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Legacy Home Healthcare

(269) 888-23331615 W Centre Ave, Suite 201, Portage, MI 49024
CMS Certification Number 239161 · Proprietary · Medicare-certified since 02/25/2011
16deficiencies since 2018
1serious
2inspections
2CMS 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 · 13 deficiencies · CMS source report (PDF)
Serious Skilled Professional Services

The Agency failed to ensure the Physical Therapist (PT) followed accepted standards of practice in assuming responsibility for the care of 1 (MR #7) of 1 record with supplemental oxygen use concurrent with an active smoking status and diabetic needs (See G704); failed to provide education/safety…

Source: CMS Form 2567, inspection 2022-10-20, tag G0700 · view on CMS
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Moderate Plan Based On All Hazards Risk Assessment

The Agency failed to develop and maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for Agency personnel in the event of an actual disaster.

Source: CMS Form 2567, inspection 2022-10-20, tag E0006 · view on CMS
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Moderate Ep Testing Requirements

The Agency failed to conduct exercises that are community-based to test its Emergency Preparedness (EP) program; and failed to provide documentation of any community-based drills, tabletop exercises and emergency events, resulting in the Agency's inability to ensure staff actions align with…

Source: CMS Form 2567, inspection 2022-10-20, tag E0039 · view on CMS
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Moderate Content Of The Comprehensive Assessment

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 7…

Source: CMS Form 2567, inspection 2022-10-20, tag G0526 · 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 (iv) a process for tracking and securely documenting the COVID-19 vaccination status of all staff, resulting in the potential for the development and spread of the COVID-19 virus to staff and all patients…

Source: CMS Form 2567, inspection 2022-10-20, tag G0687 · view on CMS
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Moderate Responsibilities Of Skilled Professionals

The Agency failed to ensure Physical Therapy (PT) and Skilled Nursing (SN) met the needs of the patient in 1 (MR #7) of 1 record reviewed with supplemental oxygen concurrent with an active smoking status and diabetic needs, from a total sample of 7 records reviewed, resulting in the potential for…

Source: CMS Form 2567, inspection 2022-10-20, tag G0704 · view on CMS
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Minor Participate In Care

The agency failed to ensure that 1 (MR's #1) of 7 records reviewed were included in their overall planning of care including informing the patient/caregiver in advance of which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of…

Source: CMS Form 2567, inspection 2022-10-20, tag G0434 · view on CMS
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Minor A Review Of All Current Medications

The Agency failed to ensure the start of care (SOC) comprehensive assessment included a comprehensive review of all medications to determine any adverse effects which included physician notification in 5 (MR's #1, 3, 5, 6, 7) of 7 total sample records reviewed; and failed ensure a Registered Nurse…

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 goals on the Plan of Care (POC) were measurable in 5 (MR#'s 1, 2, 3, 4, 7) of 7 records reviewed out of a total sample of 7 records; and failed to include pertinent safety measures/education to protect patient/others from injury in 1 (MR#7) of 1 record reviewed with…

Source: CMS Form 2567, inspection 2022-10-20, tag G0574 · view on CMS
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Minor Patient And Caregiver Education

The Agency failed to provide education/safety instructions in 1 (MR#7) of 1 patient on oxygen with nicotine dependence; resulting in the potential for unmet patient care needs and a poor clinical outcome.

Source: CMS Form 2567, inspection 2022-10-20, tag G0714 · view on CMS
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Minor Communication With Physicians

The Agency failed to ensure the physician was notified of the staff not providing services as ordered in the plan of care and reportable parameters in 2 (MR#s 2 and 3) of 7 records reviewed; and failed to notify the physician concerning low blood oxygen levels in 1 (MR#7) of 1 record reviewed with…

Source: CMS Form 2567, inspection 2022-10-20, tag G0718 · view on CMS
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Minor Required Items In Clinical Record

The agency failed to ensure clinical notes were accurate for 1 of 7 (MR# 3) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

Source: CMS Form 2567, inspection 2022-10-20, tag G1012 · view on CMS
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Minor Discharge And Transfer Summaries

The Agency failed to ensure a transfer summary was sent to the physician/receiving facility within 2 business days of the patient's transfer for 1 (MR #4) of 1 record in which the patient was transferred to an inpatient facility; and failed to maintain documentation concerning when discharge…

Source: CMS Form 2567, inspection 2022-10-20, tag G1022 · view on CMS
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Inspection 2019-10-24

· Recertification · 3 deficiencies · CMS source report (PDF)
Moderate Plan Of Care

The agency failed to provide physical therapy and occupational therapy services as ordered in the plan of care for 2 of 7 (MR#s 2, 6) records reviewed in which physical therapy services were ordered and 3 of 5 records reviewed (MR#s 2, 3, 6) in which occupational therapy services were provided out…

Source: CMS Form 2567, inspection 2019-10-24, tag G0572 · view on CMS
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Moderate Supervise Skilled Professional Assistants

The physical therapist failed to supervise the services provided by the physical therapy assistant at least every 30 days for 3 of 3 records reviewed (M.R.# 3, 4, and 6) with therapy services provided at least 30 days, out of a total of 7 records reviewed, resulting in the potential for unmet…

Source: CMS Form 2567, inspection 2019-10-24, tag G0724 · view on CMS
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Minor Discharge And Transfer Summaries

The agency failed to ensure that discharge and transfer summaries were sent to the physician for 1 of 1 discharge (MR# 3) and 1 of 2 transferred (MR# 5) records reviewed out of a total sample of 7 records, resulting in the physician not having knowledge of the patient's health status or a summary…

Source: CMS Form 2567, inspection 2019-10-24, tag G1022 · view on CMS
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