Every finding on record at Reymac Home Healthcare, LLC

A recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/19/21-10/21/21 at Reymac Home Health Care. 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 10/19/21 through 10/21/21 at: Reymac Home Health Care 13030 W. 7 Mile Rd. Detroit, MI 48235 This agency has no extension sites. For this survey 7 discharge records were reviewed. There were no active patients therefore, no home visits were made. At the conclusion of the survey the agency was found to be out of compliance with Condition 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 document review and interview, the Agency (HHA) failed to include contact information for the home health agency's administrator in the agency's Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns or complaints. Findings include: On 10/19/21 at 11:00 a.m., the agency's admission packet was reviewed. The packet included a consent form, admission agreement, beneficiary notice and patient rights and responsibilities forms. There was no documented contact information for the agency's administrator including the administrator's name, business address and phone number available to the patient. These findings were reviewed with the office manager (OM#1) during an interview on 10/21/21 at 2:30 p.m., OM#1 acknowledged the findings.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on document review and interview, the Agency (HHA) failed to include contact information for the State of Michigan home health agency hotline in the agency's Patient Admission/Orientation Packet, or in the patient's record, resulting in the potential for unaddressed patient concerns or complaints. Findings include: On 10/19/21 at 11:00 a.m., the agency's admission packet was reviewed. The packet included a consent form, admission agreement, beneficiary notice and patient rights and responsibilities forms. There was no documented contact information for the State of Michigan home health care hotline available to the patient. These findings were reviewed with the office manager (OM#1) during an interview on 10/21/21 at 2:30 p.m., OM#1 acknowledged the findings.

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 document review and interview, it was determined the home health agency failed to advise the patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the area where the patient resides, resulting in the potential for patient needs being unmet. Findings include: During review of the agency's patient information folder on 10/19/21, it was discovered that the information for Federally and State funded patient resource entities were not provided to the patients. During an interview on 10/21/21 at 2:30 p.m., after a brief review of the patient information handbook, the office manager (OM#1) stated, "I will add those resources to the book."

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT 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 based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and fails to reflect the patient's current health status in 7 of 7 records reviewed (MR#s 1, 2, 3, 4, 5, 6, 7), resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: MR #1: The SOC was dated 3/5/21. The Plan of Care (POC) identified the diagnoses of osteoarthritis, weakness, pain and hypertension. A review of the Comprehensive Assessment (OASIS) on 10/19/21, documented under the category (M1021, 1023): "Patient Diagnoses", the only information provided was a list of 9 diagnoses. There was no information under M1021, 1023 or anywhere else in the OASIS assessment regarding the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. MR #2: The SOC was dated 5/26/21. The POC identified the diagnoses of osteoarthritis, weakness and hypertension. A review of the Comprehensive Assessment (OASIS) on 10/20/21, documented under the category (M1021, 1023): "Patient Diagnoses", the only information provided was a list of 8 diagnoses. There was no information under M1021, 1023 or anywhere else in the OASIS assessment regarding the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. MR #3: The SOC was dated 7/28/20. The POC identified the diagnoses of hypertension, weakness and schizophrenia. A review of the Comprehensive Assessment (OASIS) on 10/20/21, documented under the category (M1021, 1023): "Patient Diagnoses", the only information provided was a list of 6 diagnoses. There was no information under M1021, 1023 or anywhere else in the OASIS assessment regarding the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. MR #4: The SOC was dated 5/26/21. The POC identified the diagnosis of osteoarthritis. A review of the Comprehensive Assessment (OASIS) on 10/20/21, documented under the category (M1021, 1023): "Patient Diagnoses", the only information provided was a list of 1 diagnosis. There was no information under M1021, 1023 or anywhere else in the OASIS assessment regarding the onset, exacerbations, prior treatments and outcomes, or history of how the above illness led to the need for the current home care admission. MR #5: The SOC was dated 2/1/21. The POC identified the diagnoses of hypertension, osteoarthritis and back pain. A review of the Comprehensive Assessment (OASIS) on 10/20/21, documented under the category (M1021, 1023): "Patient Diagnoses", the only information provided was a list of 7 diagnoses. There was no information under M1021, 1023 or anywhere else in the OASIS assessment regarding the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. MR #6: The SOC was dated 9/15/20. The POC identified the diagnoses of hypertension, osteoarthritis and leg pain. A review of the Comprehensive Assessment (OASIS) on 10/21/21, documented under the category (M1021, 1023): "Patient Diagnoses", the only information provided was a list of 10 diagnoses. There was no information under M1021, 1023 or anywhere else in the OASIS assessment regarding the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. MR #7: The SOC was dated 5/26/21. The POC identified the diagnoses of hypertension, osteoarthritis and leg pain. A review of the Comprehensive Assessment (OASIS) on 10/21/21, documented under the category (M1021, 1023): "Patient Diagnoses", the only information provided was a list of 1 diagnosis. There was no information under M1021, 1023 or anywhere else in the OASIS assessment regarding the onset, exacerbations, prior treatments and outcomes, or history of how the above illness led to the need for the current home care admission. These findings were reviewed with the office manager (OM#1) during an interview on 10/21/21 at 2:30 p.m., OM#1 acknowledged the 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, it was determined the agency failed to have a registered nurse (RN) perform a comprehensive drug review in 5 of 7 (MR # 2, 4, 5, 6 and 7) records, resulting in the potential for harmful medication side effects for all agency patients. Findings include: Policy MR #2: The SOC was dated 5/26/21. The Plan of Care (POC) identified the diagnoses of osteoarthritis, weakness, and hypertension. The only service provided to this patient was physical therapy (PT). On 10/19/21, a review of the record found no documentation of an RN reconciling the patient's medications. An RN is required to review all medications, regardless of whether RN services are ordered or not. MR #4: The SOC was dated 5/26/21. The Plan of Care (POC) identified the diagnoses of osteoarthritis. The only service provided to this patient was physical therapy (PT). On 10/20/21, a review of the record found no documentation of an RN reconciling the patient's medications. An RN is required to review all medications, regardless of whether RN services are ordered or not. MR #5: The SOC was dated 2/1/21. The Plan of Care (POC) identified the diagnoses of hypertension, osteoarthritis and back pain. Skilled nursing and physical therapy (PT) services were ordered. On 10/20/21, during a review of the record, it was discovered that the start of care OASIS assessment was signed by a PT. There was no documentation of an RN reconciling the patient's medications. An RN is required to review all medications, regardless of whether RN services are ordered or not. MR #6: The SOC was dated 9/15/20. The Plan of Care (POC) identified the diagnoses of osteoarthritis, leg pain, weakness and hypertension. The only service provided to this patient was physical therapy (PT). On 10/21/21, a review of the record found no documentation of an RN reconciling the patient's medications. An RN is required to review all medications, regardless of whether RN services are ordered or not. MR #7: The SOC was dated 5/26/21. The Plan of Care (POC) identified the diagnoses of polyosteoarthritis. The only service provided to this patient was physical therapy (PT). On 10/21/21, a review of the record found no documentation of an RN reconciling the patient's medications. An RN is required to review all medications, regardless of whether RN services are ordered or not. During an interview on 10/21/21 at 2:30 p.m., the office manager (OM#1) acknowledged the findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD 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 3 of 7 records (M.R.#s 1, 3 and 5), from a total of 7 records reviewed, resulting in the potential for a plan of care not meeting the patient's needs. Findings include: MR #1: The start of care (SOC) date was 3/5/21. The plan of care (POC) documented diagnoses of osteoarthritis, weakness and hypertension. During record review on 10/19/21, it was noted that the goals on the POC were not measurable, for example, one goal stated, "Fall precautions and to stay out of hospital." Another stated, "Physical therapy evaluation will be performed and a plan of care to increase functional independence will be established and counter signed by physician." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR #3: The SOC date was 7/28/20. The POC documented diagnoses of schizophrenia , weakness and hypertension. During record review on 10/20/21, it was noted that the goals on the POC were not measurable, for example, one goal stated, "Patient and caregiver will be able to identify fall risk factors by 8/22/20." Another stated, "Patient/caregiver will be able to demonstrate pain relief measures to mitigate pain by 8/22/20." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR #5: The SOC date was 2/1/21. The POC documented diagnoses of osteoarthritis, back pain and hypertension. During record review on 10/20/21, it was noted that the goals on the POC were not measurable, for example, one goal stated, "Physical therapy evaluation will be performed and a plan of care to increase functional independence will be established and counter signed by physician." There was no evidence of how this goal could be objectively measured to ascertain progress toward goals. During an interview on 10/21/21 at 2:30 p.m., the office manager (OM#1) acknowledged the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the agency failed to have skilled nursing provide services ordered in the plan of care (POC) in 1 of 7 records, from a total of seven records reviewed, resulting in the potential for unmet care needs for the patient. Findings include: MR #5: The SOC date was 2/1/21. The POC documented diagnoses of osteoarthritis, back pain and hypertension. The POC also documented skilled nursing with a visit frequency of 1w4, and a physical therapy frequency of 2w1 and 1w5. During record review on 10/20/21, it was discovered that skilled nursing never made a visit. There was no documentation in the record as to why no visit was ever made. There was no physician order to discontinue skilled nursing services documented in the record. During an interview on 10/21/21 at 2:30 p.m., the office manager (OM#1) acknowledged the findings.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a clinical manager was available during all agency operating hours, resulting in the potential for unaddressed clinical issues (SEE 950); and failed to ensure that at least one qualifying service was provided directly by agency employees (SEE 982). The systemic effects of the above deficiencies had the potential to affect all 48 patients admitted in the past 12 months, resulting in the provision of substandard care, patients not receiving needed services and the potential for poor patient outcomes.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure a clinical manager was available during all agency operating hours, resulting in the potential for unaddressed clinical issues. Findings include: During the entrance conference on 10/19/21 at 10:00 a.m., the administrator (Adm#1) was asked about the availability of the clinical manager. Adm#1 said the clinical manager was in dialysis and would not be available until after 3:00 p.m.. When asked about the availability of the alternate clinical manager, Adm#1 said she was unable to get a hold of her. During an interview on 10/21/21 at 2:30 p.m., the office manager (OM#1) stated, "We still have not been able to get a hold of the alternate clinical manager, and we may need to find a different clinical manager that is available when needed."

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on interview and record review, the administrator failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for all services to be provided by contracted staff. Findings include: During the entrance conference on 10/19/21, the administrator (Adm#1) was asked what services were currently provided by the agency. The response was, "We offer Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), and Speech Therapy (ST) services." When asked what service was provided directly by the agency, Adm#1 stated, "All clinical staff are contracted." On 10/21/21 at approximately 2:30 p.m., when questioned about all services being contracted, the office manager stated, "I will make sure we have one service that is not contracted."