Caretenders

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that had been reviewed, updated and included strategies to address the identified risks included in the Hazardous Vulnerability Assessment, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients actively serviced by this Agency in the event of a facility emergency or disaster. Findings include: On 12/18/24 at 1:30 p.m., the Administrator was asked for permission to review the agency’s Emergency Preparedness documents. Upon receipt and review, it was noted that the plan was dated 11/27/24. Although the plan was dated for the 2024 calendar year, it had not been updated to include strategies that addressed the identified risks in the agency’s Hazardous Vulnerability Assessment. These findings were reviewed with and acknowledged by the Administrator at the time of discovery.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and establish written Emergency Preparedness policies and procedures that addressed this agency’s location and was based on the Emergency Preparedness plan and the risks identified in the agency’s Hazardous Vulnerability Assessment, resulting in the agency’s inability to implement appropriate emergency actions and the potential for poor outcomes for all staff and patients services by this agency in the event of a disaster. Findings include: On 12/18/24 at 1:30 p.m., the Administrator was asked for permission to review the agency’s Emergency Preparedness documents. Upon receipt and review of the Emergency Preparedness policy titled “Emergency Preparedness/Operations Plan”, it was noted that the policy addressed other states such as Mississippi, Colorado and New York. There was no reference made to this agency or it’s residing state. These findings were reviewed with and acknowledged by the Administrator at the time of discovery and again on 12/19/24.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 8 (P-1, P-2, P-3, P-4, P-9, P-11, P-12, P-13) patients were included in the overall planning of their care including informing the patient/caregiver in advance of the disciplines that would be providing care and the days/frequency in which services would be provided, from a total of 13 sampled records reviewed, resulting in lack of inclusion in planning their care, the potential for missed visits and unmet care needs. Findings include: P-9: The patient’s start of care (SOC) was 12/11/24 with diagnoses that included Sarcopenia and Thrombocytosis. On 12/17/24 at 11:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT). Upon arrival to the Assisted Living Facility, where the patient resided, a person who was identified as the patient’s Durable Power of Attorney (DPOA) stated to the Therapist, “I never know who’s coming. There was another person here before and I’m not sure who that was, but they were walking in the halls.” The Therapist responded, “I’m not sure who that was. I’ll have to check.” Once inside the patient’s unit, the Admission Packet was reviewed. The calendar that was to include visits to be made by the ordered disciplines (Physical Therapy and Occupational Therapy) was noted be blank. Additionally, the “Patient Consent” form signed by the Therapist and the patient’s DPOA, was void of any mention of the ordered disciplines or the frequencies in which services would be provided. These findings were reviewed with and acknowledged by the Administrator during an interview on 12/18/24 4:02 p.m. P-11: The patient’s SOC was 4/17/24 with diagnoses that included Venous Hypertension with Ulcer and COPD. The Plan of Care (POC) ordered Skilled Nursing (SN) services to be provided at a frequency of 2x/wk. x 9 wks. and 2 prn (as needed) visits for wound complications. During the clinical record review on 12/18/24 at 9:40 a.m. it was noted that the Patient Consent form was void of the of the ordered discipline and the frequency in which services would be provided. This finding was reviewed with and acknowledged by the Administrator during an interview on 12/18/24 at 4:28 p.m. P-12: The patient’s SOC was 12/6/24 with diagnoses that included Left Total Knee Amputation. The POC ordered PT, Occupational Therapy (OT) and Speech Therapy (ST) services to be provided. During the clinical record review on 12/18/24 at 11:20 a.m., it was noted that the Patient Consent form was void of the ordered disciplines and the frequency in which services would be provided. These findings were reviewed with and acknowledged by the Administrator during an interview on 12/19/24 who reported, “We have an electronic consent form also, but there are no disciplines or frequencies on there.” P-13: The patient’s SOC was 11/20/24 with a diagnosis of Osteoarthritis Bilateral Hips. The POC ordered SN, OT and PT services to be provided. During the clinical record review on 12/18/24 at 2:30 p.m., it was noted that the Patient Consent form was void of the ordered disciplines and the frequency in which services were to be provided. These findings were reviewed with and confirmed by the Administrator during an interview on 12/18/24 at 4:40 p.m. P-1: The patient’s start of care (SOC) was 9/27/24 with diagnoses of sarcopenia and end stage renal disease (ESRD). During a home visit on 12/16/24, the patient’s home care folder was reviewed. The “Patient Consent” form in the patient’s home care folder, was signed by the patient and failed to include the ordered disciplines or the frequency services would be provided. P-2: The patient’s start of care (SOC) was 12/9/24 with diagnoses of venous insufficiency, skin changes, and arthritis. During a home visit on 12/17/24, the patient’s home care folder was reviewed. The “Patient Consent” form in the patient’s home care folder, was signed by the patient and failed to include the ordered disciplines or the frequency services would be provided. P-3: The patient’s start of care (SOC) was 11/22/24 with diagnoses of urinary catheter placement, urine retention, and a-fib. During review of the patient’s record on 12/18/24, it was discovered that the consent to treat form signed by the patient failed to include the ordered disciplines or the frequency services would be provided. P-4: The patient’s start of care (SOC) was 11/9/24 with diagnoses of femur fracture, hypertension, and diabetes. During review of the patient’s record on 12/18/24, it was discovered that the consent to treat form signed by the patient failed to include the ordered disciplines or the frequency services would be provided. These findings were reviewed with and acknowledged by the Administrator (Adm-A) during an interview on 12/19/24 at 1:30 p.m.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on record review and interview, the agency failed to accurately advise patients of the names, addresses and telephone numbers of Federally funded and State funded entities that serve the areas where the patients reside, resulting in a lack of information regarding available resources which has the potential to negatively affect the quality of care for the agency’s 155 current patients. Findings include: On 12/16/24, the agency’s admission documentation titled, “Caretenders Michigan Patient Orientation for Home Health Care” was reviewed. Page 11 of the documents informs the patient of the names, addresses, and telephone numbers of Federally funded and state-funded entities that serve the state of Michigan in the following cities: Traverse City, Marquette, Lansing, and Escanaba. The cities of Marquette and Escanaba are in Michigan’s upper peninsula. Traverse City is in northern Michigan and Lansing is in central Michigan. Caretenders is in Farmington Hills, which is northwest of Detroit. The document directs the patient to contact the Agency on Aging in Traverse City or Escanaba MI; the Center for Independent Living in Traverse City or Marquette, MI; Protection and Advocacy Agency in Lansing or Marquette, MI; Aging and Disability Resource Centers in Traverse City or Escanaba, MI; and Quality Improvement Organization in Annapolis Junction, MD. The agency’s patients were not given accurate information regarding the names, addresses, and telephone numbers of Federally funded and State funded entities that serve the areas where the patients reside in the Farmington Hills area in Michigan. The findings were reviewed with and acknowledged by the administrator (Adm-A) during an interview on 12/16/24 at 11:00 a.m. Adm-A acknowledged the findings at the time of discovery.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure the patient’s medical and nursing needs were adequately met in the patient’s home for 1 (P-9) patient observed during a home visit, who complained of left shoulder pain, from a total of 13 sampled records reviewed, psychological decline, unrelieved pain and unmet care needs. Findings include: P-9: The patient’s start of care was 12/11/24 with diagnoses that included Sarcopenia and Thrombocytosis. On 12/17/24 at 11:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist. Prior to performing therapeutic exercises, the patient was queried about pain and reported having pain to her left shoulder. Ther therapist did not obtain a quantitative pain level. When instructed to stand and grab hold to her wheelchair, the patient grimaced and complained of pain to her upper left extremity. The patient was also observed using her right hand to guide her left hand in reaching for the wheelchair. The Physical Therapist proceeded with the therapy session and assisted the patient with walking in the hallway. During the provision of additional exercises, the patient proceeded to complain of pain to her left upper extremity. No additional action was taken by the Therapist. On 12/17/24 at 1:00 p.m., during the clinical record review, it was noted that the Initial Comprehensive Assessment dated 12/11/24 reflected the patient expressed a level 5/10 pain to her left shoulder on admission and documented, “L Clavicle has left upper extremity disuse following fracture with swelling left hand and wrist and decreased range of motion at shoulder.” The Plan of Care was void of any pain relief measures or medications to relieve pain. Additionally, there was no documented evidence that the agency’s clinicians notified the Physician of the absence of pain relief measures/medications. The agency failed to ensure the patient’s medical and nursing needs were adequately met in the patient’s home. These findings were reviewed with and acknowledged by the Administrator during an interview on 12/18/24 at 4:02 p.m.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was promptly informed of a change in the patient’s condition for 1 of 13 (P-8) records reviewed, resulting in the potential for a poor patient outcome. Findings include: P-8: This patient was admitted to home care on 5/24/24 with diagnoses of heart failure with chronic kidney disease and congestive heart failure. The patient received skilled nursing, physical therapy, occupational therapy (OT), and speech therapy services. On 5/28/24 the OT evaluation noted the patient’s pain at 0 and the same on 6/4/24. On 6/13/24, the OT noted the patient’s pain at 1 (scale of 0 none to 10 severe) categorized as generalized joint pain. The OT documented on the 7/3/24 visit note that the patient’s pain was rated at 9. The note explains that the patient complains of severe neck pain with difficulty in moving her head without pain and unable to get much sleep last night due to pain. The note documents that the caregiver was consulted, and written communication was left for the assisted living facility nurse. There was no documentation to indicate the OT promptly informed the physician of the change in the patient’s condition. The pain rating of 9 was a dramatic change in the patient’s normal pain ratings of 0 to 1. The 5/24/24 plan of care orders the OT to report pain greater than 6. The findings were reviewed with the administrator (Adm-A) during an interview on 12/18/24 at 2:00 p.m. Adm-A acknowledged that the physician should have been informed.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to provide 1 (P-9) patient observed during a home visit, with a Medication Profile that included the names, dosages and frequencies of the patient’s prescribed medications, in plain language, from a total of 13 sampled records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: P-9: The patient’s start of care was 12/11/24 with diagnoses that included Sarcopenia and Thrombocytosis. On 12/17/24 at 11:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist. During a review of the patient’s admission packet, it was noted that no Medication Profile had been provided by this agency that listed the patient’s prescribed medications, dosages and side effects. During the visit, the Physical Therapist stated, “There is no Medication Profile in the folder. I’ll have to bring that.” These findings were reviewed with the Administrator during an interview on 12/18/24 at 4:02 p.m.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the discharge summaries detailed the course of care provided with responses to treatment and the overall health status at the time of discharge, and failed to ensure the summaries were forwarded to the Physician within 5 days of the date of discharge or that transfer summaries were sent to the receiving facility within 2 days of becoming aware of the transfer in 5 (P-10, P-11, P-5, P-6, P-8) of 5 records of patients who were discharged or transferred from the agency’s services, from a total of 13 sampled records reviewed, resulting in the potential of lack of continuing care needs. Findings include: P-10: The patient’s start of care (SOC) was 4/16/24 with diagnoses that included Spinal Stenosis and Polyneuropathy. The Plan of Care (POC) ordered Physical Therapy (PT) services to be provided. During the clinical record review on 12/17/24 at 3:00 p.m., it was noted that the patient was discharged from PT services on 5/6/24. Further review revealed no documented evidence that the PT Discharge Summary dated 5/6/24, had been forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and confirmed by the Administrator during an interview on 12/18/24 at 4:22 p.m. P-11: The patient’s SOC was 4/17/24 with diagnoses that included Venous Hypertension with Ulcer and Chronic Obstructive Pulmonary Disease (COPD). The POC ordered Skilled Nursing (SN) services to be provided. During the record review on 12/18/24 at 9:40 a.m., it was noted that the patient complained of 6/10 pain on admission and required wound care during the course of care. The patient was discharged from SN services on 5/17/24. Upon review, the SN Discharge Summary dated 5/17/24, was void of a summary of care that detailed the course of care provided with responses, discharge pain level, status/measurement of reported wounds and the patient’s overall health status at the time of discharge. Additionally, there was no documented evidence that the summary had been forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator during an interview on 12/18/24 at 4:28 p.m. P-5: This patient was admitted to home care on 3/27/24 with diagnoses of stage 4 pressure ulcer sacral region, atrial fibrillation, and congestive heart failure. During record review on 12/16/24 it was noted that the patient was transferred to the hospital due to wound complications on 5/3/24. There was no evidence a transfer summary was sent to the receiving hospital. The findings were reviewed with Adm-A (administrator) on 12/18/24 at 2:00 p.m. Adm-A acknowledged that a transfer summary was not sent to the receiving hospital within 2 days of becoming aware of the transfer. The agency’s policy 2.1.004 titled, Patient Discharge/Transfer Process (revised 10/1/23) failed to align with regulatory requirements. The policy was written for patients in Mississippi, Nebraska, Delaware, Colorado, Minnesota, New Jersey, Rhode Island, Tennessee, and Louisiana not for patients in Michigan. P-6: This patient was admitted to home care on 10/30/24 with diagnoses of sarcopenia (age-related gradual loss of muscle mass and strength) and high blood pressure. During record review on 12/17/24 it was noted that the patient was transferred to the hospital due to lethargy (extreme tiredness) on 11/17/24. The physical therapist documented a transfer data collection note on 11/18/24. The patient resumed care with the agency on 12/2/24. There was no evidence a transfer summary was sent to the receiving hospital. An interview was conducted with Adm-A on 12/18/24 at 2:00 p.m. Adm-A reviewed the medical record and acknowledged that a transfer summary was not sent to the receiving hospital within 2 days of becoming aware of an unplanned transfer. P-8: This patient was admitted to home care on 5/24/24 with diagnoses of heart failure with chronic kidney disease, macular degeneration, and chronic obstructive pulmonary disease. During record review on 12/18/24, it was noted that the patient was transferred to the hospital on 6/21/24 with admission for dysrhythmia and care was resumed on 6/27/24; transferred to the hospital on 7/4/24 with admission due to chest pain and care resumed on 7/10/24; transferred to the hospital on 7/12/24 with admission due to chest pain and kidney failure. An interview was conducted with Adm-A on 12/18/24 at 2:00 p.m. Adm-A reviewed the medical record and acknowledged that transfer summaries were not sent to the receiving hospitals within 2 days of becoming aware of multiple unplanned transfers. P-10: The patient’s start of care (SOC) was 4/16/24 with diagnoses that included Spinal Stenosis and Polyneuropathy. The Plan of Care (POC) ordered Physical Therapy (PT) services to be provided. During the clinical record review on 12/17/24 at 3:00 p.m., it was noted that the patient was discharged from PT services on 5/6/24. Further review revealed no documented evidence that the PT Discharge Summary dated 5/6/24, had been forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and confirmed by the Administrator during an interview on 12/18/24 at 4:22 p.m. P-11: The patient’s SOC was 4/17/24 with diagnoses that included Venous Hypertension with Ulcer and Chronic Obstructive Pulmonary Disease (COPD). The POC ordered Skilled Nursing (SN) services to be provided. During the record review on 12/18/24 at 9:40 a.m., it was noted that the patient complained of 6/10 pain on admission and required wound care during the course of care. The patient was discharged from SN services on 5/17/24. Upon review, the SN Discharge Summary dated 5/17/24, was void of a summary of care that detailed the course of care provided with responses, discharge pain level, status/measurement of reported wounds and the patient’s overall health status at the time of discharge. Additionally, there was no documented evidence that the summary had been forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator during an interview on 12/18/24 at 4:28 p.m. P-5: This patient was admitted to home care on 3/27/24 with diagnoses of stage 4 pressure ulcer sacral region, atrial fibrillation, and congestive heart failure. During record review on 12/16/24 it was noted that the patient was transferred to the hospital due to wound complications on 5/3/24. There was no evidence a transfer summary was sent to the receiving hospital. The findings were reviewed with Adm-A (administrator) on 12/18/24 at 2:00 p.m. Adm-A acknowledged that a transfer summary was not sent to the receiving hospital within 2 days of becoming aware of the transfer. The agency’s policy 2.1.004 titled, Patient Discharge/Transfer Process (revised 10/1/23) failed to align with regulatory requirements. The policy was written for patients in Mississippi, Nebraska, Delaware, Colorado, Minnesota, New Jersey, Rhode Island, Tennessee, and Louisiana not for patients in Michigan. P-6: This patient was admitted to home care on 10/30/24 with diagnoses of sarcopenia (age-related gradual loss of muscle mass and strength) and high blood pressure. During record review on 12/17/24 it was noted that the patient was transferred to the hospital due to lethargy (extreme tiredness) on 11/17/24. The physical therapist documented a transfer data collection note on 11/18/24. The patient resumed care with the agency on 12/2/24. There was no evidence a transfer summary was sent to the receiving hospital. An interview was conducted with Adm-A on 12/18/24 at 2:00 p.m. Adm-A reviewed the medical record and acknowledged that a transfer summary was not sent to the receiving hospital within 2 days of becoming aware of an unplanned transfer. P-8: This patient was admitted to home care on 5/24/24 with diagnoses of heart failure with chronic kidney disease, macular degeneration, and chronic obstructive pulmonary disease. During record review on 12/18/24, it was noted that the patient was transferred to the hospital on 6/21/24 with admission for dysrhythmia and care was resumed on 6/27/24; transferred to the hospital on 7/4/24 with admission due to chest pain and care resumed on 7/10/24; transferred to the hospital on 7/12/24 with admission due to chest pain and kidney failure. An interview was conducted with Adm-A on 12/18/24 at 2:00 p.m. Adm-A reviewed the medical record and acknowledged that transfer summaries were not sent to the receiving hospitals within 2 days of becoming aware of multiple unplanned transfers.”