Caring Nurses of Michigan, Inc

The Agency failed to provide documented evidence to ensure the Emergency Preparedness plan had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The home health agency failed to include any performance improvement activities that tracked adverse patient events, analyze potential causes, and formulate preventive actions (See G 654); failed to document the quality improvement projects from April 2022 through March 2025, and document the…

The Agency failed to provide documented evidence to ensure the Emergency Preparedness plan had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure an Emergency Preparedness plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, that had been reviewed and updated at least every 2 years, resulting in the potential for lack of preparedness and poor…

The agency failed to develop and establish written Emergency Preparedness policies and procedures that were based on the Emergency Preparedness plan, risk assessment and communication plan that had been updated at least every 2 years, resulting in the agency’s inability to implement appropriate…

The facility failed to develop and maintain an Emergency Preparedness communication plan that complied with Federal, State and local laws, that had been updated and reviewed at least every 2 years, resulting in the potential for staff to not be able to communicate effectively in the event of an…

The facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently…

The Agency failed to develop an Emergency Preparedness testing and training program based on the Emergency Preparedness plan, that had been reviewed and updated at least every 2 years, resulting in the potential for staff not being properly trained or prepared in the event of an actual emergency or…

The Agency failed to provide initial and ongoing training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees and volunteers as appropriate, and failed to maintain documentation of training's, resulting in the potential for inappropriate…

The agency failed to ensure its skilled disciplines provided care and services in accordance with the Physician ordered visit frequency for 3 (P-2, P-4, P-7) patients, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical…

The Agency failed to develop a Performance Improvement Project (PIP)/activities, as part of the Agency's Quality Assessment Performance Improvement (QAPI) program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions having the potential to…

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the annual quality improvement projects, the reasons for conducting these projects, and the measurable progress achieved on these projects since April 2022, resulting in the Agency's inability…

Based record review and interview, it was determined the Governing Body (GB) failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that incorporated performance improvement activities that addressed priorities for improved quality of…

The Agency failed to include any aspects of analyzing/evaluating collected infection control data, and the formulation of improvement actions aimed at mitigating potential breakdown in infection control, resulting in the potential spread of infections between patient care staff and the Agency's 11…

The Agency failed to ensure that SN (skilled nursing) appropriately notified the physician of all relevant aspects concerning a SCIC (significant change in condition) in 1 (P-6) of 1 home visits made with SN, out of a total sample of 7 records reviewed, resulting in the physician having an…

The Agency failed to ensure that the individuals who furnished Home Health Aide services on its behalf, met the competency evaluation requirements of this section by ensuring the subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section were evaluated by a…

The agency failed to ensure that 1 (HHa #1) of 2 Home Health Aides employed by this agency, who's personnel file was reviewed, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency failed to ensure the skilled discipline made an annual onsite observation visit at the patient's residence to observe the care being provided, by 1 (HHa #1) of 2 Home Health Aides employed by this agency, who's personnel file was reviewed, resulting in the potential for the provision of…

The Agency failed to have an active Governing Body (GB) that met at least annually, assumed the responsibility for the Agency's overall management and operations, all services provided, the fiscal operations, and review of the Agency's budget and operations plans, resulting in the potential to…

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the Agency terminating on-going care for 2 (P-1, P-7) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end covered…

The Agency failed to ensure the Registered Nurse performed the initial start of care comprehensive assessment within 48 hours of the date of the referral to ascertain immediate care needs and establish homebound status for 1 (P-2) record in which both Nursing and Physical Therapy services were…

The Agency failed to ensure Activity of Daily Living needs were adequately met in the patient's home for 3 (P-1, P-2, P-3) of 3 patients assessed as needing assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, psychological decline unmet…

The Agency failed to ensure its procedure to perform a comprehensive review was sufficient within accepted standards of professional practice in determining any potential adverse medication effects such as: side effects, drug interactions, and duplicate drug therapy in 1 (P-7) of 7 records reviewed…

The Agency failed to ensure SN (skilled nursing) documented on the comprehensive assessment the primary caregivers' willingness, ability, their availability and scheduled hours and days to provide care for patients in 2 (P-6, P-7) of 7 total records reviewed, resulting in a potential for poor…

The Agency failed to ensure the comprehensive assessment was updated and revised within 48 hours of the patient's return home post discharge from a hospital for 1 (P-7) of 1 record reviewed in which care had been resumed following hospitalization, resulting in unaddressed clinical needs the delay…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 6 (P-1, P-2, P-3, P-5, P-6, P-7) records from a total of 7 sampled records reviewed, resulting in…

The Agency failed to ensure its skilled disciplines provided care and services only as ordered by the Physician for 2 (P-2, P-6) patients, from a total of 7 sampled records reviewed, resulting in the potential for the provision of substandard care, unnecessary treatment and unmet care needs.

The agency failed to ensure the Physician's verbal orders were appropriately authenticated, signed and dated by the nurse receiving the order and the ordering Physician in 1 (P-1) record of a patient discharged from the agency's services, from a total of 7 sampled records reviewed, resulting in the…

The Agency failed to ensure the clinical record was completed and included detailed Physical Therapy and Skilled Nursing notes for 1 (P-3) record with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and…

The Administrator failed to ensure a Clinical Manager was available during all operating hours, resulting in the potential for lack of clinical and supervisory oversight of patient care services and unmet care needs for all 11 patients currently serviced by this agency.

The Agency failed to ensure the clinical record was complete and appropriate, including physician orders, assessments, and evaluations for 2 (P-5, P-6) of 7 total records reviewed, resulting in no authentication of patient care orders, an incomplete evaluation of the patient's health status, and…

The Agency failed to ensure the Plan of Care (POC) included goals in 2 (P-5, P-6) of 7 total records reviewed, resulting in no plan to measure progress made (or lack of) concerning ordered interventions/treatments for improved quality patient measures.

The Agency failed to ensure a discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 3 (P-1, P-4, P-6) records where the patient was discharged from an agency service…

The Agency failed to ensure the Plans of Care included all the required elements of this requirement, including services ordered, frequencies, reportable parameters and measurable goals for 7 (MR's #1, 2, 3, 4, 5, 6, 7) of 7 records, from a total of 7 sampled records reviewed, resulting in the…

The Agency failed to monitor and assess the patient's cardiac status, including weights and edema for 1(MR #5) of 3 patients with a diagnosis of Hypertensive Heart Disease and Congestive Heart Failure, from a total of 7 sampled patients reviewed, resulting in the potential for unidentified…

The Agency failed to ensure the Clinical Manager coordinated patient care in 1 (MR #1) of 1 scheduled home visit where State Surveyors was scheduled to observe, and 1 (MR #7) of 1 record with interruption in Physical Therapy services, from a total of 7 sampled records reviewed, resulting in lack of…

The Agency failed to ensure the clinical record was complete and included a Comprehensive Discharge assessment and Discharge Summary that accurately captured the status of the patient at the time of discharge for 6 (MR #s 1, 2, 3, 5, 6 and 7) of 6 records, from a total of 7 sampled records…

The Agency failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the following required subject areas (1) Names and contact information for the following: (i) Staff, (ii) Entities providing services under…

The Agency failed to provide initial and ongoing training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of trainings, resulting in staff being ill-prepared in the…

The Agency failed to ensure that all staff, including contracted staff who were granted clinical privileges, received education and training in Infection Control, resulting in the potential for the development and spread of infection.

The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 3 (MR's #2, 6, 7) of 3 records reviewed where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and…

The Agency failed to ensure the Initial Comprehensive Assessment included a thorough review of all the patient's medications in order to ascertain any untoward drug interactions and duplicate drug therapies and failed to ensure the Physician was notified in accordance with the Agencies policy in 4…

The Agency failed to ensure the Comprehensive Assessment was updated and completed at the time of discharge from the agency's services in 2 (MR's #1, 3) of 3 discharged records, from a total of 7 sampled records reviewed, resulting in no indication of the patient's progression towards their…

The Agency failed to ensure the Plans of Care included all the required elements of this requirement, including services ordered, frequencies, reportable parameters and measurable goals for 7 (MR's #1, 2, 3, 4, 5, 6, 7) of 7 records, from a total of 7 sampled records reviewed, resulting in the…

The Agency failed to ensure the Physician was promptly notified of 1 (MR #4) of 1 patient with elevated pain levels; and failed to ensure the Physician was notified of 1(MR #5) of 1 patient who was transferred to a hospital, and 1 (MR #6) of 1 patient who was transferred and required…

The Agency failed to monitor and assess the patient's cardiac status, including weights and edema for 1(MR #5) of 3 patients with a diagnosis of Hypertensive Heart Disease and Congestive Heart Failure, from a total of 7 sampled patients reviewed, resulting in the potential for unidentified…

The Agency failed to ensure the Occupational Therapist and the Physical Therapist assisted the Physician in evaluating the patient's level of functioning, and helped to develop the Plan of Care for 2 (MR's #4, 6) of 2 records reviewed in which Occupational/Physical Therapy services were ordered…

The Agency failed to ensure Physical Therapy, Medical Social Work and Occupational Therapy services were provided in accordance with the Physician's orders for 5 (MR's #3, 4, 5, 6, 7) records reviewed with the various services (Occupational Therapy, Medical Social Work and Physical Therapy)…

The Agency failed to ensure the clinical record was completed and included detailed Physical Therapy notes for 2 (MR #2, 5) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient…

The Agency failed to ensure the Clinical Manager coordinated patient care in 1 (MR #1) of 1 scheduled home visit where State Surveyors was scheduled to observe, and 1 (MR #7) of 1 record with interruption in Physical Therapy services, from a total of 7 sampled records reviewed, resulting in lack of…

The Clinical Manager failed to ensure all assigned disciplines followed the plan of care as ordered by the Physician for 5 (MR's #3, 4, 5, 6, 7) of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for decline in Physical functioning, Psychological decline…

The Agency failed to ensure the clinical record was complete and included a Comprehensive Discharge assessment and Discharge Summary that accurately captured the status of the patient at the time of discharge for 6 (MR #s 1, 2, 3, 5, 6 and 7) of 6 records, from a total of 7 sampled records…

The Agency failed to ensure the transfer/discharge summaries were completed, detailed, and provided the patient's current health status at the time of transfer/discharge, included information on progress toward goals, and forwarded to the receiving facility within 2 days, and forwarded to the…

The Agency failed to ensure the emergency plan included strategies for addressing the emergency events identified by the risk assessment, resulting in the potential to affect the Agency's ability to provide patient care in the event of an actual emergency.

The Agency failed to include in its emergency plan the procedures needed to follow-up with staff and patients to determine services that are needed in the event services are interrupted due to an emergency and to inform state and local authorities of any on-duty staff or patients that the Agency is…

The Agency (HHA failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the following required subject areas (1) Names and contact information for the following: (i) Staff, (ii) Entities providing services under…

The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, local emergency preparedness staff and other sources of assistance, resulting in the lack of essential information in the event of an…

The facility failed to develop and maintain an emergency preparedness communication plan that included a primary and alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency preparedness officials, resulting in the lack of essential information in the…

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section.

The Agency (HHA) failed to provide documentation for the required annual tabletop and community based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan, resulting in the potential to affect all patients and staff, in the event staff is…

The agency (HHA) failed to ensure the Registered Nurse (RN) prepared clear written patient safety precautions, in 2 of 2 Home Health Aide (HHa) records in which aide services were provided, from a total of 7 records reviewed, (MR's #5 and 6) resulting in the inability of the agency to ensure…

The skilled nurse failed to follow agency policy as required regarding supervision of Home Health aide (HHa) services in 2 of 2 records in which home health aide services were provided (MR# 5, and 6) out of a total of 7 records reviewed.

The agency failed to inform the patient in advance of the disciplines that will furnish care in 1 of 7 records reviewed (MR#5) from a total sample of 7 records reviewed, resulting in the patient not having knowledge of the plan for treatment.

The agency failed to ensure the plan of care (POC) contained interventions and goals for one (MR#1) of two sampled patient records reviewed for occupational therapy (OT) services, resulting in the potential of unmet goals, outcomes, and therapeutic needs identified at the start of care.

The agency failed to ensure the clinical record contained interventions to monitor patient's function and response to therapy interventions for one (MR#3) of six sampled patients reviewed for therapy services, resulting in the potential for unidentified, unaddressed health concerns and unmet care…

The Agency failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, and progress toward goals in three (#s 4, 5, and 6) of three sampled patients reviewed for discharged records, resulting in the potential for unidentified…