Every finding on record at Michigan Community VNA, LLC

Observed in Record Review. In 1 of 19 , The surveyor noted in HOSNHV#1 that physician orders for wound care treatments had not been obtained throughout all certification periods spanning over five months. The patient had two Stage Three sacral ulcers on admission, a new onset heel wound all with ongoing treatments using Triad Paste topically under the dressing. Reviewed with leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, The surveyor noted during the record review on HOSNHV#8 that the registered nurse had not conducted a supervisory visit within the fourteen day period as the gap was over twenty five days. Reviewed with leadership. Observed in Record Review. In 2 of 14 patient records reviewed, The surveyor noted in HOSNHV#2 that the required every fourteen day Home Health Aide supervision was not performed. The aide supervision was not performed for over twenty five days. Reviewed with leadership.

Observed in Data Session. During the review of the volunteer program , the surveyor observed that the organization had not met the requirement for 5% of care provided by volunteer staff. In 2024 the rate was 2%, This was verified with leadership.

Observed in Patient Home. In 1 of 4 home visits conducted, The surveyor noted during HOSHV#1 that the medication profile had inaccuracies including medications no longer being given and dosage inconsistencies. Examples of medications not being administered as reflected on the current medication profile: Escitalopram 20 mg QD, Gabapentin 100 mg 2 caps three times per day, Apixaban 5 mg twice a day. Reviewed with leadership.

Observed in Individual Tracer. On HOS HV#2 record review it was found that the Plan Of Care stated the patient was on Oxygen 2L prn. The care giver was asked where the oxygen was stored and she stated the patient was not on oxygen. The aide providing the visit also stated he had not seen oxygen in the home.

Observed in Individual Tracer. In 3 of 3 home visits conducted, The organization policy #9-014.2 states that equipment utilized on patient care should be cleaned with alcohol after use. On 3 of 3 home visits in Hospice the staff used santi-wipes or Clorox wipes to clean equipment. This was verified with the Hospice Director and review of policy.

Observed in HR File Review. In 3 of 7 HR files reviewed, In review of 3 of 7 HR files it was found that competencies for the Chaplain and the Medical Director had not been documented for 2020 or 2021. There was also no competency found for the NP for 2021. This was verified with the COO during HR review.

Observed in Infection Control System Tracer. In 2 of 3 home visits conducted, It was found on HOS HV #1 and HOS HV#3 that a full oxygen cylinder was freestanding leaning against another tank which was in a holder. When the nurse was questioned regarding the location of the cylinder and should it be lying down, she stated that the DME company said the tank should not be laid down, however the Hospice Director stated it should be on it's side or in a holder.