Every finding on record at Allied Home Health Care, Inc

ACTS Reference Number: Complaint No. 107599 A CMS authorized Validation Survey was conducted at Allied Home Health Care on 6/17/24 to determine compliance with the following Condition of Participation related to Home Health Agencys: - 42 CFR 484.50 Patient Rights The Agency was found to be at Standard Level non-compliance, and a statement of deficiencies was generated as a result of the investigation of this complaint.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) 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. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on interviews and record review, for one of three sampled patients (Patient #1), the Agency failed to ensure they provided Patient #1 with written notices of the patient's rights and responsibilities and the Agency’s transfer and discharge policies. Findings include: Review of the Agency Home Care Bill of Rights Policy, undated, indicated patients/clients will be informed of their rights as a consumer of home care services. Review of the Patient Orientation Guide indicated Patient Rights included the right to be informed of patient's rights and responsibilities and the right to be informed of the Agency's transfer and discharge policies. Review of Patient #1's record indicated there was no documentation to support the Agency having provided Patient #1 with a written notice of the patient's rights and responsibilities and the Agency’s transfer and discharge policies. During an interview on 6/17/24 at 1:44 P.M., the Administrator said that the Agency had not provided written notices to Patient #1 of his/her patient's rights and responsibilities and the Agency’s transfer and discharge policies.

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: Based on interview and record review, for one of three sampled patients (Patient #1), the Agency failed to ensure they provided Patient #1 with contact information for the Agency administrator, including the administrator's name, business address, and business phone number in order to receive complaints. Findings include: Review of the Agency Home Care Bill of Rights Policy, undated, indicated patients/clients will be informed of their rights as a consumer of home care services. Review of the Patient Orientation Guide indicated Patient Rights included the right to be informed of contact information for the Agency administrator, including the administrator's name, business address, and business phone number in order to receive complaints. Review of Patient #1's record indicated there was no documentation to support the Agency having provided Patient #1 with contact information for the Agency administrator, including the administrator's name, business address, and business phone number in order to receive complaints During an interview on 6/17/24 at 1:44 P.M., the Administrator said that the Agency had not provided Patient #1 with contact information for the Agency administrator, including the administrator's name, business address, and business phone number in order to receive complaints.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on interview and record review, for one of three sampled patients (Patient #1), the Agency failed to ensure they provided Patient #1 with written notices regarding the extent to which payment for Agency services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the Agency. Findings include: Review of the Agency Home Care Bill of Rights Policy, undated, indicated patients/clients will be informed of their rights as a consumer of home care services. Review of the Patient Orientation Guide indicated Patient Rights included the right to be informed both orally and in writing of the Agency billing procedures and the extent to which payment may be expected from Medicare, Masshealth, any other federally funded or aided program or any other third party source known to the Agency. Review of Patient #1's record indicated there was no documentation to support the Agency having informed Patient #1 both orally and in writing of the Agency billing procedures and the extent to which payment may be expected from Medicare, Masshealth, any other federally funded or aided program or any other third party source known to the Agency. During an interview on 6/17/24 at 1:44 P.M., the Administrator said that the Agency had not informed Patient #1 both orally and in writing of the Agency billing procedures and the extent to which payment may be expected from Medicare, Masshealth, any other federally funded or aided program or any other third party source known to the Agency.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on interview and record review, for one of three sampled patients (Patient #1), the Agency failed to ensure they provided Patient #1 with the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local Agencies. Findings include: Review of the Agency Home Care Bill of Rights Policy, undated, indicated patients/clients will be informed of their rights as a consumer of home care services. Review of the Patient Orientation Guide indicated Patient Rights included the right to be advised when accepted for treatment or care, of the availability of the state's toll-free home care hotline number, its purpose and hours of operation. Review of Patient #1's record indicated there was no documentation to support the Agency having provided Patient #1 the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local Agencies. During an interview on 6/17/24 at 1:44 P.M., the Administrator said that the Agency had not provided Patient #1 with the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local Agencies.

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 interview and record review, for one of three sampled patients (Patient #1), the Agency failed to ensure they provided Patient #1 with 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. Findings include: Review of the Agency Home Care Bill of Rights Policy, undated, indicated patients/clients will be informed of their rights as a consumer of home care services. Review of the Patient Orientation Guide indicated Patient Rights included the right to 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. Review of Patient #1's record indicated there was no documentation to support the Agency advised Patient #1 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. During an interview on 6/17/24 at 1:44 P.M., the Administrator said that the Agency had not advised Patient #1 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.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interviews and record review, for one of three sampled patients (Patient #1) the Agency failed to ensure staff reported an allegation that, on 3/23/24, Home Health Aide (HHA) #1 misappropriated $10,000 from Patient #1, to the Department of Public Health (DPH) within 48 hours, in accordance with state law. Findings include: The Agency Policy titled, Identifying and Reporting Abuse/Neglect/Exploitation of Clients, undated, indicated that it was the policy of the Agency to report allegations of exploitation to appropriate authorities. The “Special Instructions” included in the policy indicated staff were to immediately report allegations to the Administrator and a copy of the report regarding the allegation would be sent to the appropriate Agency as required by State law. Massachusetts General Law 105 CMR 155.003 indicates that a reporting individual shall immediately make an oral report of misappropriation of patient property to their employer and upon receiving such report, said employer shall within 48 hours complete an internal investigation and if within 48 hours there is reasonable cause to suspect misappropriation, said employer shall immediately notify the DPH. During a telephone interview on 6/26/24 at 3:45 P.M., HHA #1 said that during a visit on 3/30/24, Family Members #1 and #2 accused her of having stolen $10,000 from Patient #1 during a visit on 3/23/24. HHA #1 said she notified the Agency of the allegation. During an interview on 6/17/24 at 11:35 A.M., the Coordinator said that on 4/01/24, she became aware that Family Member’s #1 and #2 accused HHA #1 of stealing $10,000 from Patient #1. The Coordinator said that she initiated an internal investigation. Review of the report submitted by the Agency to the DPH via the Health Care Facility Reporting System (HCFRS), dated 6/17/24, indicated the Agency submitted a report of the allegation that HHA #1 misappropriated $10,000 from Patient #1, at 6:49 P.M. on 6/14/24. The Coordinator said that she reported the allegation that HHA #1 misappropriated $10,000 from Patient #1 to the DPH 6/14/24, around ten weeks after she became aware of and initiated an investigation into the allegation.