Every finding on record at Atchison Hospital Association

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (#1D8331-H1) at the above-named Home Health Agency (HHA) on 10/30/25 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (#1D8331-H1) conducted at the above-named Home Health Agency (HHA) from 09/30/25 to 10/02/25 resulted in a finding of substantial compliance respective to applicable Condition of Participation (COP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

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 record review and document review, the Home Health Agency (HHA) failed to ensure the patient's right to receive the contact information for the HHA's administrator, including the administrator's name, business address, and business phone number in order to receive complaints for 10 of 10 sample patients (Patients 1-10). The agency's failure to ensure the patient's right to receive the contact information for the administrator, placed all patients currently on service, at risk for unmet needs due to not being able to contact the home health agency's administrator. Findings Include: Review of all admission documents for Patients 1 through 10, showed the agency failed to document any evidence the Agency's Administrator contact information was provided to the patients during the admission process or thereafter. Review of Agency Admission packet and all admission documents provided, showed the agency failed to provide any written information regarding the Agency's Administrator contact information, such as name, address or business phone number, being giving during the admission process or thereafter.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the Home Health Agency (HHA) failed to ensure that when receiving a general referral for home health services that the physician was contacted for orders based off of assessment finding when developing patient plans of care for 8 of 10 sample patients (Patients 1,2,3,4,6,7,8,10). This deficient practice placed all patients at risk for unmet care needs, and adverse outcomes related to the lack of care coordination with the physician regarding the plan of care. Findings Include: Patient 1 Review of Patient 1's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/12/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/12/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 2 Review of Patient 2's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/19/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/19/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 3 Review of Patient 3's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/27/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/29/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 4 Review of Patient 4's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/04/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/04/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 6 Review of Patient 6's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/18/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/18/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 7 Review of Patient 7's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/06/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment not showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatment listed on the plan of care. The Occupational Therapist completed their evaluation on 09/08/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 8 Review of Patient 8's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/14/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatment listed on the plan of care. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 10 Review of Patient 10's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/11/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatment listed on the plan of care. The Occupational Therapist completed their evaluation on 06/11/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. During an interview on 10/02/25 at 9:15 AM, Staff A, Agency Director confirmed the above finding of lack of care coordination with the physician regarding the plan of care.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the Home Health Agency (HHA) failed to ensure all patients plans of care included all required elements, such as all safety measures for all medications they were taking for 4 of 10 sample patients (Patients 5, 6, 9, 10). This deficient practice placed all patients at risk for unmet care needs, and adverse outcomes. Findings Include: Patient 5 Review of Patient 5's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 08/22/25. The Principle Diagnosis showed; Metabolic Encephalopathy. The listed medications showed; Aspirin 81 mg oral tab once daily. Review of the safety measures listed on the plan of care lacked evidence of bleeding precautions for the patient. Patient 6 Review of Patient 6's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/18/25. The Principle Diagnosis showed; Acute Cystitis with Hematuria. The listed medications showed; Plavix 75 mg oral tab once daily. Review of the safety measures listed on the plan of care lacked evidence of bleeding precautions for the patient. Patient 9 Review of Patient 9's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/24/25. The Principle Diagnosis showed; Displaced Fracture of Femur. The listed medications showed; Aspirin 81 mg oral tab once daily. Review of the safety measures listed on the plan of care lacked evidence of bleeding precautions for the patient. Patient 10 Review of Patient 10's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/11/25. The Principle Diagnosis showed; Compression Fracture of T11 and T12 Vertebra. The listed medications showed; Aspirin 81 mg oral tab once daily. Review of the safety measures listed on the plan of care lacked evidence of bleeding precautions for the patient. During an interview on 10/02/25 at 9:50 AM, Staff A, Agency Director confirmed the above findings of not having all the specific requirements, treatments, and safety measures included as a part of the patient's plans of care.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, and staff interview, it was determined the Home Health Agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient health care services for 1 of 10 sample patients (Patient 10). The HHA also failed to send a discharge summary to the primary care physician responsible for patient's health care services, within 5 business days from the date of discharge for 1 of 10 sample patients (Patient 8). This deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. Findings Include: Patient 10 Review of Patient 10's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/11/25. Review of visit notes for the current certification period showed a transfer to the hospital on 07/03/25. The HHA completed an OASIS/Transfer to In-Patient Facility (TIF) on 07/03/25 however, there was no evidence of a Transfer Summary being completed with the TIF. There was no evidence of a Transfer Summary being sent to the receiving facility. Patient 8 Review of Patient 8's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/14/25. Review of the visit notes for the current certification period showed the patient was discharged on 07/28/25 and a discharge summary was completed at that time. However, the summary was not sent to the physician until 08/11/25 which was greater than 5 business days from the discharge date of 07/28/25. During an interview on 10/02/25 at 10:05 AM, Staff A, Agency Director, confirmed the above findings of the agency not providing Transfer/Discharge Summaries in a timely manner to the receiving health care providers.

A Vaccine Requirement Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Service (CMS). An unannounced on-site Vaccine Requirement survey conducted at the above named Home Health Agency (HHA) facility on 08/22/2022 resulted in findings of substantial compliance respective to applicable Conditions of Participation (CoP) under 484.70 Infection Prevention and Control with the following standard level deficiency cited below. Patient Sample Size: 0 Staff Sample Size: 8

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and agency policy review, the Home Health Agency (HHA) failed to have a process for ensuring the use of additional precautions for staff who were not fully vaccinated for COVID-19. Of the current 15 staff members, 11 (73.3%) were fully vaccinated, and four (26.7%) staff members had been granted a non-medical exemption and were unvaccinated. This had the potential to affect all staff of the HHA and all patients who receive care from the HHA agency. Finding include: Review of the HHA policy titled “Covid-19 Universal PPE [personal protective equipment],” undated, revealed, “Masks are required to protect the airway. Eye protection is required as infectious droplets could meet the eye and spread down the tear duct into the respirator tract. Use of eye protection and universal masking mitigate this transmission from occurring. Due to continually evolving evidence, we expect these guidelines will be further refined and revised. Universal PPE does not replace other precautions such as standard, droplet, contact, or airborne…ENGAGEMENT CONSIDERATIONS 1. To be successful, this will require support from all employees and the following is expected: a. Meticulous adherence to hand hygiene, b. Proper mask use, including wearing the mask as directed to cover the mouth and nose, c. Strict avoidance of manipulation/touching the mask or eye protection to reduce the risk of contamination and self-inoculation, d. Proper use of eye protection as outlined.” No information was identified in the policy related to a process for ensuring additional precautions for staff who were not fully vaccinated for COVID-19. Interview on 08/22/22 at 11:30 AM via telephone with the Chief Nursing Officer (CNO) revealed the HHA implemented universal precautions and had not implemented additional precautions for staff who were unvaccinated or contingency plans for staff who were not fully vaccinated. She stated that precautions used are the same regardless of vaccination status. When staff members have contact with patients, they are to wear a mask and use good hand hygiene, unless the patient has COVID or is under investigation for COVID, and then are expected to wear appropriate PPE. She indicated that the policies had not been updated to reflect current practice due to the frequency of changes and staff were provided with updates on an ongoing basis following task force meetings. Interview on 08/22/22 at 12:40 PM, the Infection Preventionist (IP) verified the HHA policies and procedures did not address additional precautions for unvaccinated staff, or contingency plans for unvaccinated staff. Interview on 08/22/22 at 2:00 PM, with a Registered Nurse (RN1) who had been granted a non-medical exemption revealed she did not use any precautions other than those that staff who were vaccinated for COVID-19 were expected to use. She reported that she wore a surgical mask and used antibiotic gel and good handwashing when making home visits to patients, unless the patient was COVID positive or suspected to have COVID, then she would wear full PPE including a N95 mask, goggles, gown, gloves, booties, and use good handwashing and antibiotic gel before and after. Interview on 08/22/22 at 2:20 PM, with RN2 who had been granted a non-medical exemption revealed she was not required to use any extra precautions than staff members who were vaccinated. She reported that she wore a mask in patient homes and used good handwashing. She used full PPE if caring for a patient with COVID-19 or if the patient had symptoms. She said she calls the patient prior to the visit to screen for symptoms so she knows if she needs to use full PPE prior to entering the home.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (#4EE04-H1) at the above-named Home Health Agency from 06/23/22 to 06/24/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (#4EE04-H1) at the above-named Home Health Agency from 06/23/22 to 06/24/22 resulted in a finding of substantial compliance respective to applicable COP under 42 CFR 484, Subpart A through C, with the following standard deficiencies.

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 document review, policy review and interview, the Home Health Agency (HHA) failed to ensure a written notice of the HHA’s transfer and discharge policies as set forth in 42 CFR 484.50(d) was provided to the patient and patient's legal representative (if any), during the initial evaluation visit, in advance of furnishing care to patients. The HHA’s failure to ensure patients receive written transfer and discharge policies in advance of furnishing care has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of U.S. Code of Federal Regulations at 42 CFR 484.50(d) required: Standard: Transfer and discharge: The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: The transfer or discharge is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; The patient or payer will no longer pay for the services provided by the HHA; The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; The patient refuses services, or elects to be transferred or discharged; The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: (i) Advise the patient, representative (if any), the physician(s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and (iv) Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records; The patient dies; or The HHA ceases to operate. Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d). Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to be free from mental and sexual abuse, including injuries of unknown source, neglect and misappropriation of property. The HHA’s failure to ensure patients received comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights Policy,” undated, showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed each patient shall have the right to be free from verbal, physical and psychological abuse. The Bill of Rights did not include the right to be free from mental, sexual, injuries of unknown source, neglect, and misappropriation of property. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to make complaints to the HHA regarding the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA. The HHA’s failure to ensure patients receive a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights, undated, showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed the written notice of Rights did not include the right to make complaints to the HHA regarding the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to participate in, be informed about, and consent or refuse care during treatment, where appropriate, with respect to; Completion of all assessments; The care to be furnished, based on the comprehensive assessment; Establishing and revising the plan of care; Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits and Any factors that could impact treatment effectiveness. The HHA’s failure to ensure patients receive a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights Policy, undated," showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed the written notice of Rights did not include the right to participate in, be informed about, and consent or refuse care during treatment, where appropriate, with respect to; Completion of all assessments; The care to be furnished, based on the comprehensive assessment; Establishing and revising the plan of care; Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits and Any factors that could impact treatment effectiveness. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

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, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to receive all services outlined in the plan of care. The HHA’s failure to ensure patients receive a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights Policy, undated," showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed the written notice of Rights did not include the right to receive all services outlined in the plan of care. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to a confidential clinical record that included access to or release of patient information and clinical records permitted in accordance with 45 CFR parts 160 and 164. The HHA’s failure to ensure patients receive a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights Policy, undated," showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed the written notice of Rights did not include the right to a confidential clinical record that included access to or release of patient information and clinical records permitted in accordance with 45 CFR parts 160 and 164. During an interview on 06/24/22 at 8:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to be advised ,orally and in writing, of any changes in: 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 and The charges the individual may have to pay before care is initiated.. 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’s failure to ensure patients receive a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights Policy, undated," showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed the written notice of Rights did not include the right to be advised, orally and in writing, of any changes in: 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 and The charges the individual may have to pay before care is initiated. The policy did not include that 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. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA’s failure to ensure patients receive a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights Policy, undated," showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed the written notice of Rights did not include the right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities 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 that included: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization. The HHA’s failure to ensure patients received comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights Policy, undated," showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed the written notice of Rights did not include the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to be informed of the right to access auxiliary aids and language services , and how to access these services. The HHA’s failure to ensure patients received comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patient Bill of Rights Policy, undated," showed the purpose was to establish the rights and responsibilities of patients. Review of the HHA’s patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled, "Home Health Bill of Rights,” undated showed the written notice of Rights did not include the right to be informed of the right to access auxiliary aids and language services, and how to access these services. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency written notice of patient's rights and responsibilities not contain all required rights.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the patient and representative (if any) were informed of the agency's policies for transfer and discharge. The HHA failed to ensure the agency's written policy for discharge and transfer included the required circumstances under which the HHA may transfer or discharge the patient from the HHA. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d). Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure patients are informed that the agency may transfer or discharge the patient from the agency if necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity.. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that require the HHA to ensure patients are informed that the agency may transfer or discharge the patient from the agency if is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure patients are informed that the agency may transfer or discharge the patient from the agency if the patient or payer will no longer pay for the services provided by the HHA. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that require the HHA to ensure patients know that the agency may transfer or discharge the patient from the agency if the patient of payer will no longer pay for the services provided by the HHA. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure patients are informed that the agency may transfer or discharge the patient from the agency if the transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that require the HHA to ensure patients are informed that the agency may transfer or discharge the patient from the agency if the transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure patients are informed that the agency may transfer or discharge the patient from the agency if the patient refuses services or elects to be transferred or discharged. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that require the HHA to ensure patients are informed that the agency may transfer or discharge the patient from the agency if the patient refuses services or elects to be transferred or discharged. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure patients are informed that the agency may transfer or discharge the patient from the agency if the HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of 42 CFR 484.50 paragraphs (d)(5)(i) through (d)(5)(iii) , that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that require the HHA to ensure patients are informed that the agency may transfer or discharge the patient from the agency if the HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii), that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to include in their policy that the agency will advise the patient, representative (if any), the physician(s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered, prior to discharge of patients for cause. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that require the HHA to ensure the agency advise the patient, representative (if any), the physician(s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered, prior to discharge of patients for cause. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the agency made efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation, prior to discharging patients for cause. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that require the HHA to ensure the agency make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation, prior to discharging patients for cause. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the HHA provided the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care, prior to discharging patients for cause. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that require the HHA to ensure the HHA provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care, prior to discharging patients for cause. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to have in policy that efforts would be made to document and resolve the problem(s) and entered this documentation into its clinical records prior to discharging patients for cause. The HHA’s failure to adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer Procedure," undated, showed the Policy/Purpose was to ensure a smooth transition for patient and family due to discharge or transfer of care. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency documented the problem(s) and efforts made to resolve the problem(s) and entered this documentation into its clinical records prior to discharging patients for cause. Review of the HHA’s patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 06/24/22 at 11:32 AM, Staff A, Administrative Director, confirmed the information and policies provided to patients regarding discharges, transfers and rights and responsibilities from the agency required revision. The agency failed to develop transfer and discharge policies with required information for disclosure to patients, as required on admission.