Every finding on record at Bethlen Home of the Hungarian Reformed Federation of America

Based on the findings of an on-site unannounced Medicare recertification and state relicense survey conducted 7/16/2024 through 7/19/2024, Concordia Home Health of Bethlen was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification and state relicense survey conducted 7/16/2024 through 7/19/2024, Concordia Home Health of Bethlen was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on review of policies and procedures, medical records (MR) and staff (EMP) interview the agency failed to ensure the plan of care contained all patient care orders and referred services for one (1) of thirteen MR reviewed MR5. Findings Included: Review of the agency admission packet on 7/16/2024 at approximately 12:02 PM revealed, “Patient Information for Home Health Care…Plan of care and treatment-you have the right to…Quality of care-you have a right to…*Be admitted by the agency only if we have the resources needed to provide your care safely and at a required level of intensity as determined by a professional assessment…” Review of the agency policy on 7/19/2024 at approximately 1:10 PM revealed, “SUBJECT Policy VII-1, I. Policy (Agency) accepts referrals on adult patients who are essentially homebound and in need of home care visits by nurses, physical therapists, occupation al therapists, speech language pathologist, medical social workers, dietitians, and home health aides…II. Procedure…D. All patients will be evaluated to ensure they meet the criteria for home health services such as payer criteria, medical necessity and need for intermittent skilled care…E. The Home Care personnel may confer with any or all of the following to evaluate the patient’s status: the attending physician, support physician(s), clinic staff, supervisors, patient, family, and significant other (s) with references to the following items: 1. The adequacy and suitability of personnel to provide the skilled services in the home, as ordered by the physician, in accordance with the established plan of care…F. The patient will be referred to alternate resources as appropriate, and the referring physician is notified, when the organization is unable to meet identified patient needs or the patient does not meet eligibility criteria for home health services. Reviews of MR5 was conducted on 7/18/2024 at approximately 11:50 AM, start of care was 6/25/2024 with a certification period of 6/25/2024 to 8/23/2024 with a primary diagnosis of urinary tract infection site not specified. A review of the documentation provided the following information: “(Agency) DOCUMENTATION OF FACE TO FACE ENCOUNTER AND CERTIFICATION…4. I certify that, based on my findings, the following services are medically necessary home health services (Check all that apply): Nursing, Physical Therapy, Speech language Pathology, Occupational Therapy, Medical Social Worker, HHA (Home Health Aide), Psych Nurse (written).” The following services were marked with an “X” “Nursing, Physical Therapy, Occupational Therapy, Medical Social Worker, HHA, Psych Nurse.” During review of the MR the surveyor could not confirm medical social worker or Psych nurse evaluation were conducted or that the patient declined services. An exit interview conducted with the administrator, manager quality and intake, director of compliance and education and private care manager on 7/19/2024 at approximately 1:30 PM which confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on review of manufactures directions for use, observations (OBS) , review of agency policy and procedure, and staff (EMP) interview the agency failed to ensure that acceptable standards of practice for infection control/prevention were maintained for three (3) of five (5) OBS (OBS1, OBS4 and OBS5). Findings include: Review of the manufacture’s recommendation s for use on 7/25/2024 at approximately 1:03 PM revealed, “Review of manufacturer's directions for use (on container) for disinfectant wipes "Micro-Kill One Germicidal Alcohol Wipes: ... Disinfecting: To disinfect hard, non-porous surfaces use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must be visibly wet for one (1) minute to achieve complete disinfection of all pathogens listed on this label...” Review of the manufacture’s recommendation s for use on 7/19/2024 at approximately 1:10 PM revealed, “MEDLINE MICROKILL AF2 DISINFECING, DEODORIZING, CLEANNING WIPES, ELIMINATES GERMS IN JUST 2 MINUTES…DIRECTIONS FOR USE…TO CLEAN AND DISINFECT/VIRUCIDAL DIRECTIONS: Wipe hard, nonporous surface with wipe until surface is visible wet. Allow surface to remain wet for 2 minutes…” Review of the agency policy on 7/19/2024 at approximately 1:10 PM revealed, “Skills: Supply Bag Technique (Home Health Care)- CE/NCPD…Preparing The Bag 1. Store hand hygiene supplies (i.e., antimicrobial soap, waterless handwashing gel, paper towels, and barrier) in the outermost pocket of the bag (sometimes referred to as the dirty section). 2. Create a dedicated area of the bag for clean, reusable items, such as blood pressure cuff. 3. Create a dedicated area of the bag for clean, sterile, nonreusable items, such as dressings and supplies. Anything removed from this section will not be returned to it following use…Using the Bag…3. When reentering the home, place the bag on clean, dry surface with a water resistant barrier placed between the bag and the surface…” During (OBS1) MR1 on 7/19/2024 at approximately 7:33 AM the following was observed: The surveyor confirmed the disinfectant being used was Medline Micro-Kill One Germicidal Alcohol Wipes. Observation of EMP8 revealed after direct patient care was completed reusable thermometer and blood pressure cuff was cleaned and placed directly into a see-through plastic bag without dry time being observed. During (OBS4) MR3 on 7/19/2024 at approximately 10:00 AM the following was observed: EMP9 placed a chuck/barrier on a table with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier against the top section of a chair. During (OBS5) MR4 on 7/19/2024 at approximately 11:53 AM the following was observed: The surveyor confirmed the disinfectant being used was Medline Micro-Kill One Germicidal Alcohol Wipes. Observation of EMP10 revealed after direct patient care was completed the reusable stethoscope, pulse oximeter, thermometer and blood pressure cuff was cleaned and placed directly into the supply bag with no dry time observed. An exit interview conducted with the administrator, manager quality and intake, director of compliance and education and private care manager on 7/19/2024 at approximately 1:30 PM which confirmed the above findings.

Based on the findings of an unannounced onsite Medicare Recertification and State Re-Licensure survey completed on July 16, 2021, Bethlen Communities Home Health services was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies- Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare Recertification and State Re-Licensure survey completed on July 16, 2021, Bethlen Communities Home Health services was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of Agency Policy/Procedure, Clinical Records (CR), Home Visit Observation, and staff (EMP) interview the agency failed to ensure the Plan of Treatment included supplies and equipment for one (1) of ten (10) CR's reviewed (CR8), and medications and treatments for three (3) of ten (10) CR's reviewed (CR4, 8, & 9.) Findings included: Review of Agency Policy and Procedure manual on 7/16/21 at approximately 11:00am revealed: No agency policy clearly defining required contents of the Plan Of Treatment. Review of CR on 7/14/21 between approximately 1:00 pm and 2:30 pm, 7/15/21 between approximately 11:00 am and 1:15 pm, and 7/16/21 between approximately 12:00 pm and 2:00 pm revealed: CR4, start of service (SOS)9/21/2020, period reviewed 9/21/2020-10/16/2020, CR revealed patient required 3Liters of Oxygen delivered via Nasal Canula, Pan of Treatment failed to include Oxygen in medication list. Plan of Treatment also failed to include as needed (PRN) indicators for the following listed medications: acetaminophen 325 mg 2 tablets by mouth every 4 hours PRN ClearLax 17gm by mouth Daily PRN IPRAT-albut 0.5-3(2.5)MG/3ML, 1 dose Nebulizer every 4 hours PRN Tussin DM 10ml by mouth 4 times a day PRN CR7, SOS 6/18/21, period reviewed 6/18/21-7/15/21, CR revealed patient admitted to Home Health services post hospital stay for Sepsis related for foot wound. Plan of Treatment failed to include wound care as ordered in referral. CR8, SOS 6/29/21, period reviewed 6/29/21-7/15/21, Observation of Home Visit on 7/15/21 at approximately 10:00 am revealed cane present in patient home. Patient stated that cane is generally the device used for ambulation, however, was having a harder morning so chose walker. Plan of Treatment failed to include cane. CR9, SOS 6/25/21, period reviewed 6/25/21-7/15/21, Referral revealed patient to take Procrit 10000 units/mL injection 1000units 3 times a week on Monday-Wednesday-Friday through 7/2/21. Plan of Treatment failed to include medication end date. Interview conducted wit family member during home visit on 7/15/21 at approximately 2:00 pm revealed medication taken "a few times after 7/2/21." Exit interview on 7/16/21 at approximately 2:00 pm with Administrator, Office Manager, and Clinical Supervisor confirmed findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of Agency Policy/Procedure, Clinical Records (CR), Home Visit Observation, and staff (EMP) interview the agency failed to ensure the Physician ordered Plan of Treatment was followed for three (3) of ten (10) clinical records (CR5, 7, & 9) reviewed. Findings included: Review of Agency Policy and Procedure manual on 7/16/21 at approximately 11:00 am revealed: "...FREQUENCY of visits...Example 2: ...When a range of visits is ordered, the upper limit of the range is considered the specific frequency...If there is are 0 visits made withing that week then send a VO (Verbal Order) to the PCP (Primary Care Physician) stating why the visits were missed..." Review of CR on 7/14/21 between approximately 1:00 pm and 2:30 pm, 7/15/21 between approximately 11:00 am and 1:15 pm, and 7/16/21 between approximately 12:00 pm and 2:00 pm revealed: CR5, start of service (SOS) 8/1/2020, period reviewed 8/1/2020-9/29/2020, CR revealed Home Health Aide to provide services 1-2 times a week for 9 weeks beginning 8/3/2020. CR failed to contain evidence of Home Health Aide visits after 8/29/2020. Home Health Aide discharge order written 9/17/2020. No HHA documentation available for weeks of 8/30/2020-9/5/2020, 9/6/2020-9/12/2020, or 9/13/2020-discharge 9/17/2020. No evidence of missed visits documented or communication to physician. CR7, SOS 6/18/21, period reviewed 6/18/21-7/15/21, CR revealed patient to receive skilled nursing services 1-3 times a week for 10 weeks. Interview with nurse on 7/15/21 at approximately 9:20 am after Observation of Home Visit revealed nursing visits being conducted one time a week. Review of clinical record confirms nursing visits one time a week. CR9, SOS 6/25/21, period reviewed 6/25/21-7/15/21, CR revealed Home Health Aide to provide services 1-2 times a week for 9 weeks beginning 6/28//2021. CR failed to contain evidence of Home Health Aide visits week of 7/4/21-7/10/21. No evidence of missed visits documented or communication to physician. Exit interview on 7/16/21 at approximately 2:00pm with Administrator, Office Manager, and Clinical Supervisor confirmed findings.