Every finding on record at Alpha Home Health Care LLC - Southern Utah

Based on interview and record review, it was determined the home health agency (HHA) failed to notify the state agency of a change of address, and the office was not adequately staffed during posted business hours on multiple occasions; the ADM (administrator) appeared confused and disorganized which required 1:1 direction from the survey staff so that required documents could be obtained and reviewed; requested information was not submitted in a timely fashion; a director of nursing (DON)/clinical manager had not been hired to oversee all patient care services and personnel; home visits during the survey process were not accurately given to the survey staff which impeded on-site home visits from the survey staff; an accurate active patient and discharge list was not provided to the survey staff; and the agency ADM submitted a letter to the survey staff of his intent to "voluntarily" cease doing business in the State of Utah under the current licenses to do so. This resulted in a finding of immediate threat to patient health and safety (immediate jeopardy (IJ)) in the areas of governing body, quality assessment/performance improvement and nursing services, The ADM was verbally notified of the IJ on 12/27/2022 at 9:02 AM and via written correspondence on 12/27/2022. The ADM was directed to modify the plan of discharge to include verbal notification of the agency closing to all patient's/family members, options given for other agencies in the area, date of each patient discharge and where the patient was discharged to and where medical records would be stored. Findings include: 1. On 12/19/2022 1:35 PM, an abbreviated survey was attempted at the home health agency (HHA) address on file. The sign posted on the door was for a real estate company. The door was locked. There was no answer to repeated knocks on the door. A telephone call was placed to the ADM/owner on 12/19/2022 at 1:50 PM. The ADM stated the HHA had moved to a new location. The address of the new location was given. 2. An entrance conference with the ADM and registered nurse (RN) 1 was conducted on 12/19/2022 at 2:30 PM. Written and verbal instructions were given related to the information that needed to be electronically submitted to the survey team. The ADM was unable to focus on the information that was being presented and repeatedly asked the surveyor why he was at the HHA. When the ADM was asked questions related to the entrance requirements, the ADM referred the questions to RN 1 who appeared to be doing work at a computer. At one point, the ADM asked RN 1 to "pay attention". RN 1 responded with, "There is no need to. My last day is Friday, three days from now". The ADM was asked who the HHA’s director of nursing was. The ADM stated, "I guess (RN 1)." RN 1 stated, "That's news to me." The ADM was unable to provide the requested documents to the survey team and stated that he had contracted with a "friend" to assist him with gathering the required documents. On 12/19/2022 at 3:30 PM, the entrance request guidelines were again reviewed with the ADM. The ADM was encouraged to comply with submitting required information within the 1 hour and 3-hour time frames. The ADM acknowledged his understanding. On 12/19/2022 at 8:25 PM, the ADM sent a text message to one of the surveyors. The ADM stated there was no HHA employees that were scheduled to do patient visits during the week of the survey. No other information was submitted as required on the entrance request form. 2. On 12/20/2022 at 9:05 AM, an attempt to gain access to the HHA office was made. The office was locked. There was no answer to repeated knocks on the door. A telephone call was placed to the ADM at 9:07 AM. The ADM stated he had to leave the office and return home to obtain information that was requested on the entrance document. The ADM stated he would be back at the office in ten minutes. Another attempt to gain access to the HHA office was made at 12:26 PM. The office was locked. There was no answer to repeated knocks on the door. Another call was placed to the ADM. The ADM stated he had gone to lunch and would be returning to the office in five minutes. On 12/20/2022 at 12:47 PM, a google meeting with the survey team and the ADM was conducted. One surveyor was on-site with the ADM and two surveyors as well as the Director of Medicare Services were off-site. The missing documents that were requested during the entrance conference on 12/19/2022 was reviewed. The ADM was given one hour to provide the survey team with all documents in an electronic format. 3. On 12/20/2022 at 1:07 PM, the Home Visit Worksheet was received. It was documented that one patient had a home visit scheduled with an aide on 12/20/2022 in the morning. Note: The survey staff were previous told that no home health visits were scheduled during the week of the survey. Additionally, two of the four patients identified as having home visits during the week of the survey had been discharged from the HHA prior to 12/19/2022. 4. On 12/20/2022 at 1:15 PM, an active patient list was received. The patient list identified four patient that were on HHA services. However, it was later determined that two of the patients had been discharged from the agency prior to 12/19/2022. 5. On 12/20/2022, a telephone call was placed to the Director of Medicare Certification Programs, at the Department of Health and Human Services, with the State of Utah. Due to the concerns of patient safety, it was determined a full recertification survey would be conducted. 6. On 12/27/2022 at 8:10 AM, a letter addressed to the Director of Medicare Certification Programs was received via e-mail from the ADM. The ADM documented in the letter, "...At this time, I feel it is in the best interest of all concerned, that Alpha Home Health Care, LLC – Southern Utah “voluntarily” ceases to do business in the State of Utah under the current licenses to do so." The ADM further wrote, "A great deal of the problem has been obtaining competent staffing and that can affect patient care..." The ADM was contacted via telephone that the discharge plan of action needed to be modified to include patient/family notification of the intent to close the office, when and where each patient was discharged to, and where the medical records would be stored. 7. On 12/28/2022, multiple attempts were made to contact the ADM via telephone (the office phone number and the ADMs personal cell phone) and e-mail related to the disposition of the patients and the modification of the discharge plan. All attempts went unanswered. 8. On 12/28/2022 at 11:23 AM, the surveyors contacted the two current patients/family members receiving services with the HHA to ensure the safety of the patients. The patients/family members were informed of the agency intent to close. Both patients were Veteran Administration (VA) patients. The VA case managers were contacted and began working on alternative placement for the two patients. All other patients had been discharged from HHA prior to the start of the survey of 12/19/2022. 9. On 12/29/2022 at 9:00 AM, the discharge plan was received. All patient's had been discharged from the agency. 10. On 12/20/2022 the HHA deceased to function as an HHA. It is recommended the HHAs certification be terminated as of 12/29/2022.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to maintain a HHA-wide, data-driven quality assurance and performance improvement (QAPI) program. Refer to tag G0642.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to maintain a HHA-wide, data-driven quality assurance and performance improvement (QAPI) program. Specifically, the HHA failed to fully develop, implement, evaluate, and maintain an effective, ongoing QAPI program which reflected the complexity of its organization and services. This resulted in a finding of immediate threat to patient health and safety (immediate jeopardy) (IJ) on 12/27/2022. Findings Include: 1. On 12/19/2022, an entrance interview was conducted with the administrator. During entrance, QAPI meeting for the last 12 months were requested. 2. On 12/22/2022 at 3:51 PM, an interview was conducted with the administrator. The administrator stated the HHA had not completed QAPI or performance improvement projects. 3. By 12/27/2022, the HHA had failed to provide evidence, by interview or documentation that they had developed, implemented, evaluated, and maintained an effective, ongoing, HA-wide data-driven QAPI program which reflected the complexity of its organization and services.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: 1. Based on interview and record review, it was determined the governing body failed to appoint an administrator (ADM) that was responsible for the agency's overall management and operation, the provision of all home health services, fiscal operation, review of the agency's budget and its operation plans, and its quality assessment and performance improvement (QAPI) program. Refer to tag G0942 2. Based on observation, interview, and record review, it was determined the agency failed to appoint a clinical manager (director of nursing (DON)) that was responsible for the day-to-day operations of the agency. Including making patient and personnel assignments, coordinating patient care, assuring that patient needs are continually assessed and assuring the development, implementation, and updates of the individual plan of care. (Patient identifiers: 1, 2, 3 and 4). Refer to tag G0958.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume 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 its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the governing body failed to appoint an administrator (ADM) that was responsible for the agency's overall management and operation, the provision of all home health services, fiscal operation, review of the agency's budget and its operation plans, and its quality assessment and performance improvement (QAPI) program. Specifically, the governing body (GB) consisted only of the ADM and the HHA had not had a governing body meeting. Additionally, throughout the survey process, the ADM was confused, disorganized, forgetful and required multiple reminders to submit requested information in a timely fashion. This resulted in a finding of immediate threat to patient health and safety (immediate jeopardy) (IJ) on 12/27/2022. Findings include: 1. On 12/19/2022 at 1:35 PM, an abbreviated survey was attempted at the home health agency (HHA) address on file, in St. George, UT. The sign posted on the door was for a real estate company. The door was locked. There was no answer to repeated knocks on the door. A telephone call was placed to the ADM/owner on 12/19/2022 at 1:50 PM. The ADM stated the HHA had moved to a new location. The address of the new location was provided. 2. An entrance conference with the ADM and registered nurse (RN) 1 was conducted on 12/19/2022 at 2:30 PM. Written and verbal instructions were given related to the information that needed to be electronically submitted to the survey team. The ADM was unable to focus on the information that was being presented and repeatedly asked the surveyor why he was at the HHA. When the ADM was asked questions related to the entrance requirements, the ADM referred the questions to RN 1 who appeared to be doing work at a computer. At one point, the ADM asked RN 1 to "pay attention". RN 1 responded with, "There is no need to. My last day is Friday, three days from now." The ADM was unable to provide the requested documents to the survey team and stated that he had contracted with a "friend" to assist him with gathering the required documents. On 12/19/2022 at 3:30 PM, the entrance request guidelines were again reviewed with the ADM. The ADM was encouraged to comply with submitting required information within the 1 hour and 3-hour time frames. The ADM acknowledged his understanding. 2. On 12/19/2022 at 8:25 PM, the ADM sent a text message to one of the surveyors. The ADM stated there was no HHA employees that were scheduled to do patient visits during the week of the survey. No other information was submitted as required on the entrance request form. 3. On 12/20/2022 at 9:05 AM, an attempt to gain access to the HHA office was made. The office was locked. There was no answer to repeated knocks on the door. A telephone call was placed to the ADM at 9:07 AM. The ADM stated he had to leave the office and return home to obtain information that was requested on the entrance document. The ADM stated he would be back at the office in ten minutes. Another attempt to gain access to the HHA office was made at 12:26 PM. The office was locked. There was no answer to repeated knocks on the door. Another call was placed to the ADM. The ADM stated he had gone to lunch and would be returning to the office in five minutes. 4. On 12/20/2022 at 12:47 PM, a google meeting with the survey team and the ADM was conducted. One surveyor was on-site with the ADM and two surveyors as well as the Director of Medicare Services were off-site. The missing documents that were requested during the entrance conference on 12/19/2022 was reviewed. The ADM was given one hour to provide the survey team with all documents in an electronic format. 5. On 12/20/2022 at 1:07 PM, the Home Visit Worksheet was received. It was documented that one patient had a home visit scheduled with an aide on 12/20/2022 in the morning. Note: The survey staff were previous told that no home health visits were scheduled during the week of the survey. Additionally, two of the four patients identified as having home visits during the week of the survey had been discharged from the HHA prior to 12/19/2022. 6. On 12/20/2022 at 1:15 PM, an active patient list was received. The patient list identified four patient that were on HHA services. However, it was later determined that two of patients had been discharged from the facility prior to the survey of 12/19/2022. 7. The ADM was asked to provide governing body minutes for the last 12 months. The ADM was unable to provide documented evidence of governing body minutes. The ADM was interviewed on 12/22/2022 a 3:15 PM. The ADM was asked if the governing body had a meeting in the last 12 months. The ADM stated, "No." The ADM was asked who the governing board members were. The ADM stated, "Me and my wife" Note: The ADM's wife was not alert and oriented and unable to be interviewed related to the functioning of the HHA. 8. The ADM was unable to provide a copy of the HHA's basic operating body. 9. The ADM was asked to provide the agency's QAPI plan, performance improvement projects (PIPs) and evidence of QAPI meetings. On 12/22/2022 at 3:15 PM, the ADM stated there were no PIPs or QAPI meetings.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on observation, interview, and record review, it was determined the agency failed to appoint a clinical manager (director of nursing (DON)) that was responsible for the day-to-day operations of the agency. Including making patient and personnel assignments, coordinating patient care, assuring that patient needs are continually assessed and assuring the development, implementation, and updates of the individual plan of care. (Patient identifiers: 1, 2, 3 and 4). This resulted in a finding of immediate threat to patient health and safety (immediate jeopardy) (IJ) on 12/27/2022. Findings include: 1. On 12/19/2022 at 2:30 PM, an interview was conducted with the administrator (ADM). The ADM was asked who the home health agency's (HHA) DON was. The ADM stated, "I guess (name of registered nurse (RN)1)." RN 1 stated, "That's news to me." 2. In an interview conducted on 12/20/2022 at 2:59 PM with RN1, he stated, when ask what his position was: “I am the only RN with the company, so I am doing all office stuff that requires a nurse, filling in for visits and doing admits. I think the ADM called me the clinical director.” He further stated “This is actually my fourth job. I work 4 nights a week, night shifts, at a care center. So, I have a couple hours available in the afternoon. Then I can work Thursday and Friday. My availability is pretty limited. I gave my two weeks’ notice; my last day is the end of the week.” (12/23/2022). The interview with RN1 was not complete before he stated, about halfway through the interview, that he needed to wrap things up. 3. A review of the personnel record for RN1 contained no documented evidence of a job description for clinical manager. 4. In an interview with the ADM he stated that he had hired a nurse that day but that there was not a plan for a clinical manager in the future. 5. A review of the medical records for 2 active patients and 4 discharged patients was completed. A review of each record revealed a lack of coordination of care. There was a lack of documentation to indicate that each patient's needs were continually assessed. There was a lack of documentation to indicate the development, implementation and updating of each patient's individualized plan of care. a. A review of the medical records for patient 1 with a diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris was completed on 12/29/2022. Patient 1 had orders from the Veterans Affairs (VA) stating that he was able to receive up to 20 hours per week for homemaking/health aide visits. During the last certification period patient 1 was only receiving approximately 5 hours per week from the HHA. The family was paying for 24-hour care privately. In an interview with HHA1, she stated she showered and made breakfast for the patient 5 days per week for Alpha and was also paid by the family to come back in the afternoons. Additionally, patient 1’s current plan of care (POC) was incomplete. b. A review of the medical records for patient 2 with a diagnosis of hypertension with atherosclerosis heart disease of the native coronary artery was completed on 12/29/2022. Patient 2 was listed on the current census report received on 12/20/2022 at 1:15 PM as an active patient. Patient 2 had a re-evaluation visit with physical therapy (PT) on 10/19/2022. It was recommended to continue PT for 4 to 6 more weeks. The PT visit on 10/19/2022 was the last visit that occurred. In an email received from the ADM on 12/28/2022 at 9:03 AM; he wrote that patient 2 had moved and with that knowledge he was discharged. The ADM was unable to provide a date of discharge or where she had discharged to. Additionally, patient 2’s POC was incomplete c. A review of the medical records for patient 3 with a diagnosis of hemiplegia following a cerebral infraction effecting left dominant side was completed on 12/29/2022. Patient 3 was listed on the current census report received on 12/20/2022 at 1:15 PM as an active patient. During record review it was found that patient 3 had been discharged on 12/16/2022. Additionally, patient 3’s POC was incomplete. d. A review of the medical records for patient 4 with a diagnosis of Essential (primary) hypertension was completed on 12/29/2022. Patient 4’s POC stated that he was to receive skilled Nursing (SN) visits once every 60 days, aide visits three times per week and homemaking visits 2 times per week. All homemaking and aide visits were being completed by a personal care agency. In an interview with patient 4 on 12/28/2022 at 1:15 PM, patient 4 stated that he did not know who Alpha Home Health was. Patient 4’s current plan of care was not complete and inaccurate.