← All agencies in Pontiac, MI · Michigan

Compassionate Home Health Services

(248) 681-121135 S Johnson Ave, Suite 3B, Pontiac, MI 48341
CMS Certification Number 239199 · Proprietary · Medicare-certified since 10/19/2011
33deficiencies since 2018
2serious
2inspections
1.5CMS quality stars
Data from CMS inspection reports (Form 2567), 2018-01-02 to 2026-10-15, downloaded 2026-10-21; CMS agency list file dated 2026-09-21. What the labels mean

Inspection 2023-06-15

· Recertification · 21 deficiencies · CMS source report (PDF)
Moderate Update Of The Comprehensive Assessment

The Agency failed to ensure the comprehensive assessment was updated and revised in 1 (P-1) of 1 record in which the patient was transferred to an inpatient facility related to elevated blood glucose levels, from a total of 7 sampled records reviewed, resulting in lack of information in determining…

Source: CMS Form 2567, inspection 2023-06-15, tag G0544 · view on CMS
Show inspector's text

Loading…

Moderate Services Under Arrangement

The agency failed to ensure 1 of 1 contract (Contractor-1) met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that receive contracted services.

Source: CMS Form 2567, inspection 2023-06-15, tag G0976 · view on CMS
Show inspector's text

Loading…

Moderate Skilled Services Furnished

The agency failed to ensure that at least one qualifying service was provided directly by agency employees for 1 of 1 (Contractor-1) contract reviewed, resulting in the agency contracting for all patient services.

Source: CMS Form 2567, inspection 2023-06-15, tag G0982 · view on CMS
Show inspector's text

Loading…

Minor Written Notice Of Patient'S Rights

The agency failed to ensure patients received written notice of the agency's transfer and discharge policies, resulting in a lack of information regarding discharge and transfer rights for all 53 patients admitted to the agency in the past 12 months.

Source: CMS Form 2567, inspection 2023-06-15, tag G0412 · view on CMS
Show inspector's text

Loading…

Minor Hha Administrator Contact Information

The agency failed to ensure patients were informed of the Administrator's business address, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect the quality of care for the agency's 23 current patients.

Source: CMS Form 2567, inspection 2023-06-15, tag G0414 · view on CMS
Show inspector's text

Loading…

Minor Participate In Care

The agency failed to ensure the patient participated in care planning and was informed of the time and frequency of visits for 1 of 7 (P-7) records reviewed, resulting in anxiety and frustration for this patient.

Source: CMS Form 2567, inspection 2023-06-15, tag G0434 · view on CMS
Show inspector's text

Loading…

Minor Written Notice For Non-Covered Care

The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the Agency terminating on-going care for 1 (P-1) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services.

Source: CMS Form 2567, inspection 2023-06-15, tag G0442 · view on CMS
Show inspector's text

Loading…

Minor Contact Info Federal/State-Funded Entities

The agency failed to 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…

Source: CMS Form 2567, inspection 2023-06-15, tag G0446 · view on CMS
Show inspector's text

Loading…

Minor Access To Auxiliary Aids And Language Service

The agency failed to ensure patients were informed of their right to access auxiliary aids and language services and how to access these services, resulting in a lack of information and resources for all patients with disabilities or limited English proficiency.

Source: CMS Form 2567, inspection 2023-06-15, tag G0450 · view on CMS
Show inspector's text

Loading…

Minor Rn Performs Assessment

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 2 of 7 (P#'s 6, 1) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients.

Source: CMS Form 2567, inspection 2023-06-15, tag G0514 · view on CMS
Show inspector's text

Loading…

Minor Health, Psychosocial, Functional, Cognition

The Agency failed to ensure the comprehensive assessment accurately reflected the patient's condition at the start of care for 1 (P-1) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health needs and poor patient outcomes.

Source: CMS Form 2567, inspection 2023-06-15, tag G0528 · view on CMS
Show inspector's text

Loading…

Minor A Review Of All Current Medications

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 1 (P-5) record, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication side effects or interactions.

Source: CMS Form 2567, inspection 2023-06-15, tag G0536 · view on CMS
Show inspector's text

Loading…

Minor At Discharge

The Agency failed to ensure the Comprehensive Assessment was updated and completed at the time of discharge from the agency's services in 1 (P-1) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in no indication of the patient’s progression towards their identified…

Source: CMS Form 2567, inspection 2023-06-15, tag G0550 · view on CMS
Show inspector's text

Loading…

Minor Plan Of Care Must Include The Following

The agency failed to ensure the plan of care included appropriate interventions with reportable parameters, safety measures and objectively measurable goals specific to the individualized needs of the patient in 6 (P-1, P-3, P-4, P-5, P-6, P-7) records, from a total of 7 sampled records reviewed…

Source: CMS Form 2567, inspection 2023-06-15, tag G0574 · view on CMS
Show inspector's text

Loading…

Minor Verbal Orders

The agency failed to ensure physician orders were signed for 2 of 3 (P-4, P-6) discharge records reviewed, resulting in a lack of physician authentication for patient care orders for this patient.

Source: CMS Form 2567, inspection 2023-06-15, tag G0584 · view on CMS
Show inspector's text

Loading…

Minor Name/Contact Information Of Clinical Manager

The agency failed to ensure written information was provided to patients that detailed the name and contact information for the agency's clinical manager, resulting in a lack of information to enable the agency's 23 current patients to contact the clinical manager.

Source: CMS Form 2567, inspection 2023-06-15, tag G0622 · view on CMS
Show inspector's text

Loading…

Minor Interdisciplinary Assessment Of The Patient

The Agency failed to ensure the Registered Nurse performed baseline assessments and re-assessments of the patient's health status and needs in 1 (P-1) record of a patient with a diagnosis of Hypertensive Heart Disease, from a total of 7 sampled records reviewed, resulting in the potential for…

Source: CMS Form 2567, inspection 2023-06-15, tag G0706 · view on CMS
Show inspector's text

Loading…

Minor Provide Services In The Plan Of Care

The agency failed to ensure the medical social worker and skilled nursing provided services as ordered by the physician in the plan of care for 1 (P-5) record, from a total of 7 sampled records reviewed, resulting in the potential for poor patient outcomes for this patient.

Source: CMS Form 2567, inspection 2023-06-15, tag G0710 · view on CMS
Show inspector's text

Loading…

Minor Preparing Clinical Notes

The Agency failed to ensure the clinical record was completed and included detailed Skilled Nursing notes for 1 (P-1) of 1 record of a patient who was transferred to the hospital due to elevated blood glucose levels, from a total of 7 sampled records reviewed, resulting in the potential for…

Source: CMS Form 2567, inspection 2023-06-15, tag G0716 · view on CMS
Show inspector's text

Loading…

Minor Must Have A Written Agreement

The agency failed to ensure a contract for services indicated the agency maintains overall responsibility for the services provided under arrangement for 1 of 1 (Contractor-1) contract reviewed, resulting in a lack of overall responsibility by the agency for the services provided under arrangement.

Source: CMS Form 2567, inspection 2023-06-15, tag G0978 · view on CMS
Show inspector's text

Loading…

Minor Discharge And Transfer Summaries

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 (P-1, P-4) of 2 records in which the patient was…

Source: CMS Form 2567, inspection 2023-06-15, tag G1022 · view on CMS
Show inspector's text

Loading…

Inspection 2020-11-23

· Focused Infection Control, Other-Fed, Recertification · 12 deficiencies · CMS source report (PDF)
Serious Home Health Aide Services

The home health agency failed to ensure the home health aide was qualified to provide home health aide service (Refer to G 752), the agency failed to ensure the home health aide competency evaluation was completed by observing the aide's performance of the tasks with a patient prior to being deemed…

Source: CMS Form 2567, inspection 2020-11-23, tag G0750 · view on CMS
Show inspector's text

Loading…

Serious Organization And Administration Of Services

The Home Health Agency failed to ensure the Governing Body assumed full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and it's operational plans and it's quality…

Source: CMS Form 2567, inspection 2020-11-23, tag G0940 · view on CMS
Show inspector's text

Loading…

Moderate Home Health Aide Qualifications

The home health agency failed to ensure the home health aide was qualified to provide home health aide service for 1 of 2 aides (HHA #2) providing service, for a potential of substandard aide services.

Source: CMS Form 2567, inspection 2020-11-23, tag G0752 · view on CMS
Show inspector's text

Loading…

Moderate Competency Evaluation

The agency failed to ensure the home health aide competency evaluation was completed by observing the aide's performance of the tasks with a patient prior to being deemed competent to perform aide services for 2 of 2 aides (Aide #1 and #2), from a total sample of 2 aides personnel files reviewed…

Source: CMS Form 2567, inspection 2020-11-23, tag G0768 · view on CMS
Show inspector's text

Loading…

Moderate Laboratory Services/Clia Waivers

The home health agency failed to ensure the Clinical Laboratory Improvement Amendment certificate was kept current for the years 2019 and 2020, for a potential of the inability to meet the testing needs of all the patients requiring self-testing.

Source: CMS Form 2567, inspection 2020-11-23, tag G0862 · view on CMS
Show inspector's text

Loading…

Moderate Governing Body

The Home Health Agency failed to ensure the Governing Body assumed full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and it's operational plans and it's quality…

Source: CMS Form 2567, inspection 2020-11-23, tag G0942 · view on CMS
Show inspector's text

Loading…

Minor Hha Administrator Contact Information

The home health agency failed to inform patients of the contact information for the administrator, including the administrator's name, business address, and business phone number in order to receive complaints, resulting in a potential for unaddressed patient concerns or complaints for all 31…

Source: CMS Form 2567, inspection 2020-11-23, tag G0414 · view on CMS
Show inspector's text

Loading…

Minor Payment From Federally Funded Programs

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, Medicaid or other private insurance sources for 7 of 7 patients (M.R. #1, 2, 3, 4, 5, 6, and 7) receiving services from the…

Source: CMS Form 2567, inspection 2020-11-23, tag G0440 · view on CMS
Show inspector's text

Loading…

Minor Contact Info Federal/State-Funded Entities

The home health agency failed to advise their patients of the names, addresses and telephone numbers of the federally and state funded entities that serve the counties in which each patient resides, resulting in the potential for unmet patient care needs for all 31 patients currently serviced by…

Source: CMS Form 2567, inspection 2020-11-23, tag G0446 · view on CMS
Show inspector's text

Loading…

Minor Onsite Supervisory Visit Every 14 Days

The registered nurse failed to supervise the home health aides' services no less frequently than every 14 days for 2 of 4 records reviewed (MR. #3, and 5) with home health aide services, for a potential of unmet and unsafe patient care.

Source: CMS Form 2567, inspection 2020-11-23, tag G0808 · view on CMS
Show inspector's text

Loading…

Minor Administrator Appointed By Governing Body

The Home Health Agency failed to ensure the Governing Body appointed the administrator's position, for a potential of lack in management for all the staff.

Source: CMS Form 2567, inspection 2020-11-23, tag G0946 · view on CMS
Show inspector's text

Loading…

Minor Ensures Qualified Pre-Designated Person

The Administrator and the Governing Body failed to identify in writing an alternate administrator and an alternate Clinical Manager, for a potential of a lack of oversight and management of patient care services and the staff.

Source: CMS Form 2567, inspection 2020-11-23, tag G0954 · view on CMS
Show inspector's text

Loading…