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Atrio Home Health Lakeshore

(616) 796-38009 E 8TH St, Holland, MI 49423
CMS Certification Number 237411 · Non-Profit · Medicare-certified since 10/25/1996
23deficiencies since 2018
1serious
2inspections
3.5CMS quality stars
Data from CMS inspection reports (Form 2567), 2018-01-02 to 2026-10-15, downloaded 2026-10-21; CMS agency list file dated 2026-09-21. What the labels mean

Inspection 2022-10-20

· Recertification · 18 deficiencies · CMS source report (PDF)
Serious Care Planning, Coordination, Quality Of Care

The Agency failed to ensure the plan of care addressed the individualized needs of the patient and included all pertinent interventions with reportable parameters and objectively measurable goals for 10 of 17 (MR#'s 1, 2, 3, 4, 5, 6, 9, 15, 16) records reviewed, resulting in patients not receiving…

Source: CMS Form 2567, inspection 2022-10-20, tag G0570 · view on CMS
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Moderate Discharge Or Transfer Summary Content

The Agency failed to ensure the Speech Therapist completed a detailed Discharge Summary that detailed the course of care provided, the patient's health status at the time of discharge and was forwarded to the Physician within 5 days of the date of discharge for 1 (MR #16) record, from a total of 17…

Source: CMS Form 2567, inspection 2022-10-20, tag G0564 · view on CMS
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Moderate Covid-19 Vaccination Of Home Health Agency Staff

The Agency failed to establish Vaccine protocol written policies and procedures that included (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for tracking/documenting information provided by staff who have requested/been granted an…

Source: CMS Form 2567, inspection 2022-10-20, tag G0687 · view on CMS
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Moderate Competency Evaluation

The Agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide's performance of the required tasks with a patient…

Source: CMS Form 2567, inspection 2022-10-20, tag G0768 · view on CMS
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Moderate Home Health Aide Assignments And Duties

The Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to providing care in 2 (MR#'s 7, 15) of ___ records in which Home Health Aide services were ordered, from a total of 17 sampled…

Source: CMS Form 2567, inspection 2022-10-20, tag G0798 · view on CMS
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Minor Participate In Care

The Agency failed to ensure that 3 (MR's #13, 14, 15) of 3 patients observed during home visits, were included in the overall planning of care including the timeliness of services received; and failed to inform the patient/caregiver in advance of the days in which services would be provided…

Source: CMS Form 2567, inspection 2022-10-20, tag G0434 · view on CMS
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Minor Document Complaint And Resolution

The Agency failed to provide documented evidence of the details of the investigation and the resolution of the complaints, as per this requirement, resulting in the potential for unaddressed patient/family concerns, inability to exercise one's rights and unmet care needs.

Source: CMS Form 2567, inspection 2022-10-20, tag G0484 · view on CMS
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Minor Health, Psychosocial, Functional, Cognition

The agency failed to ensure the comprehensive assessment included an accurate reflection of the patient’s current health, psychosocial, and functional status in 7 of 17 records reviewed (MR# 8, 10, 11, 12, 14, 15, 16) resulting in incomplete clinical information to aid in determining the needs of…

Source: CMS Form 2567, inspection 2022-10-20, tag G0528 · view on CMS
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Minor A Review Of All Current Medications

The agency failed to identify potential clinically significant medication issues and report to the physician in 1 of 17 (MR#1) records reviewed.

Source: CMS Form 2567, inspection 2022-10-20, tag G0536 · view on CMS
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Minor Plan Of Care Must Include The Following

The Agency failed to ensure the plan of care addressed the individualized needs of the patient and included all pertinent interventions with reportable parameters and objectively measurable goals for 10 (MR#'s 1, 2, 3, 4, 5, 6, 9, 15, 16) records, from a total of 17 sampled records reviewed…

Source: CMS Form 2567, inspection 2022-10-20, tag G0574 · view on CMS
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Minor Only As Ordered By A Physician

The agency failed to ensure the physician ordered treatment for wound care was administered only as ordered for 1 of 3 (MR# 9) sample records for which the patient was receiving wound care from a total of 17 records reviewed resulting in the potential for unidentified complications and unrecognized…

Source: CMS Form 2567, inspection 2022-10-20, tag G0580 · view on CMS
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Minor Promptly Alert Relevant Physician Of Changes

The Agency failed to ensure the Physician was promptly notified of the severe drug interactions that were identified in 4 (MR#'s 14, 15, 16, 17) records reviewed that were found to have severe drug interactions, and 2 (MR#s 11, 17) records with significant fluctuations in weight, from a total of 17…

Source: CMS Form 2567, inspection 2022-10-20, tag G0590 · view on CMS
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Minor Integrate All Orders

The agency failed to ensure the integration of medication orders from all physicians involved in the plan of care for 1 of 4 (MR# 8) sample records reviewed for which a home visit was made with a patient residing in an assisted living facility potentially resulting in undetected overmedication and…

Source: CMS Form 2567, inspection 2022-10-20, tag G0604 · view on CMS
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Minor Patient Medication Schedule/Instructions

The agency failed to provide 2 (MR#'s 14, 15) of 3 patients observed during home visits, with a Medication Profile that included the names, dosages, frequencies and side effects of the patient's prescribed medications, in plain language, from a total of 17 sampled records reviewed, resulting in…

Source: CMS Form 2567, inspection 2022-10-20, tag G0616 · view on CMS
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Minor Name/Contact Information Of Clinical Manager

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet for Skilled Nurse openings, resulting in the potential for unaddressed patient concerns.

Source: CMS Form 2567, inspection 2022-10-20, tag G0622 · view on CMS
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Minor Development And Evaluation Of Plan Of Care

The Agency failed to ensure the Physical Therapist (PT), Occupational Therapist and Speech Therapist assisted the Physician in evaluating the patient's level of function and helped to develop the plan of care for 3 (MR#'s 15, 16, 17) records in which Therapy services were required, from a total of…

Source: CMS Form 2567, inspection 2022-10-20, tag G0708 · view on CMS
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Minor Preparing Clinical Notes

The Agency failed to ensure the clinical record was complete and included accurate documentation within Nursing visits for 1 (MR #15) record; and, failed to ensure the clinical record included approved medical abbreviations in 1 (MR #1) record, from a total of 17 sampled records reviewed, resulting…

Source: CMS Form 2567, inspection 2022-10-20, tag G0716 · view on CMS
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Minor Discharge And Transfer Summaries

The Agency failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge and identified the patients progress toward goals in 2 (MR#s 16, 17) of 5 records in which the patient was discharged from the Agency's services, from a total of 17…

Source: CMS Form 2567, inspection 2022-10-20, tag G1022 · view on CMS
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Inspection 2019-10-25

· Recertification · 5 deficiencies · CMS source report (PDF)
Moderate Content Of The Comprehensive Assessment

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, objective baseline data for future assessments, and ascertained the patient's immediate care needs in 3 of 13 sampled patient records reviewed (MR#s 1, 2…

Source: CMS Form 2567, inspection 2019-10-25, tag G0526 · view on CMS
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Moderate Conformance With Physician Orders

The agency failed to ensure services were provided as ordered by the physician for 3 of 13 records reviewed (MR# 4, 8, 13), resulting in the potential for poor outcomes for the patients.

Source: CMS Form 2567, inspection 2019-10-25, tag G0578 · view on CMS
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Minor Plan Of Care Must Include The Following

The agency failed to ensure the plan of care included objectively measurable outcomes and goals for 4 of 13 (MR# 1, 2, 3, and 4) records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress towards goals and the…

Source: CMS Form 2567, inspection 2019-10-25, tag G0574 · view on CMS
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Minor Promptly Alert Relevant Physician Of Changes

The agency failed to promptly notify the physician that the patient's weight was outside the reportable parameters in 1 of 13 records reviewed (MR#4), resulting in the potential for poor outcomes.

Source: CMS Form 2567, inspection 2019-10-25, tag G0590 · view on CMS
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Minor Services Provided By Hh Aide

The home health aide failed to provide services that were consistent with home health aide training in 1 of 7 sampled records reviewed in which home health aide services were provided, resulting in the potential for poor surgical outcomes or unmet post surgical care needs.

Source: CMS Form 2567, inspection 2019-10-25, tag G0800 · view on CMS
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