Beaumont Home Health

The agency failed to attempt to reschedule missed visits to meet the frequency in the plan of care in 2 (P-2 and P-4) of 17 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure skilled nursing (SN) prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions in 2 (Patient/P-7, P-8) of 2 records in which home health aide (HHa) services were ordered, from a total of 17 sampled records…

The agency failed to ensure the patient received all services outlined in the plan of care for 2 (P-2 and P-16) of 17 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure that 1 (Patient/P-6) of 4 patients reviewed with severe pain levels had an appropriate documented response in addressing the pain, from a total of 17 sampled patients resulting in unidentified health concerns, delay in treatment and unmet patient care needs.

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, and failed to provided documented evidence that the physician was notified of identified drug interactions in 10 (Patient/P-6, P-9, P-10, P-11, P-12, P-13, P-14, P-15…

The agency failed to ensure the plan of care included patient specific parameters to meet the needs of the patient for 10 (P-1, P-2, P-3, P-4, P-6, P-9, P-14, P-15, P-16 and P-17) of 17 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential…

The agency failed to ensure communication to integrate all services to ensure patient needs were met in 1 (P-2) of 17 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs Findings include: Patient #2 (P-2) was admitted to this home care agency on 7/2/25 with…

The agency's skilled nursing (SN) services failed to coordinate and facilitate care as ordered by the physician in 1 (Patient/P-7) of 2 records reviewed with congestive heart failure, from a total sample of 17 records reviewed, resulting in the lack of cardiac monitoring and the potential for poor…

The agency failed to ensure patients were provided with the name and contact information of the clinical manager in 1 (P-1) of 7 records reviewed, resulting in the potential for patients to be unaware of who to contact regarding concerns about the agency.

The agency failed to ensure the professional staff provided ongoing reassessment in 7 (P-1, P-2, P-4, P-9, P-10, P-14, P-16) of 17 records, resulting in the potential for unidentified patient needs.

The agency failed to ensure clinical notes were accurate and individualized for 3 (Patient/P-6, P-9, P-10) of 17 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure the physical therapist and occupational therapist provided services as ordered by the physician in the plan of care for 1 of 1 (MR# 1) record reviewed with physical therapy and occupational therapy services, resulting in the potential for poor patient outcomes for this…

The agency failed to ensure the home health aide provided care in accordance with the plan of care for 1 of 2 (MR#1) records reviewed in which aide services were provided, resulting in the potential for poor patient outcomes.

The agency failed to ensure the clinical manager provided oversight and coordination of patient care services and personnel regarding the provision of physical therapy, occupational therapy, and home health aide services for 1 of 1 (MR#1) record reviewed with these services, resulting in a lack of…

The agency failed to provide evidence of a Quality Assessment and Performance Improvement (QAPI) program that measured, tracked, and analyzed it's quality indicators in order to quantitatively assess outcomes concerning care and services furnished by the agency (See G 642); failed to provide data…

The agency failed to ensure effective infection prevention and control measures were utilized (G-682); failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that was incorporated into the…

The Agency failed to ensure the Physical Therapist (PT) followed accepted standards of practice in assuming responsibility for the care of 1 (MR #16) of 1 patient with therapy only services who required heart failure management (See G704); failed to ensure the Skilled Nurse performed baseline…

The Agency failed to provide documented evidence to support that 3 of 3 Home Health Aides employed by this Agency were trained, qualified and deemed competent to provide care and services to the Agency's patient population in accordance with this requirement, resulting in the potential for the…

The Agency failed to provide documented evidence of staff qualifications to practice as skilled professionals in the State of Michigan and be granted clinical privileges for 240 staff employed by this Agency, including contracted employees, resulting in the potential for non-regulated unsafe health…

The agency failed to include individual emergency preparedness plans for each patient as part of the comprehensive assessment, for all 17 records reviewed, resulting in the agency's inability to ensure patient safety during an emergency, which could result in the agency not providing quality health…

The agency's Emergency Preparedness (EP) plan, policies, and procedures, failed to address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs…

The agency failed to develop and maintain an Emergency Preparedness (EP) training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan.

The agency failed to ensure 4 (MR #6, 9, 11, 17) of 17 patients received care and services as written in the patient's individualized plan of care (POC), from a total of 17 records reviewed, resulting in the potential for unmet care needs and further physical decline.

The agency failed to provide evidence of a Quality Assessment and Performance Improvement (QAPI) program that measured, tracked, and analyzed its quality indicators to quantitatively assess outcomes concerning care and services furnished by the agency, resulting in the potential to negatively…

The agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement program (QAPI), which had the potential to negatively affect all 3,140 patients currently…

The agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the annual performance improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2020, 2021, and 2022 to date, resulting in the…

The Agency's Governing Body failed to implement an effective means to access collected data used to evaluate its Quality Assessment and Performance Improvement (QAPI) program, resulting in the potential to adversely affect the quality of care to all 3,140 patients currently receiving services.

The Agency failed to ensure the Skilled Nurse utilized Infection Control standards of practice during the provision of care and services for 1 (MR #2) patient observed during a home visit, who required wound care, from a total of 17 sampled records reviewed, resulting in the potential for the…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases.

The Agency (HHA) failed to provide documented evidence that infection control education was provided to all staff employed by the agency and who were granted clinical privileges, resulting in the potential for the development and spread of infection.

The Agency failed to provide documented evidence to support that all staff employed by this Agency and those who had been granted clinical privileges, had been vaccinated against the Covid-19 virus, resulting in the potential for the development and spread of Covid-19 to staff and all 3,140…

The Agency failed to ensure the needs of the patient were met in 1 (MR #16) of 1 record reviewed with heart failure and therapy only services ordered from a total sample of 17 records reviewed, resulting in the potential for physical harm to the patient.

The Agency failed to provide documented evidence to support that 3 of 3 Home Health Aides employed by this Agency were trained, qualified and deemed competent to provide care and services to the Agency's patient population in accordance with this requirement, resulting in the potential for the…

The agency failed to ensure the Registered Nurse (RN) prepared complete written instructions for patient safety needs in 5 (MR#'s 9, 13, 15, 4, 5) of 6 records in which aide services were provided, from a total of 17 records reviewed, resulting in the potential for unsafe, substandard care and…

The Agency failed to include contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed concerns for all patients serviced by this agency.

The Agency failed to ensure that 6 (MR's #1, 2, 3, 7, 13, 15) of 7 patients observed during home visits, from a total of 17 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided…

The Agency failed to inform the patient/caregiver before care was initiated of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient for 2 of 3 patients observed during…

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 1 of 17 records reviewed (MR #14), from a total sample of 17 records reviewed, resulting in a delay in determining the patient's immediate care and support needs.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status and events that lead to the need for home care, in 7 (MR's #1, 4, 5, 6, 7, 8, 9) of 7 records, from a total of 17 sampled records reviewed, resulting in incomplete clinical information…

The Agency (HHA) failed to ensure the start of care (SOC) comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required, failed to ensure a skilled nurse reviewed all medications, and failed to…

The Agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety measures and objectively measurable goals specific to the individualized needs of the patient in 9 (MR's #1, 2, 4, 5, 6, 11, 12, 13, 16) records, from a total of 17 sampled records…

The Agency failed to ensure the Physician was promptly notified of significant changes in the patient's condition for 1 (MR #4) of 1 patient with an elevated weight and elevated blood glucose level, and complaints of swelling and heaviness to her lower extremity, from a total sample of 17 records…

The Agency failed to provide 5 (MR#'s 1, 2, 3, 7, 15) of 7 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, from a total of 17 sampled records reviewed, resulting in lack of…

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

The Agency failed to ensure the Skilled Nurse performed baseline assessments and reassessments, including monitoring patient's weight and measurable assessments of edema for 2 (MR's #1, 4) patients who required ongoing monitoring, from a total of 17 sampled records reviewed, resulting in the…

The Agency failed to ensure the Physical Therapist (PT) evaluated and developed a plan of care within the Agency standard of 5 days for 1 (MR #13) of 16 records in which PT services were ordered, from a total sample of 17 records reviewed, resulting in the potential for decline in physical…

The Agency failed to ensure that Skilled Nursing (SN) services were administered in accordance with the physician's orders on the plan of care in 1 (MR #17) of 1 record which required catheter changes, resulting in the potential for unmet patient needs and poor outcomes.

The Agency failed to provide education/safety instructions in 1 (MR# 12) of 1 patient on oxygen with nicotine dependence and failed to ensure the patient and caregiver were provided education/instructions in 1 (MR #15) of 2 patients requiring wound care; resulting in the potential for unmet patient…

The Registered Nurse failed to supervise the services provided by the Licensed Practical Nurse (LPN) for 1 (MR#12) of 4 records reviewed with LPN services out of a total sample of 14 records reviewed with nursing services, resulting in failure of the LPN to provide services as ordered by the…

The Registered Nurse failed to accurately document findings obtained during a wound assessment for 1 (MR #2) patient observed during a home visit who required care of a surgical wound, from a total of 17 sampled patients reviewed, resulting in an inconsistent inaccurate clinical record designed to…

The Agency failed to ensure a transfer summary was completed and sent to the physician/receiving facility within 2 business days of the patient's transfer for 2 (MR #12, 4,) of 2 records in which the patient was transferred to an inpatient facility; and failed to ensure a discharge summary was…

The Agency failed to provide care and services in accordance with the plan of care in 5 (MR's # 1, 2, 3, 4, and 5) of 5 records reviewed for provision of services, resulting in the potential for decline in physical functioning and unmet care needs (See G572).

The Agency failed to provide care and services in accordance with the plan of care in 5 (MR's # 1, 2, 3, 4, and 5) of 5 records reviewed for provision of services, resulting in the potential for decline in physical functioning and unmet care needs.

The agency failed to ensure the plan of care included measurable outcomes and goals for 13 of 17 (MR# 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 17) records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress towards goals…

The agency failed to ensure the occupational therapist assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 1 of 1 (MR# 7) records reviewed in which additional services were requested, resulting in the potential for decline in physical…

The Agency (HHA) failed to document actual weights for Congestive Heart Failure patient in 1 record, from a total of 17 sampled records reviewed (MR's # 7), resulting in the physician not having a clear and concise clinical picture of the patient's health status and progression towards goals…

The registered nurse failed to supervise the services provided by the Licensed Practical Nurse (LPN) every 60 days for 1 of 1 records reviewed with LPN services that were longer than 60 days (MR# 7) out of a total of 17 records reviewed with nursing services, resulting in failure of the LPN to…