to Home Health Services" 2.014, 12/1/17 stated, "The agency will accept a patient for home health services on a reasonable expectation that the patient's medical, nursing an d social needs can be met adequately in the patient's residence." A policy regarding the above deficiency was requested, however, upon review, there was no language that addressed the timeliness of the Initial Comprehensive Assessment. MR #1: The patient's start of care (SOC) was 1/9/22 with diagnoses of Fibromyalgia, pain left leg, difficulty walking and diabetes mellitus. On 2/22/22 at 1:16 p.m., during the clinical record review the following was noted: The referral for home care services was dated 1/6/22 and documented, "SOC (start of care) 1/8/22 Skilled RN (Registered Nurse) visits for IV (Intravenous) Antibiotic therapy administration..., weekly labs and weekly PICC (peripherally inserted central catheter) dressing changes. Will deliver medications/supplies to pt's (patient's) home on 1/7/22 by 6 pm. Diagnosis: L (left) knee PJI (Prosthetic Joint Infection)..., URGENT." During the review, it was noted that the Agency began services on 1/9/22. Further, there was no documented evidence that the patient refused services or requested a later start of care date. Additionally, there was no documented evidence that the Physician was notified that care had not begun on the date specified. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Vice President of Clinical Excellence (VPE #1) during an interview on 2/22/22.