Michigan Home Health Services

The agency failed to ensure 2 of 10 (P-1, 6) patients received care and services as ordered, from a total of 10 sampled records reviewed, resulting in the potential for unmet care needs and further physical decline.

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any duplicate therapy or adverse effects and failed to ensure the physician was notified of potential drug interactions or duplicate therapy in 1 of 10 (P-6) records reviewed, resulting in the…

The agency failed to ensure the plan of care was updated to reflect changes in the patient's medications for 1 of 10 (P-8) records reviewed, resulting in the potential for harmful medication effects for this patient.

The agency failed to ensure the discharge summaries were sent to the physician within 5 business days of discharge in 3 (P-1, 6, 7) of 3 records in which the patient was discharged from the agency's services, from a total of 10 sampled records reviewed, resulting in the potential for unidentified…

The Agency failed to develop an emergency preparedness plan that must be reviewed, updated, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure that 2 (MR's #1 and 2) 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 resulting…

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 3 (MR# 2, 3, 4) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients…

The Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all 25 patients currently…

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 the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 2 (MR#s 4 and 6), of 2 records in which the patient was…

The Agency failed to ensure that its 73 regularly utilized contracted personnel had documentation of licensure and other qualifications, prior to being granted clinical privileges resulting in the potential for the rendering of substandard care and services to all 25 patients currently serviced by…

The Agency failed to develop an emergency preparedness plan that must be reviewed, updated and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor patient and staff…

The Agency failed to develop an Emergency Preparedness policy/Plan, that included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs during the COVID-19 crisis, resulting in the potential for the interruption in needed care and services for…

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 the 25 patients currently…

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…

The Agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency.

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all 25 patients currently…

The Agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2019 and 2020 calendar years, resulting in the Agency's…

Based record review and interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness…

The Agency failed to ensure the skilled nurse followed accepted Infection Control standards of practice during wound care for 1 (MR #1) of 1 patient observed during a home visit, who required wound care treatment, from a total sample of 7 sampled records reviewed, resulting in the potential for the…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control of infectious and communicable diseases including Covid-19, and failed to develop a method of screening all field staff employed by this agency, and those granted clinical…

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 1 Home Health Aide files 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 that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs.

The agency failed to ensure that its clinical records were properly stored, secured and safeguarded against loss or unauthorized use, including 1 (MR #1) of 1 record that was discarded, from a total of 7 sample records reviewed, resulting in the potential for compromise of protected health…

The Agency failed to ensure that 2 (MR's #1 and 2) 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 resulting…

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 (MR# 4, and 5) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end covered…

It was noted that the Agency failed to advise their patients of the names, addresses and telephone numbers of federally funded and state-funded entities that serve the area where the patient resides, resulting in the potential for unmet patient care needs for all 25 patients currently serviced by…

The Agency failed to ensure that all drugs, care, and services were provided consistently in accordance with Physician's orders for 1 (MR #1) of 1 patient who required wound care, from a total of 7 records reviewed, resulting in the potential for physical decline, worsening of wounds and unmet care…

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 3 (MR# 2, 3, 4) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients…

The Agency failed to ensure the patient's Medical Social Work needs were adequately met in the patient's home for 1 (MR #4) of 1 who required assistance with meals; and failed to ensure the Activity of Daily Living needs were met in 1 (MR# 5) of 1 records in which the patient required assistance…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review, and failed to ensure the Physician was notified of potential drug interactions in 5 (MR#'s 3, 4, 5, 6 and 7) of…

The Agency failed to ensure that all drugs, care, and services were provided only in accordance with Physician's orders for 1 (MR #1) of 1 record with change of Physician coverage, from a total of 7 records reviewed, resulting in the potential for the provision of unsafe, unauthorized care and…

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 Home Health Aide provided care and services as ordered in the plan of care for 1 (MR #3) of 1 patient observed during an Aide home visit, from a total of 7 sampled records reviewed, resulting in the potential for the rendering of unsafe care and unmet 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) 1 Home Health Aide employed by this agency, who's file reviewed, resulting in the potential for the provision of substandard care…

The Agency failed to ensure the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 2 (MR#s 4 and 6), of 2 records in which the patient was…