Every finding on record at Bethesda Incorporated

A recertification and complaint survey was initiated on 9/9/24 with the Alternate Administrator. Agency census: L&C-0 LHH-0 PAS-52 Intake: 446559 The agency was in compliance with 42 CFR part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification and complaint survey was initiated on 9/9/24 with the Alternate Administrator. Agency census: L&C-0 LHH-0 PAS-52 Intake: 446559 Abbreviations: L&C-Licensed and Certified Home Health LHH-Licensed Home Health PAS-Personal Assistant Services NOMNC- Notice of Medicare Non-Coverage QIO-Quality Improvement Organization CoPs-Conditions of Participation

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: Previously cited at G446 on 9/7/2021 Based on record review of agency documents and interviews, the agency failed to provide the correct name of the current QIO, in accordance with the Centers for Medicare and Medicaid in 1 (Patients 1) of 1 discharged Medicare patient whose records were reviewed, in that: the agency failed to include the name, address, or telephone number of the QIO on the NOMNC form. The failure could place any future agency patients at risk of harm if the NOMNC form is not provided with accurate information for the current QIO, in the event such information was needed by the Patients at discharge. Findings included: Patient #1: Review of the discharged clinical record was completed on 9/12/24. Patient #1’s record contained a plan of care for episode 11/3/21 through 1/1/22 signed and dated by the Administrator/Supervising Nurse/RN. Patient #1 was discharged on 12/15/21 by the Administrator/Supervising Nurse/RN. The NOMNC discharge document contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document, dated and signed by Patient #1 on 12/8/2021, revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO} to appeal." However, the patient had no access to the current QIO because the agency failed to list the current QIO contact information: (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. During an interview with the Administrator/Supervising Nurse/RN on 9/12/24 at approximately 12:35 p.m., the surveyor discussed the above findings and reviewed the agency policy related to patient rights to receive contact information for the QIO. The surveyor asked the Administrator/Supervising Nurse/RN if she knew why the information on the agency NOMNC discharge form failed to list the QIO contact information. The surveyor reviewed with Administrator/Supervising Nurse/RN that the agency was cited for the same violation last survey. The Administrator/Supervising Nurse/RN explained the agency had downloaded the new form and included the QIO contact information and thought Patient #1 received the new form that included the QIO information. The surveyor explained that the NOMNC signed by Patient #1 on 12/8/21 failed to contain the QIO contact information. Agency policy: Review of agency policy titled "RI.2 Patient Bill of Rights and Responsibilities/Rights of the Elderly" dated 031318 read in part: " ...Rights of Patient ...11. 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: a. Agency on Aging b. Center for Independent Living c. Protection and Advocacy Agency, d. Aging and Disability Resource Center; and e. Quality Improvement Organization.

An entrance conference was conducted with the Administrator on 08/31/21 at approximately 3:15 p.m. The Administrator was informed that the purpose of the survey was to conduct a recertification survey and a complaint investigation. What To Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey" was provided. Agency census: Licensed and Certified: 1 Licensed - 0 PAS - 64 Intake # 264214 An exit conference was conducted with the Administrator on 09/07/21 at approximately 3:30 pm . The preliminary findings of the survey were discussed and a written copy provided. The agency was provided with a list of records duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violations. The agency was informed intake #264214 was found unsubstantiated. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Centers for Medicare And Medicaid (CMS) Notice of Medicare Non-Coverage (NOMNC) Quality Improvement Organization (QIO) Start of Care (SOC) Skilled Nursing Services (SN) CoP - Conditions of Participation

An entrance conference was conducted with the Administrator on 08/31/21 at approximately 3:15 p.m. The Administrator was informed that the purpose of the survey was to conduct a recertification survey and a complaint investigation. What To Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey" was provided. Agency census: Licensed and Certified: 1 Licensed - 0 PAS - 64 Intake # 264214 An exit conference was conducted with the Administrator on 09/07/21 at approximately 3:30 p.m. The preliminary findings of the survey were reviewed and a written copy provided. The agency was provided with a list of records duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violations. The agency was informed that violations would be cited. The agency was informed intake #264214 was found unsubstantiated. Centers for Medicare And Medicaid (CMS) Notice of Medicare Non-Coverage (NOMNC) Quality Improvement Organization (QIO) Start of Care (SOC) Skilled Nursing Services (SN) CoP - Conditions of Participation

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 record review of agency documents and interviews, the agency failed to provide the correct name of the current QIO, in accordance with the Centers for Medicare and Medicaid in 6 (Patients 2, 3, 4, 5, 6, and 7) of 6 discharged patients whose records were reviewed, in that: the agency failed to include the name, address, or telephone number of the QIO on the NOMNC form. The failure could place the agency patients at risk of harm if the NOMNC form is not provided with accurate information for the current QIO, in the event such information was needed by the Patients at discharge. Findings included: Patient #2: Review of the discharged clinical record was completed on 09/01/21. Patient #2 was discharged on 07/01/21. The NOMNC discharge document contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO} to appeal." However, the patient had no access to the current QIO because the agency failed to list the current QIO contact information: (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #3: Review of the discharged clinical record was completed on 09/01/21. Patient #3 was discharged on 04/08/19. The NOMNC (discharge document), contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO to appeal." However, the patient had no access to the current QIO because the agency failed to list the current QIO contact information: (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #4: Review of the discharged clinical record was completed on 09/01/21. Patient #4 was discharged on 04/08/21. The NOMNC discharge document, contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO to appeal." However, the patient had no access to the current QIO because the agency failed to list the current QIO contact information: (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #5: Review of the discharged clinical record was completed on 09/01/21. Patient #5 was discharged on 05/31/21. The NOMNC discharge document, contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO to appeal." However, the patient had no access to the current QIO because the agency failed to list the current QIO contact information: (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #6: Review of the discharged clinical record was completed on 09/02/21. Patient #6 was discharged on 07/22/20. The NOMNC discharge document, contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO to appeal." However, the patient had no access to the current QIO because the agency failed to list the current QIO contact information: (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #7: Review of the discharged clinical record was completed on 09/01/21. Patient #7 was discharged on 06/13/21. The NOMNC discharge document, contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO to appeal." However, the patient had no access to the current QIO because the agency failed to list the current QIO contact information: (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. During an interview with the Administrator 09/07/21 at approximately 1:40 p.m., the surveyor discussed the above findings and asked the Administrator if she knew why the information on the agency NOMNC discharge form failed to list the QIO. The Administrator said, "I don't know." The surveyor explained that the patients would be unable to appeal the discharge if not provided with the QIO information. Agency policy: Review of agency policy titled "RI.1 Patient Bill of Rights and Responsibilities/Rights of the Elderly" dated 031318 read in part: " ...Rights of Patient ...11. 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: a. Agency on Aging b. Center for Independent Living c. Protection and Advocacy Agency, d. Aging and Disability Resource Center; and e. Quality Improvement Organization.