Every finding on record at 5 Star Healthcare, Inc

Notice of rights CFR(s): 484.50(a) Standard: Notice of rights. The HHA must- This STANDARD is not met as evidenced by: based on observation, interview and record review, the agency failed to ensure donald duck stayed wet. This has the potential to affect all ducks receiving services from the agency. During a home visit on 1/2/21, observed feathers lying on the floor at the front of the dining room. heard quacking from the rear of the house. Observed a duck with his feathers falling off. During an interview with the duck stated, the agency always prevent me from waddling in the water.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on document review, observation, patient and staff interview it was determined for 1 of 10 (Pt #2) clinical records reviewed with physical therapy (PT) the Agency failed to ensure the plan of care was followed. this has the potential to effect all patients receiving services-current census-25. 1. On 6/28/21 at 9:00 AM, the clinical record of Pt #2 was reviewed. Pt #2 was admitted on 6/1/21 with diagnoses of congestive heart failure and generalized weakness. The physician ordered physical therapy (PT) visits 3 times a week for 2 weeks, 2 times a week for 3 weeks. Documentation indicated PT evaluation visit was made on 6/9/21. There were no subsequent orders documented. 2 On 6/28/21 at 9:30 AM, the policy effective date 9/2/18, titled, "Physician Plan of Care" was reviewed. The policy indicated under "Procedure:...5. Physical therapy evaluation visits will be initiated within 5 days of comprehensive assessment, unless physician ordered otherwise." 3. On 6/28/21 at 1:00 PM, a home visit was made with the PT (E#4). E#4 stated "this is my first visit to see this patient". During the visit, it was observed Pt #2 requested to be seen in the mornings if possible, as she is tired by afternoon. E#4 replied, "we will see if we can manage that". 4. On 6/28/21 at 1:30 PM, an interview was conducted with Pt #2. Pt #2 was asked about PT initial visit. Pt #2 stated, "well I didn't think they were ever coming. I had to call the agency several times to get answers. Finally, someone showed up." 5. On 6/28/21 at 2:30 PM, an interview was conducted with E#4. E#4 was asked about the delay in initial visit. E#4 replied, "I think that is when we were short staffed. I don't believe we could see everyone, so we had to delay." E #4 was asked, "Did you notify the physician of lack of staff?" E#4 replied, "no, I did not." 6. On 6/28/21 at 3:30 PM, an interview was conducted with the home health coordinator (E#1). E#1 reviewed Pt #2's clinical record and confirmed there was no order to delay the PT initial visit.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 1/28/21. The Facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: SOC = Start of care Pt./Pts. = Patient/Patients AM = Morning PM = Afternoon # = Number COVID-19 = Coronavirus 2019

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: . A. Based on observation and Pt./staff interview, it was determined the Agency failed to ensure Pts. were given the name and contact information of the Administrator. This was found in 3 of 3 Pts. ( Pt. #3, 1, and 2) wherein home visits were conducted. Findings include: 1. Pt. #3. SOC 1/13/21. Diagnosis: Chronic Venous Hypertension with Ulcer of Left Lower Extremity. The clinical record was reviewed on 1/25/21 at 2:10 PM. The record lacked any documentation Pt. #1 was provided with the name and contact information of the Agency Administrator. A home visit was conducted on 1/26/21 at 2:00 PM, along with the Director of Patient Care Services. Pt. #1 presented the folder given to to Pt. #1 by the Agency upon admission. This folder did not contain the name/contact information of the Agency's Administrator. Pt. #1 stated he/she was unaware of the name/contact information of the Agency's Administrator. 2. Pt. #1 SOC 10/23/20. Diagnosis: Malignant Neoplasm of Unspecified Part of Right Bronchus of Lung. The clinical record was reviewed on 1/25/21 at 1:30 PM. The record lacked documentation Pt. #1 was provided with the name and contact information of the Agency Administrator. A home visit was conducted on 1/25/21 at 3:00 PM, with the Registered Nurse who asked the patient's caregiver for the Home Health Agency folder provided by agency on admission. The folder did not include the name or contact information of the Agency's Administrator. The patient's caregiver and Patient confirmed they did not know the name of the Agency's Administrator. 3. Pt. #2 SOC 7/21/20. Diagnosis: Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side. The clinical record was reviewed on 1/26/21 at 11:00 AM. The record lacked documentation Pt. #2 was provided with the name and contact information of the Agency Administrator. A home visit was conducted on 1/26/21 at 3:30 PM, with the Physical Therapist Assistant who asked the patient's caregiver for the Home Health Agency folder provided by agency on admission. The folder did not include the name or contact information of the Agency's Administrator. The patient's caregiver and patient confirmed they did not know the name of the Agency's Administrator. 4. During an interview with the Director of Patient Care Services on 1/27/21 at 2:00 PM and 3:00 PM, the Director of Patient Care Services confirmed the admission folder that was given to the patients lacked the Administrator's name and contact information.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: . A. Based on observation and Pt./staff interview, it was determined the Agency failed to ensure Pts. received a written copy of the Agency's transfer/discharge policy. This was found in 3 of 3 Pts. (Pt. #3, 1, and 2) wherein home visits were conducted. Findings include: 1. Pt. #3 SOC 1/13/21. Primary Diagnosis: Chronic Venous Hypertension with Ulcer of Left Lower Extremity. The clinical record was reviewed on 1/25/21 at 2:10 PM. The record lacked any documentation Pt. #1 was provided with the Agency's transfer/discharge policy. A home visit was conducted on 1/26/21 at 2:00 PM, along with the Director of Patient Care Services. Pt. #1 presented the folder given to to Pt. #1 by the Agency upon admission. This folder did not contain the Agency's transfer/discharge policy. Pt. #1 stated he/she was unaware of the Agency's transfer/discharge policy. 2. Pt. #1 SOC 10/23/20. Diagnosis: Malignant Neoplasm of Unspecified Part of Right Bronchus or Lung. The clinical record was reviewed on 1/25/21 at 1:30 PM. The record lacked documentation Pt. #1 was provided with the Agency's transfer and or discharge policy. A home visit was conducted on 1/25/21 at 3:00 PM, with the Registered Nurse, who asked the patient's caregiver for the Home Health Agency folder provided by agency on admission. The folder did not include the Agency's transfer and or discharge policy. The caregiver and patient confirmed they did not know about the transfer and or discharge policy. 3. Pt. #2 SOC 7/21/20. Diagnosis: Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side. The clinical record was reviewed on 1/26/21 at 11:00 AM. The record lacked documentation Pt. #2 was provided with the Agency's transfer and or discharge policy. A home visit was conducted on 1/25/21 at 3:30 PM, with the Physical Therapist Assistant who asked the patient's caregiver for the Home Health Agency folder provided by agency on admission. The folder did not include the Agency's transfer and or discharge policy. The caregiver and patient confirmed they did not know about the transfer and or discharge policy. 4. During an interview with the Director of Patient Care Services on 1/27/21 at 2:00 PM and 3:00 PM, the Director of Patient Care Services confirmed the admission folder that was given to the patients lacked the transfer and or discharge policy.