Every finding on record at Ultimacare Home Health, Inc

From 3/14/23 through 3/15/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Albridge Skilled Home 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 3/14/23 through 3/15/23 at: Albridge Skilled Home Care 2785 Garfield Rd. Traverse City, MI 49686 This agency has no branches or sub-units. All vaccination requirements were met. 2 discharge records reviewed. The agency has 0 active patients. 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.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that 2 (MR's# 1 and 2) of 2 patients were included in their overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: MR#1: The Start of Care (SOC) was dated 8/4/22. The Plan of Care (POC) identified diagnoses of Malaise, Hypertension and Falls. During record review on 3/14/23, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. MR#2: The Start of Care (SOC) was dated 8/16/23. The Plan of Care (POC) identified diagnoses of Alpha-1-antitrypsin Deficiency, Lung Transplant and Wound care. During record review on 3/14/23, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. These findings were reviewed with and acknowledged by the Administrator (Adm#1) and Clinical Manager (CLM#1) during an interview on 3/15/23 at 11:30 am.

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 ensure the Plan of Care included individualized orders in 2 of 2 records reviewed (MR#s 1 and 2), resulting in patients not receiving care specific to their needs and the potential for poor patient outcomes. Findings included: MR#1: The Start of Care (SOC) was dated 8/4/22. The Plan of Care (POC) identified diagnoses of Malaise, Hypertension and Falls. During record review on 3/14/23, it was noted that the POC failed to contain the frequency and duration of visits to be made for the scheduled disciplines. MR#2: The Start of Care (SOC) was dated 8/16/23. The Plan of Care (POC) identified diagnoses of Alpha-1-antitrypsin Deficiency, Lung Transplant and Wound care. During record review on 3/14/23, it was noted that the POC failed to contain the frequency and duration of visits to be made for the scheduled disciplines. These findings were reviewed with and acknowledged by the Administrator (Adm#1) and Clinical Manager (CLM#1) during an interview on 3/15/23 at 11:45 am.