Every finding on record at Schoolcraft Memorial Hospital

On 12/05/23 through 12/07/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Schoolcraft Memorial Homecare and Hospice. This was a standard survey. The requirements for participation in Medicare at 42 CFR Part § 484.102 Emergency Preparedness were not reviewed.

On 12/05/23 through 12/07/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at: Schoolcraft Memorial Homecare and Hospice 7870W US Highway 2 Manistique, MI 49854 The agency has no branch locations. Records reviewed: 3 records with home visits; 4 records without home visits; for a total of 7 records 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.

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 ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission to home care for 6 of 7 (P-1, 2, 4, 5, 6, 7) records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and for measuring progress toward goals/outcomes. Findings include: P-6: This 89-year-old patient was admitted to home care on 11/15/23 with diagnoses of stage 3 wound of the coccyx, syncope, and retroperitoneal hematoma. During record review on 12/6/23, it was noted that the start of care assessment (SOC) dated 11/15/23, stated there was moderate swelling to the left thigh and groin area but failed to include an actual measurement to accurately assess and monitor potential worsening. It was also noted that the SOC, documented under “Primary Diagnosis & Other Diagnoses,” all 21 other diagnoses list the same date as the assessment and all list “exacerbation,” including personal history of nicotine dependence, although the history and physical states the patient quit smoking 36 years ago. P-7: This 66-year-old patient was admitted to home care on 10/21/23 with diagnoses of hypothyroidism, dementia, and atrial fibrillation. During record review on 12/6/23, it was noted that the start of care assessment (SOC) dated 10/21/23, documented under “Primary Diagnosis & Other Diagnoses,” all 16 other diagnoses list the same date as the assessment. There was no evidence to indicate that these diagnoses were new as of 10/21/23 or that the patient had experienced exacerbations. These findings were reviewed and acknowledged during an interview with the administrator (Staff-A), the clinical manager (Staff-B), and the QA/Compliance officer (Staff-C) on 12/7/23 at 10:30 a.m. P-4: This 91-year-old patient was admitted to home care on 10/22/23 with diagnoses of a right shoulder fracture due to a recent fall, asthma, and heart disease. During record review on 12/06/23, it was noted that the SOC assessment dated 10/22/23, documented under "Primary Diagnoses & Other Diagnoses," that all 20 diagnoses had the same date of onset, 10/06/23. A few of these other diagnoses included hypothyroidism, iron deficiency, morbid obesity, and presence of cardiac pacemaker. These diagnoses are indicative of long-term chronic health issues. There was nothing in the SOC assessment to indicate that these 20 other diagnoses were all new as of 10/06/23 or that the patient had experienced exacerbations. P-5: This 89-year-old patient was admitted to home care on 11/08/23 with diagnoses of aftercare following surgery for a perforated bowel and diabetes type 2 with low blood sugars. During record review on 12/06/23, it was noted that the SOC assessment dated 11/08/23, documented under "Primary Diagnoses & Other Diagnoses," that all 17 diagnoses had the same date of onset, 11/08/23. A few of these other diagnoses included presence of aortocoronary bypass graft and prosthetic heart valve. There was nothing in the SOC assessment to indicate that these diagnoses were new as of 11/08/23 or that the patient had experienced exacerbations. The findings were reviewed with and acknowledged by the Director (Staff-A) and the Clinical Manager (Staff-B) during an interview on 12/07/23 at 11:30 a.m. P-1: The Start of Care (SOC) was dated 11/21/2023. The Plan of Care (POC) for the certification period 11/21/2023 to 1/19/2023 identified a Primary Diagnosis of Hemiplegia following cerebral infarction affecting the right dominant side; and Secondary/Other Diagnoses of Atrial Fibrillation (A-fib), Atherosclerotic disease of native coronary artery without angina pectoris, Hypertensive Heart Disease with Heart Failure (HF), Cardiomyopathy, mixed Hyperlipidemia, Vitamin D deficiency, Alcohol used with intoxication, Nicotine dependence, Long term current use of antithrombotic/antiplatelets, long term use of aspirin, and history of falls. Upon further review, it was noted the date of onset documented under “Primary Diagnosis" was dated 11/21/2023; the review of Secondary/Other Diagnoses revealed that all12 Secondary/other diagnoses list the same date as the Primary Diagnosis and document these 12 secondary diagnoses as “exacerbation.” There was no information found in the record that indicated all 13 illnesses had been diagnosed on 11/21/23. P-2: The SOC was dated 10/21/2023. The Plan of Care identified the Primary Diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Chronic Kidney Disease (CKD) and Secondary Diagnoses of Chronic Diastolic Heart Failure (CHF), Stage 3 CKD, Post-herpetic polyneuropathy, osteoarthritis. Gastro-esophageal reflux disease without esophagitis, chronic pain, hypokalemia dysphagia, malignant neoplasm of unspecified site of left female breast, rheumatoid arthritis, Vitamin D deficiency, Long-term use of aspirin. Upon review of the record, it was noted that the date of onset for the Primary Diagnosis was 10/21/23. Further review revealed that the 12 Secondary/Other Diagnoses had the same date of onset of 10/21/23 as the Primary Diagnosis. There was no information found in the record that indicated all 13 illnesses had been diagnosed on 11/21/23. These findings were reviewed with and acknowledged by the Director (Staff-A) and the Clinical Manager (Staff-B) during an interview on 12/07/23 at 12:30 p.m. P-1: The Start of Care (SOC) was dated 11/21/2023. The Plan of Care (POC) for the certification period 11/21/2023 to 1/19/2023 identified a Primary Diagnosis of Hemiplegia following cerebral infarction affecting the right dominant side; and Secondary/Other Diagnoses of Atrial Fibrillation (A-fib), Atherosclerotic disease of native coronary artery without angina pectoris, Hypertensive Heart Disease with Heart Failure (HF), Cardiomyopathy, mixed Hyperlipidemia, Vitamin D deficiency, Alcohol used with intoxication, Nicotine dependence, Long term current use of antithrombotic/antiplatelets, long term use of aspirin, and history of falls. Upon further review, it was noted the date of onset documented under “Primary Diagnosis" was dated 11/21/2023; the review of Secondary/Other Diagnoses revealed that all12 Secondary/other diagnoses list the same date as the Primary Diagnosis and document these 12 secondary diagnoses as “exacerbation.” There was no information found in the record that indicated all 13 illnesses had been diagnosed on 11/21/23. P-2: The SOC was dated 10/21/2023. The Plan of Care identified the Primary Diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Chronic Kidney Disease (CKD) and Secondary Diagnoses of Chronic Diastolic Heart Failure (CHF), Stage 3 CKD, Post-herpetic polyneuropathy, osteoarthritis. Gastro-esophageal reflux disease without esophagitis, chronic pain, hypokalemia dysphagia, malignant neoplasm of unspecified site of left female breast, rheumatoid arthritis, Vitamin D deficiency, Long-term use of aspirin. Upon review of the record, it was noted that the date of onset for the Primary Diagnosis was 10/21/23. Further review revealed that the 12 Secondary/Other Diagnoses had the same date of onset of 10/21/23 as the Primary Diagnosis. There was no information found in the record that indicated all 13 illnesses had been diagnosed on 11/21/23. These findings were reviewed with and acknowledged by the Director (Staff-A) and the Clinical Manager (Staff-B) during an interview on 12/07/23 at 12:30 p.m. P-4: This 91-year-old patient was admitted to home care on 10/22/23 with diagnoses of a right shoulder fracture due to a recent fall, asthma, and heart disease. During record review on 12/06/23, it was noted that the SOC assessment dated 10/22/23, documented under "Primary Diagnoses & Other Diagnoses," that all 20 diagnoses had the same date of onset, 10/06/23. A few of these other diagnoses included hypothyroidism, iron deficiency, morbid obesity, and presence of cardiac pacemaker. These diagnoses are indicative of long-term chronic health issues. There was nothing in the SOC assessment to indicate that these 20 other diagnoses were all new as of 10/06/23 or that the patient had experienced exacerbations. P-5: This 89-year-old patient was admitted to home care on 11/08/23 with diagnoses of aftercare following surgery for a perforated bowel and diabetes type 2 with low blood sugars. During record review on 12/06/23, it was noted that the SOC assessment dated 11/08/23, documented under "Primary Diagnoses & Other Diagnoses," that all 17 diagnoses had the same date of onset, 11/08/23. A few of these other diagnoses included presence of aortocoronary bypass graft and prosthetic heart valve. There was nothing in the SOC assessment to indicate that these diagnoses were new as of 11/08/23 or that the patient had experienced exacerbations. The findings were reviewed with and acknowledged by the Director (Staff-A) and the Clinical Manager (Staff-B) during an interview on 12/07/23 at 11:30 a.m. P-6: This 89-year-old patient was admitted to home care on 11/15/23 with diagnoses of stage 3 wound of the coccyx, syncope, and retroperitoneal hematoma. During record review on 12/6/23, it was noted that the start of care assessment (SOC) dated 11/15/23, stated there was moderate swelling to the left thigh and groin area but failed to include an actual measurement to accurately assess and monitor potential worsening. It was also noted that the SOC, documented under “Primary Diagnosis & Other Diagnoses,” all 21 other diagnoses list the same date as the assessment and all list “exacerbation,” including personal history of nicotine dependence, although the history and physical states the patient quit smoking 36 years ago. P-7: This 66-year-old patient was admitted to home care on 10/21/23 with diagnoses of hypothyroidism, dementia, and atrial fibrillation. During record review on 12/6/23, it was noted that the start of care assessment (SOC) dated 10/21/23, documented under “Primary Diagnosis & Other Diagnoses,” all 16 other diagnoses list the same date as the assessment. There was no evidence to indicate that these diagnoses were new as of 10/21/23 or that the patient had experienced exacerbations. These findings were reviewed and acknowledged during an interview with the administrator (Staff-A), the clinical manager (Staff-B), and the QA/Compliance officer (Staff-C) on 12/7/23 at 10:30 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, the agency failed to ensure the plan of care included measurable outcomes and goals for 4 of 7 (P-1, 2, 4, 7) records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine progress towards goals for these patients. Findings include: P-4: This 91-year-old patient was admitted to home care on 10/22/23 with diagnoses of a right shoulder fracture due to a recent fall, asthma, and heart disease. During record review on 12/06/23, it was noted that the plan of care failed to include measurable skilled nursing goals and outcomes. The plan of care contained the following goal: client will be knowledgeable on fall prevention techniques. There was no indication how this goal would be measured to determine the patient's progress towards discharge. The findings were reviewed with and acknowledged by Staff-A and Staff-B during an interview on 12/07/23 at 11:30 a.m. P-7: This 66-year-old patient was admitted to home care on 10/21/23 with diagnoses of hypothyroidism, dementia, and atrial fibrillation. During record review on 12/6/23, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “will have knowledge on fall prevention techniques.” There was no evidence of how this could be objectively measured to determine progress toward meeting the goals. This finding was reviewed and acknowledged during an interview with the administrator (Staff-A), the clinical manager (Staff-B), and the QA/Compliance officer (Staff-C) on 12/7/23 at 10:30 a.m. P-1: The Start of Care (SOC) was dated 11/21/2023. The Plan of Care (POC) for the certification period 11/21/2023 to 1/19/2023 identified a Primary Diagnosis of Hemiplegia following cerebral infarction affecting the right dominant side; and Secondary/Other Diagnoses of Atrial Fibrillation (A-fib), Atherosclerotic disease of native coronary artery without angina pectoris, Hypertensive Heart Disease with Heart Failure (HF), Cardiomyopathy, mixed Hyperlipidemia, Vitamin D deficiency, Alcohol use with intoxication, Nicotine dependence, Long term current use of antithrombotic/antiplatelets, long term use of aspirin, and history of falls. Upon review of the record, it was noted the goals were not objectively measurable to determine the progress towards achieving goals. Examples include: "Patient's goal is to gain strength to the right side; Patient will be compliant with daily blood pressure checks/logbook; Blood pressure will remain stable throughout care." These goals are not objectively measurable to determine the patient's progress towards at attaining the goals. P-2: The SOC was dated 10/21/2023. The Plan of Care identified the Primary Diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Chronic Kidney Disease (CKD) and Secondary Diagnoses of Chronic Diastolic Heart Failure (CHF), Stage 3 CKD, Post-herpetic polyneuropathy, osteoarthritis. Gastro-esophageal reflux disease without esophagitis, chronic pain, hypokalemia dysphagia, malignant neoplasm of unspecified site of left female breast, rheumatoid arthritis, Vitamin D deficiency, Long-term use of aspirin. Upon review of the Plan of Care for the certification period 10/21/2023 to 12/19/2023 it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards obtaining goal. Examples include: "Patients goal is to gain her strength back {sic}; Patient will demonstrate sit to stand and transfers independently and safely to maximize functional mobility independence; Patient will report G compliance to HEP to decrease risk for decline." These goals are not objectively measurable to determine the patient's progress towards at attaining the goals. These findings were reviewed with and acknowledged by the Director (Staff-A) and the Clinical Manager (Staff-B) during an interview on 12/07/23 at 12:30 p.m.

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, the agency failed to ensure skilled professionals provided services as ordered by the physician in the plan of care for 1 of 7 (P-7) records reviewed, resulting in the potential for poor patient outcomes for this patient. Findings include: P-7: This 66-year-old patient was admitted to home care on 10/21/23 with diagnoses of hypothyroidism, dementia, and atrial fibrillation. During record review on 12/6/23, it was noted there was an order on the plan of care for skilled nursing to measure the bilateral leg circumference weekly and report an increase to the physician. The record failed to include a measurement for the skilled nursing visit on 11/14/23. This finding was reviewed and acknowledged during an interview with the administrator (Staff-A), the clinical manager (Staff-B), and the QA/Compliance officer (Staff-C) on 12/7/23 at 10:30 a.m.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an onsite supervisory visit was conducted at least every 14 days for 1 of 3 (P- 4) records reviewed with aide services, resulting in a lack of supervision and oversight of aide services for this patient. Findings include: P-4: This 91-year-old patient was admitted to home care on 10/22/23 with diagnoses of a right shoulder fracture due to a recent fall, asthma, and heart disease. During record review on 12/06/23, it was noted that the 10/22/23 plan of care ordered the aide to provide 1-2 visits each week for 4 weeks. Aide services began on 10/24/23 and the aide documented that visits were provided on 10/24, 10/26, 10/31, and 11/2. The aide documented two missed visits on 11/7 and 11/10. The first documented aide supervisory visit was documented on 11/14/23, which is 21-days after the start of aide services. The agency failed to follow its own policy titled, Supervision of Clinical Staff (revised 04/2023) which states, home health aide supervisory visits will be conducted on-site at least every two (2) weeks. The findings were reviewed with and acknowledged by the Director (Staff-A) and the Clinical Manager (Staff-B) during an interview on 12/07/23 at 11:30 a.m.

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 assessments and visit notes for 1 of 7 (P-6) records reviewed, resulting in a lack of information for the physician and all agency staff caring for the patient. Findings include: P-6: This 89-year-old patient was admitted to home care on 11/15/23 with diagnoses of stage 3 wound on the coccyx, syncope, and retroperitoneal hematoma. During record review on 12/6/23, it was noted that the start of care assessment, dated 11/15/23, contained measurements of the stage 3 wound on the patient’s coccyx. Communication notes indicate the patient visited their primary care provider on 11/21/23 for wound debridement (removal of unhealthy tissue from a wound), while the weekly skilled nursing visit notes dated 11/24/23 and 12/1/23 failed to include wound measurements. This finding was reviewed and acknowledged during an interview with the administrator (Staff-A) who stated the expectation is that staff measure wounds weekly, the clinical manager (Staff-B), and the QA/Compliance officer (Staff-C) on 12/7/23 at 10:30 a.m.