Primary Choice Home Care of Michigan, LLC

The agency failed to develop an Emergency Preparedness Program that met the Federal, State and local requirements of this section (See E0004); failed to complete an Emergency Preparedness Plan that was based on a facility and community based risk assessment (See E0006); failed to develop and…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program, (refer to G-642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, (refer to G-644); failed to initiate any…

The agency failed to ensure the Administrator performed required day-to-day operations (See G 948); failed to ensure the Clinical Manager consistently monitored and assessed patient needs to ensure services were provided as ordered (See G 966) and failed to ensure the plans of care were updated…

The agency failed to ensure the clinical record was complete and included all comprehensive assessments, clinical notes, plans of care and physician orders for 3 records (MR# 2, 3, and 4) from a total of 7 sampled records (G1012), and failed to ensure a discharge summary was sent to the physician…

The Agency failed to develop and maintain an emergency preparedness program that included the required elements, that must be reviewed, and updated at least annually, resulting in the potential to affect the Agency's ability to provide safe patient care in the event of an actual emergency.

The Agency failed to conduct a facility-based and community-based risk assessment resulting in the potential for failure to identify hazards associated with the facility and less than optimal outcomes during an emergency event.

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 22 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 ensure the Plan of Care included objectively measurable and individualized goals in 3 of 5 records reviewed (MR#s 2, 5, and 7) with skilled nursing ordered out of a total of 7 records reviewed, resulting in a potential for failure to measure progress toward achievement of…

The agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 76 patients that were admitted during the past 12 months, resulting in a potential for poor patient outcomes due to the provision of…

The agency failed to monitor data for the Quality Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the governing body approved the QAPI…

Based 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, resulting in the…

The agency failed to ensure that 2 of 2 Home Health Aide employed by the Agency, 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 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 in 2 of 7 records reviewed (MR#s 1 and…

The agency failed to inform and educate the patient of potential adverse outcomes from refusing services in 1 (MR# 6) of 1 record reviewed with multiple missed visits due to patient refusal from a total sample of 7 records, resulting in the potential for unmet care needs.

The agency failed to inform the patient and the physician that a discharge for cause from the agency was being considered in 1 (MR# 6) of 1 record reviewed for discharge with cause from a total sample of 7 records, resulting in the potential for unmet care needs.

The agency failed to ensure a registered nurse performed a review of the patient's medication list in which therapy only services were ordered in 2 of 2 records (MR #4, and 6) reviewed, from a total sample of 7 records, resulting in the potential for harmful medication effects for all 76 patients…

The agency failed to ensure the plan of care contained patient specific orders, individualized to the patient's identified needs, and covered all pertinent interventions with reportable parameters for 2 of 7 records reviewed (MR#'s 2,, and 6), resulting in patients not receiving care specific to…

The agency failed to ensure the revised Plan of Care reflected the current information from the updated comprehensive assessment in 1 of 1 recertified record reviewed (MR#s 2) out of a total of 7 records reviewed, resulting in the physician not having a clear and concise clinical picture of the…

The Home Health Agency (HHA) failed to develop a QAPI (Quality Assessment Performance Improvement) program that focused on high risk, high volume or problem-prone areas of the agency, to monitor the agency's improvement in these areas resulting in the agency's inability to improve in patient care…

The agency failed to ensure the Physical Therapist and the Occupational Therapist developed plans of care in a timely manner for 2 of 6 (MR# 1 and 3) records reviewed in which more than one discipline was ordered to provide care, resulting in a potential decline in physical functioning for these…

The registered nurse failed to supervise the services provided by the Licensed Practical Nurse (LPN) every 30 days for 1 of 1 record reviewed with LPN services (MR# 2) out of a total of 7 record review with nursing services, resulting in failure of the LPN to provide services as ordered by the…

The Administrator failed to be responsible for all day-to-day operations of the Home Health Agency, resulting in a lack of supervision of the clinical staff and daily operations.

The home health agency failed to ensure services were provided as ordered on the plan of care and the patients' needs were continually assessed for 1 of 7 records reviewed (MR #4), resulting in the potential of unmet care needs for all 76 patients serviced within the last 12 months.

The Clinical Director failed to ensure the plan of care was updated as needed for 1 of 7 (MR #6) records reviewed, resulting in a potential decline in physical functioning, and verification of the patient's well-being.

The agency failed to ensure the clinical record was complete and included clinical notes for 3 of 7 (MR#'s 2, 3, and 4) records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient's health status and progression towards goals.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 2 of 2 (MR# 1 and 6) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status…

The agency failed to provide COVID-19 virus education for 1 of 4 patients/caregivers (MR# 1) resulting in the potential spread of a contagious viral infection between agency staff and the agency's 11 current patients.

The Agency failed to ensure the emergency plan included strategies for addressing the emergency events identified by the risk and hazard assessment (See E-006); failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to…

The Home Health Agency (HHA) failed to provide a copy of the signed written consent form to patients in 1 of 3 records reviewed in which a joint survey home visit occurred (refer to G 0410); the HHA failed to inform the patient, in writing, of their right to have his or her property and person…

The Agency failed to ensure the initial comprehensive assessment visit was held within 48 hours of the date the referral was received (See G-514); the physical therapist failed to ensure the Start of Care Comprehensive Assessment was complete, with pertinent pain management information in records…

The agency failed to ensure the plan of care included measurable and individualized goals and outcomes as required in 4 of 6 records reviewed (MR#s 1, 2 3, and 7) and the therapists failed to consult with the physician to approve additions to the therapists' plan of care after completion of the…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program that measure, track and analyze it's quality indicators in order to assess the processes of care and services provided by the agency, resulting in the inability to improve patient…

The Home Health Agency (HHA) failed to maintain an active infection control program for 2016 and 2017, for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI)…

The agency (HHA) failed to ensure that 2 of 2 Home Health Aides (HHa #1 and HHa#2) whom were employed by the agency for at least 12 months, received the required 12 hours of annual in-service training out of a total sample of 7 records reviewed (see G-776); failed to maintain documentation that…

The agency failed to ensure the clinical record was complete, submitted timely and included all assessments and clinical notes in 2 of 7 records reviewed (MR#s 1 and 2) out of a total of 7 sampled records (See G-1012); failed to ensure that the staff's visit notes documented the patient's progress…

The Agency failed to ensure the emergency plan included strategies for addressing the emergency events identified by the risk and hazard 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 a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency situation; and failed to document the agency's efforts of contacting these officials to…

The agency failed to include in the agency emergency plan a mechanism in the policy and procedures for follow-up with staff and patients to inform state and local authorities of any on-duty staff or patients that the agency is unable to contact.

The agency failed to comprise information in the agency policy and procedures regarding the use of volunteers and the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The home health agency's emergency preparedness plan failed to include an alternate means of communication during an emergency.

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 failed to provide documentation of participation in a community-based and tabletop drill.

The agency failed to ensure the plan of care included measurable and individualized goals and outcomes as required in 3 of 6 records reviewed (MR#s 1, 2, 3 and 7), and the physician was consulted to approve additions to the therapist's plan of care after completion of the evaluation in 2 of 6…

The agency failed to ensure patient visits were provided as ordered on the Plan of Care for Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health aide services for 2 of 7 records reviewed (MR#s 1 and 3) out of a total of 7 sampled records reviewed.

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program that measure, track and analyze it's quality indicators in order to assess the processes of care and services, provided by the agency, resulting in the inability to improve patient…

The agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the…

The Home Health Agency (HHA) failed to develop a Performance Improvement Plan/activities, as part of the agency's Quality Assessment Performance Improvement (QAPI) program to track the adverse patient events, analyze the cause, and implement preventive actions/interventions, resulting in the…

The Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all of the regulatory requirements of this section.

The Home Health Agency (HHA) failed to maintain an active infection control program for 2016 and 2017, for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI)…

The Home Health Agency (HHA) failed to provide documented evidence that infection control education was provided to staff, at time of hire and annually, resulting in the potential for the development and spread of infection.

The agency (HHA) failed to ensure that 2 of 2 Home Health Aides (HHa #1 and HHa#2) whom were employed by the agency for at least 12 months, received the required 12 hours of annual in-service training, resulting in a lack of educational opportunities pertinent to patient care for HHa#s 1 and 2, and…

The home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans and…

The agency failed to provide a copy of the signed written consent form to patients in 1 of 3 records reviewed in which a joint survey home visit occurred.

The Home Health Agency (HHA) failed to inform the patient, in writing, of their right to have his or her property and person treated with respect in 7 of 7 records reviewed (M.R. #1, 2, 3, 4, 5, 6 and 7) of a total of 7 records reviewed and a total of 94 patients who received services from the HHA…

The Home Health Agency (HHA) failed to inform the patient, in writing, of their right to..."to be free from injuries of unknown source, and misappropriation of property" in 7 of 7 records reviewed (M.R. #1, 2, 3, 4, 5, 6 and 7) of a total of 7 records reviewed, and a total of 94 patients who…

The agency failed to inform the patient/caregiver before care was initiated, of the extent to which payment for the 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 in 7 of 7 (MR #s 1, 2, 3, 4, 5…

The Home Health Agency (HHA) failed to provide the names, addresses and telephone numbers of the Federally and State-funded entities, that serve in the area where the patients resides, resulting in patients not having community resource information readily available.

The Home Health Agency (HHA) failed to inform the patient, in writing, of their right to "access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services in 7 of 7 records reviewed (M.R. #1, 2, 3, 4, 5, 6 and 7) of a total of 7 records…

The Agency failed to ensure the initial comprehensive assessment visit was held within 48 hours of the date the referral was received for 2 of 7 records, from a total of 7 records reviewed (MR#s 2 and 7), resulting in the delay of needed services and the potential for decline in health status.

The physical therapist failed to ensure the Start of Care Comprehensive Assessment was complete, with pertinent pain management information in 1 of 1 records reviewed (M.R. #6) with physical therapy service completing the Start of Care Assessment, in a total of 7 records reviewed, for a potential…

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; and…

The agency failed to ensure the initial/comprehensive assessment documented objective baseline data to use for future assessments to demonstrate the patient's progress toward achievement of the goals and measurable outcomes that were identified by the agency during the initial comprehensive…

The registered nurse or the physical therapist failed to document on the comprehensive assessment the primary and other caregivers' willingness, ability, their availability and scheduled hours and days to provide care for the patients in 3 of 7 records reviewed (MR#s 1, 4, and 6), of a total of 7…

The Agency failed to ensure the Plan of Care included functional limitations in 2 of 7 records reviewed (MR#s 1 and 2) and Safety Precautions in 3 of 7 records reviewed (MR#s 1, 2, and 3) out of a total of 7 sampled records reviewed, resulting in the delay of needed services and the potential for…

The agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care (POC) for frequency and duration of visits, interventions, and goals after the initial evaluations by physical therapy (PT), occupational therapy (OT), and Home Health aide (HHa) services…

Therapy services failed to provide the patient with a copy of the home exercise program with instructions to meet the patient's need when performing the prescribed home exercises in the home in 1 of 3 records reviewed (MR#2) in which a joint survey home visit was conducted out of a total sample of…

The home health agency failed to complete the performance improvement activities for 2016 and 2017. Findings include: Agency Policy, "Performance Improvement Plan," reviewed 7/13 stated, "The Goals and Purposes: to assess and evaluate the quality and appropriateness of care; to verify that services…

The agency failed to ensure the skilled nurse performed complete assessments and re-assessments of the patient's health status including, actual weights and edema monitoring for congestive heart failure patients; and blood sugar monitoring for diabetics in 2 of 7 records reviewed in which nursing…

The Agency failed to ensure the Physical Therapist (PT) and Occupational Therapist (OT) assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 2 of 6 records in which PT and/or OT services were ordered (MR#s 1 and 2), from a total sample of 7…

The Agency failed to maintain documentation that demonstrated the Home Health aides received at least 12 hours of in-service training during each 12-month period for 2 of 2 Home Health aides (HHa) hired for at least 12 months (HHa#s 1 and 2) resulting in no evidence that Home Health aides received…

The Home Health Aide (HHa) failed to provide only those services that were ordered on the HHa Care Plan for 1 of 2 patients receiving HHa services, from a total of 7 records reviewed (MR #1), resulting in safety concerns for the patient receiving services that were not ordered.

The Registered Nurse (RN) failed to provide onsite supervision of the home health aide services as required for 2 of 2 records reviewed for patients with Home Health Aide services, from a total of 7 sampled records reviewed, (MR's #s 2 and 3) resulting in the potential for the provision of unsafe…

The Agency (HHA) failed to ensure the registered nurse made an annual onsite observation visit at the patient's residence to observe the care being provided, for 1 of 2 Home Health Aides (HHa #2) who was employed for greater than 12 months resulting in the potential for the provision of substandard…

The governing body failed to document the appointment of the administrator and there was no documentation the administrator reported agency's affairs to the governing body in 2016 and 2017. Findings include: Agency Policy, "Governing Body" revised 7/13 stated, "The Governing Body has authority and…

The agency failed to ensure the clinical record was complete, submitted timely and included all assessments and clinical notes in 2 of 7 records reviewed (MR#s 1 and 2) out of a total of 7 sampled records reviewed for skilled nursing, physical therapy, and occupational therapy, resulting in an…

The HHA (Home Health Agency) failed to ensure that the staff's visit notes documented the patient's progress towards achieving the measurable, patient specific identified goals and outcomes in 2 of 7 records reviewed (MR#s 2, and 3) out of a total of 7 records reviewed, for an inability of…

The Agency (HHA) failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician in 2 of 2 closed records, from a total of 7 records reviewed (MR#s 1 and 7), resulting in the potential…