Sunshine Home Care of Michigan, Inc

The agency failed to develop and maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments (See E0006); failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and…

The Agency (HHA) failed to ensure the initial comprehensive assessment visit was made within 48 hours of the date of referral for 1 record (MR#3) reviewed (See G-514); failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based…

The agency failed to select the indicators that it will utilize in its QAPI program based upon identified adverse or negative patient outcomes or agency processes that the HHA wishes to monitor and measure (Refer to G- 642); failed to provide evidence of data collected to use to monitor the…

The agency failed to ensure the clinical record contained assessments, plans of care, and clinical notes for 2 of 3 (MR# 2, 3) records reviewed (refer to G1012), and failed to ensure that 25 clinical records were safeguarded against loss or unauthorized use (refer to G1028).

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.

The agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan.

The agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and communication plan.

The agency failed to ensure physical therapy and occupational therapy services were provided as ordered by the physician for 2 of 3 records (MR# 2, 3) reviewed, resulting in the potential for physical decline and unmet care needs for these patients.

The agency failed to select the indicators that it will utilize in its QAPI program based upon identified adverse or negative patient outcomes or agency processes that the HHA wishes to monitor and measure.

The agency failed to provide evidence of data collected to use to monitor the effectiveness of services and quality of care and to identify opportunities for improvement. **Agency Policy: Quality Assessment and Performance Improvement (QAPI) Plan and Program, Revised February 2021. The Policy…

660 Based on documents reviewed and interview, the Governing Body failed to approve a Performance Improvement Program for the year 2023. Findings included: **Agency Policy: "Quality Assessment and Performance Improvement (QAPI) Plan and Program." The Policy states, "The agency will establish an…

The agency failed to ensure that 1 of 1 staff (PTa-M) granted a vaccine exemption agreed to the agency's contingency plans, resulting in the potential to spread the COVID-19 virus to any of the agency's 4 patients in the past 12 months that received physical therapy assistant services.

The agency failed to ensure the Physical Therapist performed oversite and routine evaluations of the physical therapy assistant's performance and effectiveness of patient care during the provision of home visits provided by physical therapy assistants in 1 of 3 records reviewed (MR#1) in which…

The agency failed to maintain a valid Clinical Laboratory Improvement Amendment certificate of waiver, resulting in the potential for the agency to be performing unauthorized laboratory tests on all 4 patients admitted in the past 12 months.

The agency failed to ensure that clinical records were safeguarded against loss or unauthorized use, resulting in the potential compromise of protected health information for 25 patients.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 1 of 2 (MR# 3) records reviewed with skilled nursing starts of care, resulting in a delay in determining the immediate care and support needs for this patient.

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 1…

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 2 of 3 (MR# 2, 3) records reviewed.

The agency failed to ensure the comprehensive assessment at discharge included a summary of the patient's progress in meeting the care plan goals in 1 of 3 records (MR#1) reviewed resulting in the patient being discharged before the patient had met the goals on the Plan of Care.

The agency failed to ensure the plan of care was complete and included patient-specific interventions, measurable outcomes and goals, and the frequency and duration of visits for 3 of 3 (MR#1, 2, 3) records reviewed, resulting in patients not receiving care specific to their individual needs and…

The physical therapist failed to provide a written copy of the home exercise program prescribed by the physical therapist to aid the patient in performing the prescribed physical therapy exercises between scheduled physical therapy visits in 1 of 3 records reviewed (MR#1) in which Physical Therapy…

The Agency failed to initiate a Performance Improvement Program (PIP) within their QAPI program that focused on high risk, high volume, or problem prone areas, resulting in the potential for agency issues with negative consequences for high risk, high volume, or problem prone areas that could…

The agency failed to ensure skilled professionals performed assessments of the patient's health status and needs in 2 of 2 (MR# 2, 3) records reviewed with multiple disciplines, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes…

The physical therapist failed to ensure the patient had a copy of the prescribed exercises the patient was to perform daily in 1 of 3 records reviewed, resulting in the possibility of the patient not performing the therapeutic exercises on a daily basis to ensure an improvement of the patient's…

The agency failed to ensure skilled professionals prepared clinical notes for 2 of 3 (MR# 2, 3) records reviewed, resulting in a lack of information regarding the health status of these 2 patients.

The agency failed to ensure skilled professionals participated in agency-sponsored in-service training, resulting in a lack of training and educational opportunities for 12 skilled professionals employed by the agency or under arrangement.

The clinical manager failed to provide oversight of all patient care services to ensure the coordination of referrals for physical and occupational therapy services for 2 of 2 (MR# 2, 3) records reviewed in which therapy services were ordered, resulting in the potential for physical decline and…

The Agency failed to retain overall responsibility for all services provided, resulting in the potential for inappropriate care or unmet care needs for Agency patients.

The agency failed to have one service provided only by the agency and not contracted, resulting in all agency services provided with contracted staff.

The agency failed to ensure the clinical record contained assessments, plans of care, and clinical notes for 2 of 3 (MR# 2, 3) records reviewed, resulting in a lack of information for the physician and all agency staff caring for these 2 patients.