Kalamazoo Home Health Care

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.

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.

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.

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.

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.

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…

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.

The Agency failed to complete an Emergency Preparedness Plan that was based on a facility and community based risk assessment (E0006); facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all patient's physician (E0030); failed…

The agency failed to ensure the comprehensive assessment included a review of all medications by a registered nurse in 2 records (MR #4, 7), from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this Agency, and failed to…

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

The agency failed to maintain an agency wide infection control program for surveillance, identification, prevention, and control (G684); and failed to maintain a process for tracking and securely documenting the COVID-19 vaccination status of all staff (G687).

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 Agency failed to develop and maintain an emergency preparedness communication plan that included contact information for all patient's physician, which had the potential to negatively affect the health and safety of the patients serviced by this agency, resulting in the lack of effective…

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency's emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster.

We have not done anything since the last survey." The Agency failed to document the needed exercises designed for the preparation of emergency situations within the Agency and surrounding community.

The agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 8 active patients, resulting in a potential for poor patient outcomes due to the provision of substandard care.

The agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement program, which had the potential to negatively affect all patients serviced by the agency…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2020, 2021 and 2022 calendar years, resulting in the…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement program, resulting in the potential spread of infections…

The Agency failed to establish Vaccine protocol written policies and procedures that included (iv) a process for tracking and securely documenting the COVID-19 vaccination status of all staff, resulting in the potential for the development and spread of the COVID-19 virus to staff and all patients…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications by a registered nurse in 2 records (MR #4, 7), from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this Agency, and…

The agency failed to ensure the comprehensive assessment was updated to include an assessment of the patient's current health status and continuing needs for home health services for 5 (MR #2, 3, 4, 5, 6) of 7 records in which the patient was recertified for home care, from a total sample of 7…

The Agency failed to conduct a Resumption of Care assessment within 48 hours of the patients discharge from a hospital, and assess the patient's continuing needs related to hospitalization in 1 (MR #3) of 1 records in which the patient was transferred to an inpatient facility, from a total of 7…

The agency failed to ensure the plan of care (POC) included medications, diet, emergency risks and advance directives to meet the needs of the patient for 4 of 7 records reviewed (MR#s 3, 5, 6, and 7), resulting in patients not receiving care specific to their individual needs and the potential for…

The agency failed to ensure clinical notes were accurate for 4 of 7 (MR# 3, 5, 6, 7) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure that discharge summaries were sent to the physician within 5 days of discharge for 2 of 7 records reviewed resulting in incomplete results for the physicians' consideration for continuing primary care of the patient.

The Administrator failed to ensure that Federal and State agencies were notified regarding the Agency's change of address, resulting in the potential for the new facility location to be operating out of compliance with Federal requirements (See G-944).

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 1 of 7…

The Administrator failed to ensure that Federal and State agencies were notified of the Agency's change of address, resulting in the potential for the Agency to be operating out of compliance with Federal requirements.

The Agency failed to ensure skilled nursing and therapy services were provided as ordered and as stipulated by Agency policy in 4 of 7 records reviewed (MR's #1, 4, 5, and 6) from a total of 7 records reviewed, resulting in the potential for unmet care needs.