Every finding on record at Beta Factor Home Care, LLC

An Emergency Preparedness Recertification Survey was completed on 10/27/22. The agency was found to be in compliance with the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies.

A recertification survey was completed on 10/27/22. Condition level and Standard level deficiencies were cited. Glossary: AC Anticoagulant COPD Chronic Obstructive Pulmonary Disease EMR Electronic Medical Record GERD Gastroesophageal Reflux Disease PCP Primary Care Provider PIP Performance Improvement Project PRN As Needed PT Patient RN Registered Nurse QAPI Quality Assurance and Performance Improvement QI Quality Improvement YR Year

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Due to the manner and degree of the deficient practices, the agency failed to meet the Condition of Participation: Patient Rights for Home Health Agencies. Based on interview and record review, the agency failed to: Ensure the patient's property was treated with respect (see G0428); Ensure a home visit was scheduled, per the patient's preference, when home health personnel entered the home (see G0428); Protect its patients from abuse by misappropriation of medications (see G0430); Investigate allegations of abuse thoroughly (see G0430); Prevent further instances of misappropriation of medications (see G0430); Investigate an allegation of misappropriation of patient property as a complaint (see G0478); Document a complaint allegation of abuse for misappropriation of medication (see G0484); Provide patients complaint resolutions for misappropriation of medications (see G0484); and Protect patients from further misappropriation of patient property, after an allegation of theft of medications was reported to the agency and during an active investigation (see G0482 and G0486). The accumulation of these deficient practices contributed to the adverse patient outcomes, including the rationing of pain medication supply, difficulty managing pain, and multiple reported patient requests to deny future entrance to their homes by staff member H.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patients' property was treated with respect for 5 patients (#s 8, 9, 10, 11, and 12) of 5 sampled patients; and failed to ensure a home visit was scheduled, per the patients' preference, when home health personnel entered the home for 3 patients (#s 9, 11, and 12) of 5 sampled patients. Findings include: Review of agency policy, Patient Rights, last revision date of 10/13/21, showed, “…Patients’ Rights include at a minimum; Have his or her property and person treated with respect; Be free from…misappropriation of property; Make complaints to the agency 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 agency; Participate in, be informed about, and consent or refuse care in advance of and during treatment…” 1. Respect for Property Review of the Client Occurrence Report on 3/14/22, for patient #12, was categorized as “other” alleging staff member H stole his oxycodone from his home. Staff member H returned for an unscheduled, independent visit to patient #12's home right after a combined visit with staff member E. Staff member H conveyed to patient #12, staff member E had forgotten his phone at the patient's home. After staff member H left patient #12's home, he noticed his pain pills were missing from their regular placement beside his recliner, where he always kept them. No investigation was completed for the allegation reported by patient #12. Staff member H was not placed on leave and no protection for patient #12 or other patients was put in place. Review of the agency document, QI Event Summary, showed four complaint events for drug misappropriation by staff member H for patient #s 8, 9, 10, and 11. Patient #12 was not listed. Review of the agency Complaint Reports attached showed: Documented on 4/22/22 for a complaint on 4/18/22, reported by staff member D, for patient #10, alleging staff member H stole her oxycodone under the guise of needing to count them and “accidently” dumping them on the floor on 4/11/22. The patient alleged she had just filled the prescription and had only taken two pills so she should have had 21 pills remaining, but after staff member H left her home she only had eight pills left. The form showed staff member H was suspended on 4/20/22 after a meeting at 11:30 a.m., with a scheduled drug test at 3:45 p.m. The form showed on, 4/22/22 at 4:43 p.m. staff member H called and resigned and had refused the drug test. Documented on 4/22/22 for a complaint on 4/19/22, reported by staff member E, for patient #8’s family member, alleging staff member H stole patient #8's Percocet pills from his medication planner which she had just filled. Staff member H also stole two Percocet from patient #8's windowsill which he used as needed to control his pain. The form showed staff member H was asked about the event and staff member H stated she had gone to patient #8’s home at noon on 4/19/22 but did not go into the house because the prescriptions were not there to fill his medication planner. The form showed staff member H called at 4:43 p.m. on 4/21/22 to resign and the corporate office was notified of the resignation on 4/22/22. Documented on 4/22/22 for a complaint on 4/22/22, reported by staff member F, for patient #9, alleging staff member H came to his home on 3/31/22 for an unscheduled and unannounced admission visit. Staff member H refused to leave for an hour because she was digging through patient #9's garbage for his pain medications. This was after staff member H tried to force patient #9 to dig the pain medications out of the garbage himself. Patient #9 explained to staff member H he had just gotten out of the nursing home and doing that would put him back in the nursing home. Patient #9 told staff member H his daughter had disposed of the pain medication because she did not think he needed it and did not want him to become addicted to them. The form showed staff member H made a coordination note in the EMR but never completed the admission visit assessment that she announced on entrance to her unscheduled visit to patient #9's home. The form showed staff member H was suspended at noon on 4/20/22 and called with her resignation on 4/21/22 at 6:00 p.m. Documented on 5/17/22 for a late entry for 5/2/22, reported by staff member F, for patient #11, alleging staff member H showed up to her home on 5/19/22 [staff member B stated the month should have been April] and then showed up unscheduled and unannounced on 5/20/22 and 5/21/22 [staff member B stated the month should have been April]. Patient #11 did not know what staff member H's subsequent visits were related to on the 21st and 22nd, but she had just received a new refill for a month of her hydrocodone prescription, which was prescribed four times a day for pain. Patient #11 and her son stated the hydrocodone bottle label looked like someone tried to scratch off the amount of pills, which should have been 120. Patient #11 only had 60 hydrocodone pills in the bottle after staff member H's visits to her home. Patient #11 and her son had called the pharmacy to confirm the number of pills in the refill and the pharmacy conveyed they dispensed 120 pills and this was a noted trend for staff member H to steal medications and recommended patient #11 and her son should make a police report. The report noted staff member H had already resigned prior to the allegation. Multiple dates and times in these forms were contradictory for events, staff member H's resignation and documentation. During an interview on 10/26/22 at 2:43 p.m., staff member B stated some of the dates and times she documented were wrong but any other questions related to the allegations and investigations would have to be answered by an attorney. During an interview on 10/27/22 at 12:09 p.m., staff member E stated the first allegation of misappropriation of medication by staff member H he was made aware of was from patient #12, which was only a few weeks after staff member H started working (February 2022) for the agency. Patient #12 alleged staff member H returned to his home after a combined visit with staff member E. Staff member H told patient #12 staff member E left his phone at his home. Staff member E stated the allegation was reported to staff member B. Staff member E stated patient #12 was adamant his pills were stolen from beside his recliner and did not want staff member H allowed back into his home. Staff member E stated he did not know if any investigation was done, but staff member H continued working without any suspension. Staff member E stated there were several more patient allegations of misappropriation of medication by staff member H all around the same time. Staff member E stated some patients had to ration their pain medications, such as patient #11 who had half of her new medication refill stolen. Staff member E stated patient #8's daughter also reported his Percocet was missing from his medication planner and his as needed pain medication from his windowsill after staff member H showed up to patient #8's home. During an interview on 10/27/22 at 2:32 p.m., staff member F stated there were multiple patients with allegations of misappropriation of medications by staff member H. Patient #9 alleged staff member H had dug through his garbage for his pain pills. Patient #10 reported staff member H pretended to spill the pain medication all over the floor and the patient caught her in the act of stealing them. Patient #11 alleged staff member H went into the bathroom as soon as she arrived. Staff member F stated agency staff were not to use the patient’s bathrooms or any of their property that were not related to their care. 2. Respect for Person During an interview and record review on 10/26/22 at 12:37 p.m., staff member A stated they only had the scheduled visits for staff member H when she started visits independently and has no way to know what visits she accompanied other clinicians on before her first independent visits on 3/10/22. Review of the printed calendar of staff member H’s scheduled patient visits from February 2022 to April 2022 showed: 3/16/22- scheduled visit for patient #8 3/31/22- no scheduled visit for patient #9 (staff member H had an unscheduled and unannounced visit to patient #9's home) 4/11/22- scheduled visit for patient #10 4/19/22- scheduled visit for patient #11, no scheduled visit for patient #8 (staff member H had an unscheduled and unannounced visit to patient #8's home) 4/20-no scheduled visit for patient #11 (staff member H had an unscheduled and unannounced visit to patient #11's home) 4/21/22- no scheduled visit for patient #11 (staff member H had an unscheduled and unannounced visit to patient #11's home) All of these patient visits were conducted independently by staff member H from 3/16/22 to 4/21/22, and were after the initial allegation of misappropriation of medications were made by patient #12 on 3/14/22.

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 interview and record review, the agency failed to protect its patients from abuse by misappropriation of medications, failed to prevent further instances of abuse, and failed to investigate allegations of abuse thoroughly for 5 (#s 8, 9, 10, 11, and 12) of 5 sampled patients. Findings include: Review of agency policy, Duty to Report, last revised 8/5/21, showed, “…Concerns related to patient adverse events, including suspected patient abuse or neglect whether or not there is evidence of such, must be reported immediately…each reported quality of care concern/patient adverse event is promptly assessed and, as warranted, fully investigated, appropriate corrective action is taken, and as required, timely and complete notifications are made.” Review of agency policy, Patient Rights, last revision date of 10/13/21, showed, “…Patients’ Rights include at a minimum; Have his or her property and person treated with respect; Be free from…misappropriation of property; Make complaints to the agency 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 agency; Participate in, be informed about, and consent or effuse care in advance of and during treatment…” Review of agency policy, Response and Corrective Action, last revised 8/5/21, showed, “At the conclusion of each compliance investigation, the Department will ensure appropriate action is taken to correct, and prevent recurrence of, any identified compliance concern(s). Upon completion of each compliance investigation… These remedial measures may include actions, as applicable, such as: Disciplinary action…; Training…; Revision of Company policy or procedure; Implementation of a formal corrective action plan; Reporting to Federal or state authorities…" Review of agency policy, Complaints, Communication, Accessibility, last revised 10/12/21, showed, “The Administrator is responsible to ensure all aspects of complaint investigation, reporting, tracking, and communication are carried out, including escalation from the program to the corporate compliance team/legal counsel if indicated. Allegations of abuse, neglect, exploitation, and misappropriation of property will be investigated when [the agency] is made aware of the allegation and will be reported according to state statute or within 5 days, whichever is soonest. The full investigation may take longer than 5 days but the initial determination of whether an allegation of abuse, neglect, exploitation, or misappropriation of property is credible and requires external reporting should be acted upon according to this timeframe. [The agency] ensures all complaints and grievances are: documented, investigated, resolved as much as feasible to the satisfaction of the complainant.” Review of the Client Occurrence Report on 3/14/22, for patient #12 was categorized as “other” alleging staff member H stole his oxycodone from his home. Staff member H returned for an unscheduled, independent visit to patient #12's home right after a combined visit with staff member E. Staff member H conveyed to patient #12, staff member E had forgotten his phone at the patient's home. After staff member H left patient #12's home, he noticed his pain pills were missing from their regular placement beside his recliner, where he always kept them. No investigation was completed for the allegation reported by patient #12. Staff member H was not placed on leave and no protection for patient #12 or other patients was put in place. Review of the agency document, QI Event Summary, showed four complaint events for drug misappropriation by staff member H for patient #s 8, 9, 10, and 11. Patient #12 was not listed. Review of the agency Complaint Reports attached showed: Documented on 4/22/22 for a complaint on 4/18/22, reported by staff member D, for patient #10, alleging staff member H stole her oxycodone under the guise of needing to count them and “accidently” dumping them on the floor on 4/11/22. The patient alleged she had just filled the prescription and had only taken two pills so she should have had 21 pills remaining, but after staff member H left her home she only had eight pills left. The form showed staff member H was suspended on 4/20/22 after a meeting at 11:30 a.m., with a scheduled drug test at 3:45 p.m. The form showed on 4/22/22 at 4:43 p.m. staff member H called and resigned and had refused the drug test. Documented on 4/22/22 for a complaint on 4/19/22, reported by staff member E, for patient #8’s family member, alleging staff member H stole patient #8's Percocet pills from his medication planner which she had just filled. Staff member H also stole two Percocet from patient #8's windowsill which he used as needed to control his pain. The form showed staff member H was asked about the event and staff member H stated she had gone to patient #8’s home at noon on 4/19/22 but did not go into the house because the prescriptions were not there to fill his medication planner. The form showed staff member H called at 4:43 p.m. on 4/21/22 to resign and the corporate office was notified of the resignation on 4/22/22. Documented on 4/22/22 for a complaint on 4/22/22, reported by staff member F, for patient #9, alleging staff member H came to his home on 3/31/22 for an unscheduled and unannounced admission visit. Staff member H refused to leave for an hour because she was digging through patient #9's garbage for his pain medications. This was after staff member H tried to force patient #9 to dig the pain medications out of the garbage himself. Patient #9 explained to staff member H he had just gotten out of the nursing home and doing that would put him back in the nursing home. Patient #9 told staff member H his daughter had disposed of the pain medication because she did not think he needed it and did not want him to become addicted to them. The form showed staff member H made a coordination note in the EMR but never completed the admission visit assessment that she announced on entrance to her unscheduled visit to patient #9's home. The form showed staff member H was suspended at noon on 4/20/22 and called with her resignation on 4/21/22 at 6:00 p.m. Documented on 5/17/22 for a late entry for 5/2/22, reported by staff member F, for patient #11, alleging staff member H showed up to her home on 5/19/22 [staff member B stated the month should have been April] and then showed up unscheduled and unannounced on 5/20/22 and 5/21/22 [staff member B stated the month should have been April]. Patient #11 did not know what staff member H's subsequent visits were related to on the 21st and 22nd, but she had just received a new refill for a month of her hydrocodone prescription, which was prescribed four times a day for pain. Patient #11 and her son stated the hydrocodone bottle label looked like someone tried to scratch off the amount of pills, which should have been 120. Patient #11 only had 60 hydrocodone pills in the bottle after staff member H's visits to her home. Patient #11 and her son had called the pharmacy to confirm the number of pills in the refill and the pharmacy conveyed they dispensed 120 pills and this was a noted trend for staff member H to steal medications and recommended patient #11 and her son should make a police report. The report noted staff member H had already resigned prior to the allegation. Multiple dates and times in these forms were contradictory for events, staff member H's resignation and documentation. During an interview on 10/26/22 at 2:43 p.m., staff member B stated some of the dates and times she documented were wrong but any other questions related to the allegations and investigations would have to be answered by an attorney. During a QAPI interview on 10/25/22 at 9:15 a.m., staff members I, J, and K were present on a video call. Staff member I stated for complaints related to medication misappropriation she was not directly involved in the incidents. She only reviewed the reports after the investigation was completed. Staff member I stated staff member H was, “No longer Employed.” Staff member I stated the investigation was done by staff member B and if staff member B had identified any areas to change such as policies or processes, staff member I would have been involved in any training or PIPs needed in QAPI, but there were none identified. Review of the agency document, Home Health QAPI Meeting Minutes, dated 5/10/22, under the row for ‘other’ showed: “1” instance, discussion of, “Pt. alleged his oxycodone was stolen. PCP notified and switching med from bottle to blister packs, and PRN to scheduled med.” All the rest of the areas in the “other” row for "follow-up action required," "action plan," "by when" (due date), and "who" (was responsible) were left blank. Review of the agency document, Home Health QAPI Meeting Minutes, dated 8/10/22, under the row for ‘other’ showed: “1” instance, discussion of, “r/t RN taking pills,” Follow-up Action required, “No,” Action Plan, “RN no longer with us.” The "by when" (due date) and "who" (was responsible) were left blank. The agency did not track the multiple allegations of medication misappropriation by staff member H. The agency did not investigate the allegations, did not protect patients, or prevent further instances of medication misappropriation from patients by staff member H. During an interview on 10/27/22 at 12:09 p.m., staff member E stated the first allegation of misappropriation of medication by staff member H he was made aware of was from patient #12, which was only a few weeks after staff member H started working (February 2022) for the agency. Patient #12 alleged staff member H returned to his home after a combined visit with staff member E. Staff member H told patient #12 staff member E left his phone at his home. Staff member E stated the allegation was reported to staff member B. Staff member E stated patient #12 was adamant his pills were stolen from beside his recliner and did not want staff member H allowed back into his home. Staff member E stated he did not know if any investigation was done, but staff member H continued working without any suspension. Staff member E stated there were several more patient allegations of misappropriation of medication by staff member H all around the same time. Staff member E stated some patients had to ration their pain medications, such as patient #11 who had half of her new medication refill stolen. Staff member E stated patient #8's daughter also reported his Percocet was missing from his medication planner and his as needed pain medication from his windowsill after staff member H showed up to patient #8's home. During an interview on 10/27/22 at 2:32 p.m., staff member F stated there were multiple patients with allegations of misappropriation of medications by staff member H. Patient #9 alleged staff member H had dug through his garbage for his pain pills. Patient #10 reported staff member H pretended to spill the pain medication all over the floor and the patient caught her in the act of stealing them. Patient #11 alleged staff member H went into the bathroom as soon as she arrived. Staff member F stated agency staff were not to use the patient’s bathrooms or any of their property that were not related to their care. During an interview and record review on 10/27/22 at 12:54 p.m., staff member D stated from February 2022 until May 2022 they had no clinical manager for the agency. Staff member D provided a hand-written list of dates for the times staff member B was onsite at the agency. The hand-written note showed the dates of 2/9/22 to 2/10/22, 3/2/22 to 3/4/22, 3/22/22 to 3/24/22, 4/27/22 to 4/29/22, and 5/18/22 to 5/20/22. During all other times there was no supervisory oversight of personnel including nurses. During an interview on 10/27/22 at 2:05 p.m., staff member A stated staff member L left her position as Director of Clinical Services at the agency on 2/4/22 and staff member A took the position on 5/16/22.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to investigate an allegation of misappropriation of patient property as a complaint made by 1 (#12) of 5 sampled patients. Findings include: During an interview on 10/27/22 at 12:09 p.m., staff member E stated the first allegation of misappropriation of medication by staff member H he was made aware of was from patient #12, which was only a few weeks after staff member H started working (February 2022) for the agency. Patient #12 alleged staff member H returned to his home after a combined visit with staff member E. Staff member H told patient #12 staff member E left his phone at his home. Staff member E stated the allegation was reported to staff member B. Staff member E stated patient #12 was adamant his pills were stolen from beside his recliner and did not want staff member H allowed back into his home. Staff member E stated he did not know if any investigation was done, but staff member H continued working without any suspension. Review of the Client Occurrence Report on 3/14/22, for patient #12 was categorized as “other” alleging staff member H stole his oxycodone from his home. Staff member H returned for an unscheduled, independent visit to patient #12's home right after a combined visit with staff member E. Staff member H conveyed to patient #12, staff member E had forgotten his phone at the patient's home. After staff member H left patient #12's home, he noticed his pain pills were missing from their regular placement beside his recliner, where he always kept them. No investigation was completed for the allegation reported by patient #12. Staff member H was not placed on leave and no protection for patient #12 or other patients was put in place. This was not included in the complaints log for the last year.

Mistreatment, neglect or abuse CFR(s): 484.50(e)(1)(i)(B) (i)(B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to protect the rights of patients to be free from misappropriation of patient property, while an active, ongoing investigation was being conducted for 5 patients (#s 8, 9, 10, 11, and 12) of 5 sampled patients. Findings include: Review of agency policy, Response and Corrective Action, last revised 8/5/21, showed, “At the conclusion of each compliance investigation, the Department will ensure appropriate action is taken to correct, and prevent recurrence of, any identified compliance concern(s). Upon completion of each compliance investigation… These remedial measures may include actions, as applicable, such as: Disciplinary action…; Training…; Revision of Company policy or procedure; Implementation of a formal corrective action plan; Reporting to Federal or state authorities…" During an interview on 10/27/22 at 12:09 p.m., staff member E stated the first allegation of misappropriation of medication by staff member H he was made aware of, was from patient #12 only a few weeks after staff member H started working at the agency. Patient #12 alleged staff member H returned to his home after a combined visit with staff member E. Staff member H told patient #12 staff member E left his phone at his home. Staff member E stated it was reported to staff member B and patient #12 was adamant his pills were stolen from beside his recliner and did not want staff member H allowed back into his home. Staff member E stated he did not know if any investigation was done but staff member H continued to work without any suspension. Staff member E stated there were several more patient allegations all around the same time. Staff member E stated some patients had to ration their pain medications like patient #11 who had half of her new medication refill stolen. She was cutting her pills in half and quarters. Patient #8 was struggling with his pain after alleging staff member H stole his Percocet. During the time of the allegations there was no clinical oversight due to the position of clinical manager being unfilled. During an interview on 10/27/22 at 2:32 p.m., staff member F stated there were multiple patients with allegations of misappropriation of medications by staff member H. Patient #9 alleged staff member H had dug through his garbage for his pain pills. Patient #10 reported staff member H pretended to spill the pain medication all over the floor and the patient caught her in the act of stealing them. Patient #11 alleged staff member H went into the bathroom as soon as she arrived. Staff member F stated agency staff were not to use the patient’s bathrooms or any of their property that were not related to their care. Review of the Client Occurrence Report on 3/14/22, for patient #12 was categorized as “other” alleging staff member H stole his oxycodone from his home. Staff member H returned for an unscheduled, independent visit to patient #12's home right after a combined visit with staff member E. Staff member H conveyed to patient #12, staff member E had forgotten his phone at the patient's home. After staff member H left patient #12's home, he noticed his pain pills were missing from their regular placement beside his recliner, where he always kept them. No investigation was completed for the allegation reported by patient #12. Staff member H was not placed on leave and no protection for patient #12 or other patients was put in place. Review of the agency document, QI Event Summary, showed four complaint events for drug misappropriation by staff member H for patient #s 8, 9, 10, and 11. Patient #12 was not listed. Review of the agency Complaint Reports attached showed: Documented on 4/22/22 for a complaint on 4/18/22, reported by staff member D, for patient #10, alleging staff member H stole her oxycodone under the guise of needing to count them and “accidently” dumping them on the floor on 4/11/22. The patient alleged she had just filled the prescription and had only taken two pills so she should have had 21 pills remaining, but after staff member H left her home she only had eight pills left. The form showed staff member H was suspended on 4/20/22 after a meeting at 11:30 a.m., with a scheduled drug test at 3:45 p.m. The form showed on 4/22/22 at 4:43 p.m. staff member H called and resigned and had refused the drug test. Documented on 4/22/22 for a complaint on 4/19/22, reported by staff member E, for patient #8’s family member, alleging staff member H stole patient #8's Percocet pills from his medication planner which she had just filled. Staff member H also stole two Percocet from patient #8's windowsill which he used as needed to control his pain. The form showed staff member H was asked about the event and staff member H stated she had gone to patient #8’s home at noon on 4/19/22 but did not go into the house because the prescriptions were not there to fill his medication planner. The form showed staff member H called at 4:43 p.m. on 4/21/22 to resign and the corporate office was notified of the resignation on 4/22/22. Documented on 4/22/22 for a complaint on 4/22/22, reported by staff member F, for patient #9, alleging staff member H came to his home on 3/31/22 for an unscheduled and unannounced admission visit. Staff member H refused to leave for an hour because she was digging through patient #9's garbage for his pain medications. This was after staff member H tried to force patient #9 to dig the pain medications out of the garbage himself. Patient #9 explained to staff member H he had just gotten out of the nursing home and doing that would put him back in the nursing home. Patient #9 told staff member H his daughter had disposed of the pain medication because she did not think he needed it and did not want him to become addicted to them. The form showed staff member H made a coordination note in the EMR but never completed the admission visit assessment that she announced on entrance to her unscheduled visit to patient #9's home. The form showed staff member H was suspended at noon on 4/20/22 and called with her resignation on 4/21/22 at 6:00 p.m. Documented on 5/17/22 for a late entry for 5/2/22, reported by staff member F, for patient #11, alleging staff member H showed up to her home on 5/19/22 [staff member B stated the month should have been April] and then showed up unscheduled and unannounced on 5/20/22 and 5/21/22 [staff member B stated the month should have been April]. Patient #11 did not know what staff member H's subsequent visits were related to on the 21st and 22nd, but she had just received a new refill for a month of her hydrocodone prescription, which was prescribed four times a day for pain. Patient #11 and her son stated the hydrocodone bottle label looked like someone tried to scratch off the amount of pills, which should have been 120. Patient #11 only had 60 hydrocodone pills in the bottle after staff member H's visits to her home. Patient #11 and her son had called the pharmacy to confirm the number of pills in the refill and the pharmacy conveyed they dispensed 120 pills and this was a noted trend for staff member H to steal medications and recommended patient #11 and her son should make a police report. The report noted staff member H had already resigned prior to the allegation. Multiple dates and times in these forms were contradictory for events, staff member H's resignation and documentation. During an interview on 10/26/22 at 2:43 p.m., staff member B stated some of the dates and times she documented were wrong but any other questions related to the allegations and investigations would have to be answered by an attorney.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to document a complaint allegation of abuse for misappropriation of medication for 1 (#12) of 5 sampled patients; and failed to provide 5 (#s 8, 9, 10, 11, and 12) of 5 sampled patients complaint resolutions for misappropriation of medications. Findings include: Review of agency policy, Response and Corrective Action, last revised 8/5/21, showed, “At the conclusion of each compliance investigation, the Department will ensure appropriate action is taken to correct, and prevent recurrence of, any identified compliance concern(s). Upon completion of each compliance investigation… These remedial measures may include actions, as applicable, such as: Disciplinary action…; Training…; Revision of Company policy or procedure; Implementation of a formal corrective action plan; Reporting to Federal or state authorities…" During an interview on 10/27/22 at 12:09 p.m., staff member E stated the first allegation of misappropriation of medication by staff member H he was made aware of, was from patient #12 only a few weeks after staff member H started working at the agency. Patient #12 alleged staff member H returned to his home after a combined visit with staff member E. Staff member H told patient #12 staff member E left his phone at his home. Staff member E stated it was reported to staff member B and patient #12 was adamant his pills were stolen from beside his recliner and did not want staff member H allowed back into his home. Staff member E stated he did not know if any investigation was done but staff member H continued to work without any suspension. Staff member E stated there were several more patient allegations all around the same time. Staff member E stated some patients had to ration their pain medications like patient #11 who had half of her new medication refill stolen. She was cutting her pills in half and quarters. Patient #8 was struggling with his pain after alleging staff member H stole his Percocet. During the time of the allegations there was no clinical oversight due to the position of clinical manager being unfilled. Review of the Client Occurrence Report on 3/14/22 for patient #12 was categorized as “other” alleging staff member H stole his oxycodone. No investigation was completed for the misappropriation of medications allegation. This allegation was not included on the complaints and grievances report for the last year and was not treated as an allegation by the agency. Review of the agency, QI Event Summary, attachments showed four complaint events entered for drug misappropriation by staff member H as follows: Documented on 4/22/22 for a complaint on 4/18/22, reported by staff member D, for patient #10, alleging staff member H stole her oxycodone under the guise of needing to count them and “accidently” dumping them on the floor on 4/11/22; Documented on 4/22/22 for a complaint on 4/19/22, reported by staff member E, for patient #8’s family member, alleging staff member H stole patient #8's Percocet pills from his medication planner which she had just filled; Documented on 4/22/22 for a complaint on 4/22/22, reported by staff member F, for patient #9, alleging staff member H came to his home on 3/31/22 for an unscheduled and unannounced admission visit and dug thorugh his garbage to get his bottle of pain medication; Documented on 5/17/22 for a late entry for 5/2/22, reported by staff member F, for patient #11, alleging staff member H showed up to her home on 5/19/22 [staff member B stated the month should have been April] and then showed up unscheduled and unannounced on 5/20/22 and 5/21/22 [staff member B stated the month should have been April]; Patient #12's 3/14/22 allegation of misappropriation of medications was not included in this report or attachments. None of the complaint forms showed any documentation of the resolution of the multiple complaints. The complaint forms for patient #s 8, 9, 10, and 11, all showed staff member H resigned as the intervention. The complaint forms did not show any interventions or replacement of the misappropriated medications.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to protect patients from further misappropriation of patient property, after an allegation of theft of medications was reported to the agency and during an active investigation for 5 patients (#’s 8, 9, 10, 11, and 12) of 5 sampled patients. Findings include: Review of agency policy, Complaints, Communication, Accessibility, last revised 10/12/21, showed, “The Administrator is responsible to ensure all aspects of complaint investigation, reporting, tracking, and communication are carried out, including escalation from the program to the corporate compliance team/legal counsel if indicated. Allegations of abuse, neglect, exploitation, and misappropriation of property will be investigated when [the agency] is made aware of the allegation and will be reported according to state statute or within 5 days, whichever is soonest. The full investigation may take longer than 5 days but the initial determination of whether an allegation of abuse, neglect, exploitation, or misappropriation of property is credible and requires external reporting should be acted upon according to this timeframe. [The agency] ensures all complaints and grievances are: documented, investigated, resolved as much as feasible to the satisfaction of the complainant.” During an interview on 10/27/22 at 12:09 p.m., staff member E stated the first allegation of misappropriation of medication by staff member H he was made aware of was from patient #12, which was only a few weeks after staff member H started working (February 2022) for the agency. Patient #12 alleged staff member H returned to his home after a combined visit with staff member E. Staff member H told patient #12 staff member E left his phone at his home. Staff member E stated the allegation was reported to staff member B. Staff member E stated patient #12 was adamant his pills were stolen from beside his recliner and did not want staff member H allowed back into his home. Staff member E stated he did not know if any investigation was done, but staff member H continued working without any suspension. Staff member E stated there were several more patient allegations of misappropriation of medication by staff member H all around the same time. Staff member E stated some patients had to ration their pain medications, such as patient #11 who had half of her new medication refill stolen. Staff member E stated patient #8's daughter also reported his Percocet was missing from his medication planner and his as needed pain medication from his windowsill after staff member H showed up to patient #8's home. Review of the Client Occurrence Report on 3/14/22, for patient #12 was categorized as “other” alleging staff member H stole his oxycodone from his home. Staff member H returned for an unscheduled, independent visit to patient #12's home right after a combined visit with staff member E. Staff member H conveyed to patient #12, staff member E had forgotten his phone at the patient's home. After staff member H left patient #12's home, he noticed his pain pills were missing from their regular placement beside his recliner, where he always kept them. No investigation was completed for the allegation reported by patient #12. Staff member H was not placed on leave and no protection for patient #12 or other patients was put in place. Review of the agency document, QI Event Summary, showed four complaint events for drug misappropriation by staff member H for patient #s 8, 9, 10, and 11. Patient #12 was not listed. Review of the agency Complaint Reports attached showed: Documented on 4/22/22 for a complaint on 4/18/22, reported by staff member D, for patient #10, alleging staff member H stole her oxycodone under the guise of needing to count them and “accidently” dumping them on the floor on 4/11/22. The patient alleged she had just filled the prescription and had only taken two pills so she should have had 21 pills remaining, but after staff member H left her home she only had eight pills left. The form showed staff member H was suspended on 4/20/22 after a meeting at 11:30 a.m., with a scheduled drug test at 3:45 p.m. The form showed on 4/22/22 at 4:43 p.m. staff member H called and resigned and had refused the drug test. Documented on 4/22/22 for a complaint on 4/19/22, reported by staff member E, for patient #8’s family member, alleging staff member H stole patient #8's Percocet pills from his medication planner which she had just filled. Staff member H also stole two Percocet from patient #8's windowsill which he used as needed to control his pain. The form showed staff member H was asked about the event and staff member H stated she had gone to patient #8’s home at noon on 4/19/22 but did not go into the house because the prescriptions were not there to fill his medication planner. The form showed staff member H called at 4:43 p.m. on 4/21/22 to resign and the corporate office was notified of the resignation on 4/22/22. Documented on 4/22/22 for a complaint on 4/22/22, reported by staff member F, for patient #9, alleging staff member H came to his home on 3/31/22 for an unscheduled and unannounced admission visit. Staff member H refused to leave for an hour because she was digging through patient #9's garbage for his pain medications. This was after staff member H tried to force patient #9 to dig the pain medications out of the garbage himself. Patient #9 explained to staff member H he had just gotten out of the nursing home and doing that would put him back in the nursing home. Patient #9 told staff member H his daughter had disposed of the pain medication because she did not think he needed it and did not want him to become addicted to them. The form showed staff member H made a coordination note in the EMR but never completed the admission visit assessment that she announced on entrance to her unscheduled visit to patient #9's home. The form showed staff member H was suspended at noon on 4/20/22 and called with her resignation on 4/21/22 at 6:00 p.m. Documented on 5/17/22 for a late entry for 5/2/22, reported by staff member F, for patient #11, alleging staff member H showed up to her home on 5/19/22 [staff member B stated the month should have been April] and then showed up unscheduled and unannounced on 5/20/22 and 5/21/22 [staff member B stated the month should have been April]. Patient #11 did not know what staff member H's subsequent visits were related to on the 21st and 22nd, but she had just received a new refill for a month of her hydrocodone prescription, which was prescribed four times a day for pain. Patient #11 and her son stated the hydrocodone bottle label looked like someone tried to scratch off the amount of pills, which should have been 120. Patient #11 only had 60 hydrocodone pills in the bottle after staff member H's visits to her home. Patient #11 and her son had called the pharmacy to confirm the number of pills in the refill and the pharmacy conveyed they dispensed 120 pills and this was a noted trend for staff member H to steal medications and recommended patient #11 and her son should make a police report. The report noted staff member H had already resigned prior to the allegation. Multiple dates and times in these forms were contradictory for events, staff member H's resignation and documentation. During an interview on 10/26/22 at 2:43 p.m., staff member B stated some of the dates and times she documented were wrong but any other questions related to the allegations and investigations would have to be answered by an attorney.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to track, analyze the cause, and implement preventative actions for patient abuse allegations of medication misappropriation for 5 (#s 8, 9, 10, 11, and 12) of 5 sampled patients. Findings include: During a QAPI interview on 10/25/22 at 9:15 a.m., staff members I, J, and K were present on a video call. Staff member I stated for complaints related to medication misappropriation she was not directly involved in the incidents. She only reviewed the reports after the investigation was completed. Staff member I stated staff member H was, “No longer Employed.” Staff member I stated the investigation was done by staff member B and if staff member B had identified any areas to change such as policies or processes, staff member I would have been involved in any training or PIPs needed in QAPI, but there were none identified. Review of the Client Occurrence Report on 3/14/22, for patient #12, was categorized as “other” alleging staff member H stole his oxycodone from his home. Staff member H returned for an unscheduled, independent visit to patient #12's home right after a combined visit with staff member E. Staff member H conveyed to patient #12, staff member E had forgotten his phone at the patient's home. After staff member H left patient #12's home, he noticed his pain pills were missing from their regular placement beside his recliner, where he always kept them. No investigation was completed for the allegation reported by patient #12. Staff member H was not placed on leave and no protection for patient #12 or other patients was put in place. Review of the agency document, QI Event Summary, showed four complaint events for drug misappropriation by staff member H for patient #s 8, 9, 10, and 11. Patient #12 was not listed. Review of the agency Complaint Reports attached showed: Documented on 4/22/22 for a complaint on 4/18/22, reported by staff member D, for patient #10, alleging staff member H stole her oxycodone under the guise of needing to count them and “accidently” dumping them on the floor on 4/11/22. The patient alleged she had just filled the prescription and had only taken two pills so she should have had 21 pills remaining, but after staff member H left her home she only had eight pills left. The form showed staff member H was suspended on 4/20/22 after a meeting at 11:30 a.m., with a scheduled drug test at 3:45 p.m. The form showed on 4/22/22 at 4:43 p.m. staff member H called and resigned and had refused the drug test. Documented on 4/22/22 for a complaint on 4/19/22, reported by staff member E, for patient #8’s family member, alleging staff member H stole patient #8's Percocet pills from his medication planner which she had just filled. Staff member H also stole two Percocet from patient #8's windowsill which he used as needed to control his pain. The form showed staff member H was asked about the event and staff member H stated she had gone to patient #8’s home at noon on 4/19/22 but did not go into the house because the prescriptions were not there to fill his medication planner. The form showed staff member H called at 4:43 p.m. on 4/21/22 to resign and the corporate office was notified of the resignation on 4/22/22. Documented on 4/22/22 for a complaint on 4/22/22, reported by staff member F, for patient #9, alleging staff member H came to his home on 3/31/22 for an unscheduled and unannounced admission visit. Staff member H refused to leave for an hour because she was digging through patient #9's garbage for his pain medications. This was after staff member H tried to force patient #9 to dig the pain medications out of the garbage himself. Patient #9 explained to staff member H he had just gotten out of the nursing home and doing that would put him back in the nursing home. Patient #9 told staff member H his daughter had disposed of the pain medication because she did not think he needed the it and did not want him to become addicted to them. The form showed staff member H made a coordination note in the EMR but never completed the admission visit assessment that she announced on entrance to her unscheduled visit to patient #9's home. The form showed staff member H was suspended at noon on 4/20/22 and called with her resignation on 4/21/22 at 6:00 p.m. Documented on 5/17/22 for a late entry for 5/2/22, reported by staff member F, for patient #11, alleging staff member H showed up to her home on 5/19/22 [staff member B stated the month should have been April] and then showed up unscheduled and unannounced on 5/20/22 and 5/21/22 [staff member B stated the month should have been April]. Patient #11 did not know what staff member H's subsequent visits were related to on the 21st and 22nd, but she had just received a new refill for a month of her hydrocodone prescription, which was prescribed four times a day for pain. Patient #11 and her son stated the hydrocodone bottle label looked like someone tried to scratch off the amount of pills, which should have been 120. Patient #11 only had 60 hydrocodone pills in the bottle after staff member H's visits to her home. Patient #11 and her son had called the pharmacy to confirm the number of pills in the refill and the pharmacy conveyed they dispensed 120 pills and this was a noted trend for staff member H to steal medications and recommended patient #11 and her son should make a police report. The report noted staff member H had already resigned prior to the allegation. Multiple dates and times in these forms were contradictory for events, staff member H's resignation and documentation. During an interview on 10/26/22 at 2:43 p.m., staff member B stated some of the dates and times she documented were wrong but any other questions related to the allegations and investigations would have to be answered by an attorney. Review of the agency document, Home Health QAPI Meeting Minutes, dated 5/10/22, under the row for ‘other’ showed: “1” instance, discussion of, “Pt. alleged his oxycodone was stolen. PCP notified and switching med from bottle to blister packs, and PRN to scheduled med.” All the rest of the areas in the “other” row for "follow-up action required," "action plan," "by when" (due date), and "who" (was responsible) were left blank. Review of the agency document, Home Health QAPI Meeting Minutes, dated 8/10/22, under the row for ‘other’ showed: “1” instance, discussion of, “r/t RN taking pills,” Follow-up Action required, “No,” Action Plan, “RN no longer with us.” The "by when" (due date) and "who" (was responsible) were left blank. The agency did not track the multiple allegations of medication misappropriation by staff member H. The agency did not investigate the allegations, did not protect patients, or prevent further instances of medication misappropriation from patients by staff member H.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, agency staff member G failed to perform a thorough respiratory assessment; and failed to follow physician’s orders, outlined in the established plan of care for 1 patient (#7) of 3 sampled patients. Findings include: Review of the agency's policy and procedure, titled Professional Services and Personnel Qualifications, with a revision date of 10/13/21, showed: “Policy Provisions… 2. Skilled professionals assume responsibility for, and are not restricted to, the following: … …c. Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; …” 1. Respiratory Assessment Review of patient #7’s Patient Information Report, printed on 10/24/22, showed admitting diagnoses of the following: “Chronic Obstructive Pulmonary Disease, unspecified, Retention of Urine, unspecified, and Shortness of Breath.” Review of patient #7’s Home Health Certification and Plan of Care, with the start of care on 10/17/22, showed: “Skilled nurse to observe and assess respiratory system to identify changes and intervene to minimize complications. …” During an observation on 10/25/22 at 9:10 a.m., staff member G had finished taking patient #7’s vital signs and asked him if he had any breathing problems. Patient #7 stated, “No.” Staff member G did not assess patient #7’s lungs, by listening with a stethoscope, for any abnormal or diminished breath sounds. During an interview on 10/25/22 at 9:15 a.m., staff member G stated patient #7 was a poor historian and she communicated with his son at every scheduled visit, to gather accurate information. During an interview on 10/25/22 at 9:38 a.m., staff member G stated she usually listened to patient #7’s lungs at each visit but had forgotten. During an interview on 10/25/22 at 10:15 a.m., staff member A stated a respiratory assessment should consist of an oxygen saturation rate, an interview and observation of any shortness of breath, and listening to the patient’s lung sounds. 2. Nutritional Requirements Review of patient #7’s Home Health Certification and Plan of Care, with the start of care on 10/17/22, showed: “Nutritional Requirements: Regular diet as tolerated nectar thick liquids. …” Review of patient #7’s [Hospital name] hospitalization record, titled History and Physical, dated 10/6/22, showed: “Identification and Chief Complaint: [Age of patient #7] yr old male with a history of COPD, chronic oxygen use, GERD, on AC with history of acute pulmonary embolism, history of aspiration pneumonia and dysphagia…” During an observation and interview on 10/25/22 at 9:21 a.m., staff member G poured and served patient #7 a glass of water, which was not a thickened consistency. Staff member G prepared a cup of coffee to serve to patient #7, which also was not a thickened consistency. When questioned about the plan of care for patient #7 and the orders for nectar thick liquids, staff member G stated she had not added the thickener because he did not like it. Staff member G stated the order for nectar thick liquids was from when patient #7 was hospitalized for aspiration pneumonia. During an interview on 10/25/22 at 9:45 a.m., staff member G stated she reviewed the care plan with the RN every Monday morning, but the subject of the consistency of patient #7’s liquids had not been discussed. During an interview on 10/25/22 at 10:12 a.m. staff member A stated the plan of care for patients should be reviewed before each home visit. Staff member A stated the expectation was for nurses to follow the provider’s orders and if there were any questions, a call would be made to the provider to see if the orders should remain as written or be discontinued.

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 interview and record review, the agency failed to have a clinical manager from February 2022 until May 2022; and failed to provide oversight of all patient care services and personnel during that time. Findings include: During an interview on 10/27/22 at 11:24 p.m., staff member E stated there was no clinical manager during the time of the allegations and medication misappropriation by staff member H. Only staff member B, who only came onsite about one time a month. Staff member E stated staff member B was not on site during the time of the allegations of the medication misappropriation. Staff member E did not know what resulted from the investigation once he reported patient allegations of medication misappropriation by staff member H. During an interview and record review on 10/27/22 at 12:54 p.m., staff member D stated from February 2022 until May 2022 they had no clinical manager for the agency. Staff member D provided a hand-written list of dates for the times staff member B was onsite at the agency. The hand-written note showed the dates of 2/9/22 to 2/10/22, 3/2/22 to 3/4/22, 3/22/22 to 3/24/22, 4/27/22 to 4/29/22, and 5/18/22 to 5/20/22. During all other times there was no supervisory oversight of personnel, including nurses. During an interview on 10/27/22 at 2:05 p.m., staff member A stated staff member L left her position as Director of Clinical Services at the agency on 2/4/22 and staff member A took the position on 5/16/22.