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McLaren Home Health

(800) 862-31326465 Millennium, Suite 140, Lansing, MI 48917
CMS Certification Number 237008 · Non-Profit · Medicare-certified since 07/01/1966
22deficiencies since 2018
1serious
1inspections
4CMS 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 2019-02-08

· Recertification · 22 deficiencies · CMS source report (PDF)
Serious Establishment Of The Emergency Program (Ep)

The Agency (HHA) failed to develop and establish written emergency preparedness policies and procedures that were reviewed/revised/updated at least annually (E0013); failed to implement in the Emergency Preparedness policy the use of volunteers and other emergency staffing strategies, including the…

Source: CMS Form 2567, inspection 2019-02-08, tag E0001 · view on CMS
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Moderate Development Of Ep Policies And Procedures

The Agency (HHA) failed to develop and establish written emergency preparedness policies and procedures that were reviewed/revised/updated at least annually, resulting in the Agency's inability to implement an effective response specific to the emergency or disaster, which could potentially affect…

Source: CMS Form 2567, inspection 2019-02-08, tag E0013 · view on CMS
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Moderate Policies/Procedures-Volunteers And Staffing

The Agency (HHA) failed to implement in the Emergency Preparedness policy, the use of volunteers and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency; and failed…

Source: CMS Form 2567, inspection 2019-02-08, tag E0024 · view on CMS
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Moderate Names And Contact Information

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…

Source: CMS Form 2567, inspection 2019-02-08, tag E0030 · view on CMS
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Moderate Ep Training And Testing

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.

Source: CMS Form 2567, inspection 2019-02-08, tag E0036 · view on CMS
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Moderate Ep Training Program

The Agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to…

Source: CMS Form 2567, inspection 2019-02-08, tag E0037 · view on CMS
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Moderate Ep Testing Requirements

The Agency (HHA) failed to provide documentation for the required community based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan since its initiation in 2009, resulting in the potential to affect all patients and staff, in the event…

Source: CMS Form 2567, inspection 2019-02-08, 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 past medical history and current health needs in 3 of 17 patient records reviewed (MR# 1, 4 and 11), out of a total of 17 records, resulting in the potential for unmet care needs.

Source: CMS Form 2567, inspection 2019-02-08, tag G0526 · view on CMS
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Moderate Plan Of Care

The agency failed to ensure the patient received services as ordered in the plan of care for 2 of 8 records reviewed with home health aide (HHa) services (MR# 3 and #8), from a total sample of 17 records reviewed, resulting in the potential for unmet care needs.

Source: CMS Form 2567, inspection 2019-02-08, tag G0572 · view on CMS
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Moderate Home Health Aide Assignments And Duties

The Agency (HHA) failed to ensure the skilled disciplines (Registered Nurse (RN)/Physical Therapist (PT) prepared clear written patient care instructions for the home health aide (HHa) regarding client needs, prior to providing care in 3 (MR's #12, 15, 17, ) of 8 records in which Home Health Aide…

Source: CMS Form 2567, inspection 2019-02-08, tag G0798 · view on CMS
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Minor Participate In Care

The Agency (HHA) failed to inform the patient, in advance of the disciplines that will furnish care, and the proposed visit frequency in 5 records (MR's #4, 5, 12, 16, 17) from total of 17 sampled records reviewed resulting in the patients not having knowledge or a say in the plan for treatment.

Source: CMS Form 2567, inspection 2019-02-08, tag G0434 · view on CMS
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Minor Rn Performs Assessment

The Agency (HHA) failed to ensure the Registered Nurse (RN) conducted the initial assessment visit within 48 hours of referral to determine the immediate care and support needs of the patent including homebound status and eligibility for the Medicare home health benefit for 2 record (MR# 3 and 9)…

Source: CMS Form 2567, inspection 2019-02-08, tag G0514 · view on CMS
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Minor Patient'S Needs

The Agency (HHA) failed to ensure the patient's Nutritional needs were adequately met in the patient's home for 1 of 1 patient (MR #16) who required feeding through a feeding tube P.E.G.

Source: CMS Form 2567, inspection 2019-02-08, tag G0534 · view on CMS
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Minor A Review Of All Current Medications

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy; failed to document the findings of the drug regime review and; failed to ensure the physician was notified of the findings in 2 records…

Source: CMS Form 2567, inspection 2019-02-08, tag G0536 · view on CMS
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Minor Plan Of Care Must Include The Following

The agency failed to include all safety precautions in 2 of 17 records reviewed (MR# 4, 16), in a total of 17 records, resulting in the potential for unmet care needs identified on the plan of care.

Source: CMS Form 2567, inspection 2019-02-08, tag G0574 · view on CMS
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Minor Promptly Alert Relevant Physician Of Changes

The agency failed to ensure they altered the plan of care due to the patient's significant health decline in 1 of 17 records reviewed (MR# 3), from a total sample of 17 records reviewed, resulting in the potential for unmet care needs and the potential for failure to achieve the goals and…

Source: CMS Form 2567, inspection 2019-02-08, tag G0590 · view on CMS
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Minor Revisions Communicated To Patient And Mds

The agency failed to ensure the patient received services as required in a time of health status decline for 1 of 17 records reviewed (MR# 3), from a total sample of 17 records reviewed, resulting in the potential for unmet care needs and the potential for failure to achieve the goals and…

Source: CMS Form 2567, inspection 2019-02-08, tag G0596 · view on CMS
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Minor Integrate All Services

The agency failed to ensure coordination of care occurred to ensure patient needs were identified and communicated to the appropriate professional and the physician in 2 of 17 records reviewed (MR #3 and 11) out of a total sample of 17 records reviewed , resulting in potential for decline in the…

Source: CMS Form 2567, inspection 2019-02-08, tag G0606 · view on CMS
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Minor Provide Services In The Plan Of Care

The agency failed to ensure that Skilled Nursing services were administered in accordance with the physician's plan of care (POC) in 2 of 17 records reviewed (MR# 6 and 11), from a total sample of 17 records reviewed, resulting in the patient being hospitalized.

Source: CMS Form 2567, inspection 2019-02-08, tag G0710 · view on CMS
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Minor Services Provided By Hh Aide

The Agency (HHA) failed to ensure the Home Health Aide (HHa #1) provided services as ordered in the plan of care for 1 (MR #12) of 8 patients in which HHa services were ordered, from a total of 17 sampled records reviewed, resulting in the patient not receiving services as ordered.

Source: CMS Form 2567, inspection 2019-02-08, tag G0800 · view on CMS
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Minor Onsite Supervisory Visit Every 14 Days

The Agency (HHA) failed to ensure on-site supervisory visits to the patient's home were made in order to supervise the care provided by the Home Health Aide for 1 of 8 records with Home Health Aide (HHa) services ordered, from a total of 17 sampled records reviewed (MR #12) resulting in the…

Source: CMS Form 2567, inspection 2019-02-08, tag G0808 · view on CMS
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Minor Discharge And Transfer Summaries

The Agency (HHA) failed to ensure the discharge summary was complete, detailed the course of care provided with responses, and provided the patient's current health status at the time of discharge and progress toward goals in 3 (MR's #5, 11, and 15) of 5 closed/discharged records, from a total of…

Source: CMS Form 2567, inspection 2019-02-08, tag G1022 · view on CMS
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