Kalamazoo Home Health Care

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to address the potential for developing a urinary tract infection for 1 (P-6) of 1 patient with a history of urinary tract infections and an indwelling urinary catheter, resulting in the potential for hospitalization due to a urinary tract infection. Findings include: Patient #6 (P-6): Infection control documents for the agency’s infection control program were requested for review on 5/11/26 and they documented that the agency’s patients had no infections in 2025 or 2026. However, review of P-6’s Plan of Care dated 9/2/25 under the ER/Hospital Re-Admission Risk factors and interventions Directives states, “History of urinary tract infections (UTI’s).” Patient/Caregiver states, “Hospitalizations are due to: “I get sick or have an infection.” There was no documentation in the agency’s Infection Control program mentioning the history of UTIs or patient illnesses, or any documentation regarding tracking or evaluating for UTIs. There were no clinician visit notes in the record that documented the assessing of P-6 for UTI’s when the patient had an indwelling urinary catheter. During an interview on 5/14/26 at 10:55 am, the administrator (Staff-A) acknowledged the above findings.”

“Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This Standard is not met as evidenced by: Based on record review and interview, the physical therapist failed to supervise the services provided by the physical therapy assistant at least every 30 days for 2 (P-2 and P-3) of 7 records reviewed with physical therapy assistant services provided at least 30 days, resulting in the potential for unmet therapy needs. Findings include: Patient #2’s (P-2) Start of Care (SOC) was dated 6/26/25. The Plan of Care (POC) identified diagnoses of Low Back Pain and Traumatic Brain Injury. During record review on 5/13/26, the POC ordered therapy services of 2w9 (2 times a week for 9 weeks). The Physical Therapist (PT) completed a Supervisory Visit Note stating, “Visit Date: 3/30/26. Visit start: Blank. Visit end: Blank. Supervisor Signature: Staff-A. Date: 5/12/26.” The PT did not complete a visit on 3/30/26. Furthermore, the PT completed a Supervisory Visit Note stating, “Visit Date: 4/30/26. Visit start: Blank. Visit end: Blank. Supervisor Signature: Blank. Date: Blank.” The PT did not complete a visit on 4/30/26. The PT failed to complete the supervision of the Physical Therapy Assistant per agency policy. Patient #3’s (P-3) Start of Care (SOC) was dated 8/7/25. The Plan of Care (POC) identified diagnosis of Paraplegia. During record review on 5/13/26, the POC ordered therapy services of 2w9. The PT completed a Supervisory Visit Note stating, “Visit Date: 4/30/26. Visit start: Blank. Visit end: Blank. Supervisor Signature: Staff-A. Date: 5/12/26.” The PT did not complete a visit on 4/30/26. The PT failed to complete the supervision of the Physical Therapy Assistant per agency policy. During the entrance conference on 5/11/26 at 10:45 a.m., the administrator (Staff-A) stated, “PTA’s will be supervised monthly.” The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 5/14/26 at 10:00 am.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to have the clinicians submit their visit notes within 48 hours of the patient’s visit for 5 (P-2, P-3, P-4, P-5, P-6) of 7 records reviewed, resulting in the potential for decreased continuity of care between clinicians and patient visits. Findings include: Patient #4 (P-4): P-4 was admitted to home care on 8/28/25, with diagnoses of neurogenic bowel, neuromuscular dysfunction of bladder, and paraplegia. During record review on 5/11/26, it was noted that the physical therapy (PT) visit notes dated 9/4, 9/10, 9/19, 9/23, 9/25, 9/30 and 10/2/25 were not signed by the PT until 10/5/25. Visit notes 10/7, 10/9, 10/14, 10/16, 10/21, 10/23, 10/27, 10/28, 10/30, 11/4/25 were not signed until 11/8/25. Visit notes 11/7, 11/11, 11/14, 11/18, 11/20/25 were not signed until 11/26/25. Patient #5 (P-5): P-5 was admitted to home care on 8/19/25, with diagnoses of contracture of left upper arm, and abnormality of gait. During record review on 5/12/26, it was noted that the physical therapy (PT) visit notes dated 4/21/26 and 4/23/26 were not signed by the PT until 4/27/26. The PT visit notes dated 4/28/26 and 5/5/26 were signed on 5/13/26 (during the survey). The PT visit note dated 5/8/26 was not signed as of 5/13/26. Patient #6 (P-6): P-6 was admitted to home care on 9/02/25, with diagnoses of diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, and surgical procedure. During record review on 5/13/26, it was noted that the physical therapy (PT) visit notes dated 9/10/25, 9/15/25, and 9/23/25 were not signed by the PT until 10/1/25. The PT visit note dated 9/29/25 was not signed until 10/6/25. The PT visit notes dated 10/3/25, 10/9/25 and 10/17/25 were not signed until 10/31/25. The PT visit note dated 9/13/25 had no signature from the clinician as of 5/14/26. During the entrance conference on 5/11/26 at 10:45 a.m., the administrator (Staff-A) said visit notes were expected to be submitted within 48 hours of the patient visit. During an interview on 5/14/26 at 10:55 am, the administrator (Staff-A) acknowledged the above findings. Patient #2’s (P-2) Start of Care (SOC) was dated 6/26/25. The Plan of Care (POC) identified diagnoses of Low Back Pain and Traumatic Brain Injury. During record review on 5/13/26, it was noted that Physical Therapy (PT) was ordered at a frequency of 2w9 (2 times a week for 9 weeks). The Physical Therapy Assistant (PTA) completed the visit documentation on 5/1/26 for the following visits: 4/6/26, 4/10/26, 4/15/26, 4/16/26, 4/20/26 and 4/22/26. Furthermore, the PTA completed two visits on 5/5/26 and 5/8/26 that stated, “Status: In use.” Whereas all other completed visits stated, “Completed.” The agency failed to document visits timely per agency expectations. Patient #3’s (P-3) Start of Care (SOC) was dated 8/7/25. The Plan of Care (POC) identified diagnosis of Paraplegia. During record review on 5/13/26, it was noted that PT was ordered at a frequency of 2w9. The PTA completed the visit documentation on 5/1/26 for the following visits: 4/6/26, 4/9/26, 4/10/26, 4/13/26, 4/16/26, 4/20/26 and 4/22/26. The agency failed to document visits timely per agency expectations. During the entrance conference on 5/11/26 at 10:45 a.m., the administrator (Staff-A) stated, “Visit notes were expected to be submitted within 48 hours of the patient visit.” The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 5/14/26 at 10:00 am.”

“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 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. Findings include: During a review of the Agency’s patient admission packet on 5/11/25 at 11:30 am, it was noted that the information for the Federally and State funded patient resource entities (Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization) had not been included. These findings were reviewed with the Administrator (Staff-A) during an interview on 5/11/26 at 12:45 pm.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication profile and medication reconciliation was documented in the record for 2 (P-4 and P-7) of 7 records reviewed, resulting in the potential for medication related harm and adverse effects and drug interactions to go unaddressed by the agency and the clinician. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 8/11/25. The Plan of Care (POC) identified diagnoses of Traumatic Brain Injury. During record review on 5/12/26, it was noted that the comprehensive assessment completed on 8/11/25 stated, “M2001 Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medications issues? 0 – No issues for during review.” A drug interaction report was completed withing the Electronic Medical Record (EMR) that noted the following “Major” severity medication interactions: Aspirin with Ibuprofen, Aspirin with Topiramate. The EMR contains no documented evidence that the physician was notified of the major severity medication interactions. During the entrance conference on 5/11/26 at 10:45 a.m., the administrator (Staff-A) stated, “Major medication interactions are to be reported to the physician.” The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 5/14/26 at 10:00 am. Patient #4 (P-4): P-4 was admitted to home care on 8/28/25, with diagnoses of neurogenic bowel, neuromuscular dysfunction of bladder, and paraplegia. During record review on 5/11/26, it was noted that there was no documented medication profile or medication interaction report in the record. During review of the start of care comprehensive assessment on 5/11/26 under M2001, it was documented that issues were found during the medication drug review. There was no documentation of what level the drug interactions were, or if the physician was notified if needed, or what actions were needed, if any. During an interview on 5/14/26 at 10:55 am, the administrator (Staff-A) acknowledged the above findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters and safety measures specific to the individualized needs of the patient in 6 (P-1, P-2, P-3, P-4, P-5 and P-7) of 7 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes and unmet care needs. Findings include: Patient #4 (P-4): P-4 was admitted to home care on 8/28/25, with diagnoses of neurogenic bowel, neuromuscular dysfunction of bladder, and paraplegia. During record review on 5/11/26, it was noted that there were no diabetic precautions on the Plan of Care (POC) with a diagnosis of diabetes and insulin injections ordered before meals. The POC also failed do include parameters for when to contact the physician for vital signs and pain parameters. Patient #5 (P-5): P-5 was admitted to home care on 8/19/25, with diagnoses of contracture of left upper arm, and abnormality of gait. During record review on 5/12/26, it was noted that there were no pain parameters on the plan of care and the Start of Care (SOC) OASIS assessment states, “AFC staff report that when P-5 has pain, he gets very agitated and has explosive episodes. He has an additional PRN dose of oxycodone at hs (bedtime) but does not routinely need to take this dose. P-5 denies current pain when asked, but staff report when he has pain that is not managed, his mood, behavior, participation in ADLs are all effected.” Under Effectiveness of Pain Medication there is a question asking, “Is current pain medication treatment effective for pain? The yes and no boxes are unchecked. “How often is break through pain medication needed question; never, less often than daily, once daily, 2 or 3 times a day, more than 3 times a day boxes are all unchecked. The agency failed to include parameters for pain to notify the physician of break through pain other than at bedtime, and what actions to take. During an interview on 5/14/26 at 10:55 am, the administrator (Staff-A) acknowledged the above findings. Patient #1’s (P-1) Start of Care (SOC) was dated 5/2/25. The Plan of Care (POC) identified diagnoses of Muscle Weakness and Traumatic Brain Injury. During record review on 5/11/26, it was noted that the POC had Physical Therapy (PT) frequency of 2w9 (2 time per week for 9 weeks). The Physical Therapy Assistant (PTA) completed 2 visits during week 5, 5/27/25 and 5/29/25. The PT completed a 30-day evaluation visit on 5/29/25. The Electronic Medical Record (EMR) contained no evidence of an order to increase PT frequency. The agency failed to complete visits as ordered. Furthermore, the POC failed to contain vital sign parameters to notify the physician. Patient #2’s (P-2) Start of Care (SOC) was dated 6/26/25. The Plan of Care (POC) identified diagnoses of Low Back Pain and Traumatic Brain Injury. During record review on 5/13/26, it was noted that the POC had PT frequency of 2w9. The PTA completed 2 visits during week 5, 4/20/26 and 4/22/26. The PT completed a 30-day evaluation visit on 4/22/26. The EMR contained no evidence of an order to increase PT frequency. The agency failed to complete visits as ordered. Furthermore, the POC failed to contain vital sign parameters to notify the physician. Patient #3’s (P-3) Start of Care (SOC) was dated 8/7/25. The Plan of Care (POC) identified diagnosis of Paraplegia. During record review on 5/13/26, it was noted that the POC had PT frequency of 2w9. The PTA completed 3 visits during week 2, 3/6/26, 3/9/26 and 3/10/26. Furthermore, the PTA completed 2 visits during week 5, 3/27/26 and 3/28/26. The PT completed a 30-day evaluation visit on 3/29/26. The EMR contained no evidence of an order to increase PT frequency. The agency failed to complete visits as ordered. Furthermore, the POC failed to contain vital sign parameters to notify the physician. Patient #7’s (P-7) Start of Care (SOC) was dated 8/11/25. The Plan of Care (POC) identified diagnoses of Traumatic Brain Injury. During record review on 5/12/26, it was noted that the POC had PT frequency of 2w9 and Occupational Therapy (OT) 1w9. The PTA completed 3 visits during week 2, 2/8/26, 2/10/26 and 2/12/26. The EMR contained no evidence of an order to increase PT frequency. Furthermore, the OT completed 2 visits during weeks 3, 4 and 5, 2/15/26 and 2/19/26, 2/26/26 and 2/27/26, and lastly 3/5/26 and 3/7/26. The agency failed to complete visits as ordered. Furthermore, the POC failed to contain vital sign parameters to notify the physician. Additionally, it was noted that metformin (antidiabetic) 1000 mg two times daily was in medication profile with a start date of 7/11/25. It was noted that the POC Safety Measures failed to include diabetic precautions. The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 5/14/26 at 10:00 am.”

“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, it was determined that the agency failed to send a detailed discharge summary to the physician for 1 (P-4) of 2 discharge records reviewed, resulting in the physician having no knowledge of the patient’s condition at discharge. Findings include: Patient #4 (P-4): P-4 was admitted to home care on 8/28/25, with diagnoses of neurogenic bowel, neuromuscular dysfunction of bladder, and paraplegia. During record review on 5/11/26, it was noted that the discharge summary dated 11/27/25, had the boxes for “Copy sent to MD, copy sent to facility, copy sent via fax, and copy sent via mail”, all left blank. P-4 was discharged from agency services on 11/27/25. There was no documented evidence in the record, that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. During an interview on 5/14/26 at 10:55 am, the administrator (Staff-A) acknowledged the above findings.”