Every finding on record at Sparrow Community Care

A Medicare complaint investigation was conducted by the Michigan Department of Licensing and Regulatory Affairs on 4/8/2021 at: Sparrow Home Care 3315 E. Michigan Ave. suite 4 Lansing, MI 48912 This agency has two extension sites at: 525 Lafayette St., Ionia, MI 48846. 111 Lansing St. Suite 210, Charlotte, MI 48813. For this investigation, 3 active records and 3 discharged records were reviewed. At the conclusion of the investigation 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.

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 interviews and document reviews, it was determined the agency failed to ensure the staff provided visits as ordered in the plan of care for 4 of 6 records reviewed from a total sample of 6 records reviewed (MR # 2, 3, 4 and 6); which resulted in the potential for the patient's needs to go unmet. Findings include: **Agency policy: Documentation Time Lines (Undated). "RN, PT, SLP services: Physical therapy (PT) services must complete evaluation visit within 5 days of the Start of Care (SOC) or on the physician-ordered visit date ..." Document review on 4/8/21, showed MR#2 had skilled nursing (SN), home health aide (HHa), PT and occupational therapy (OT) services ordered. The patient had a SOC date of 2/21/21. The patient went to the hospital on 2/24/21 and returned home on 3/18/21. The PT's resumption of care (ROC) assessment was not performed until 3/25/21, 7 days after the patient's return home. The agency policy is for PT to visit within 5 days. The OT's ROC assessment was not performed until 3/29/21, 11 days after the patient's return home. The agency's policy is for OT to visit within 5 days. MR#3 had SN, HHa, PT, OT and speech therapy (ST) ordered. The patient had a SOC date of 3/15/21. The patient went to the hospital on 3/22/21 and returned home on 3/29/21. The HHa's ROC visit was not performed until 4/6/21, 8 days after the patient's return home. The PT's assessment was not performed until 4/1/2. PT did not make a visit within the first 7 days before the patient went into the hospital. The agency's policy is for PT to visit within 5 days. MR#4 had SN, HHa and PT services ordered. The patient had a SOC date of 3/2/21. The patient went to the hospital on 3/15/21 and returned home on 3/16/21. The PT's ROC assessment was not performed until 3/26/21, 10 days after the patient's return home. The agency's policy is for PT to visit within 5 days. MR#6 had SN, medical social worker (MSW) and PT services ordered. The patient had a SOC date of 3/17/21. The PT's assessment was not performed until 3/25/21, 8 days after the patient's SOC date. The agency's policy is for PT to visit within 5 days. 6 records were reviewed for visit timeliness. 4 of the 6 records had PT and all 4 of the PT records had late PT visits. 100% of PT records reviewed had late PT visits. Of the two records reviewed with OT services, one record declined OT services. The other OT record had a ROC visit 11 days late. 100% of OT records with services provided, had late visits. 3 records were reviewed with HHa services, and 1 of the 3 records had a late HHa visit. 33% of HHa records reviewed had late visits. During an interview on 4/8/21 at 11:15 a.m., the administrator (Admin#1), agreed with the above findings.