Every finding on record at Better Home Care, LLC

Based on the findings of an unannounced onsite Medicare recertification survey conducted June 21, 2022 through June 23, 2022, Better Home Care LLC was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a review of personnel files (PF), agency policies, and an interview with the administrator, the agency failed to document emergency preparedness training upon hire for nine (9) of nine (9) applicable personnel files reviewed: PF#1, PF#2, PF#3, PF#5, PF#6, PF#7, PF#8, PF#9, and PF#10. Findings include: A review of the following agency policies took place on June 22, 2022 at approximately 2:00 PM: Policy D-300 Employee Orientation states "Orientation for all employees shall include the following topics...#14 Emergency Preparedness;" Policy B-400 Emergency Management Policy, Section Special Instruction (page 2, #3) states, "All staff members will be oriented to the emergency preparedness plan and their associated responsibilities." A review of personnel files was conducted on June 23, 2022 starting at 09:20 AM. The date of hire (DOH) is indicated below. PF#1 DOH 11/16/2020 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. PF#2 DOH 12/13/2021 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. PF#3 DOH 03/07/2022 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. PF#5 DOH 04/18/2022 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. PF#6 DOH 05/03/2021 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. PF#7 DOH 05/04/2022 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. PF#8 DOH 05/30/2022 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. PF#9 DOH 04/03/2022 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. PF#10 DOH 05/01/2022 contained a completed orientation checklist which included various topics that were reviewed with or provided to the employee during the orientation program. Emergency preparedness training was not included on the list of topics nor was there any other evidence that emergency preparedness training was provided at time of hire. An interview conducted with the administrator and director of nursing on June 23, 2022 starting at 4:45 PM confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey conducted June 21, 2022 through June 23, 2022, Better Home Care LLC was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on a review of clinical records (CR), the Patient Admission Packet, agency policy and an interview with the administrator, the agency failed to provide a correct telephone number for the State toll free home health telephone complaint hotline for ten (10) of ten (10) CR reviewed: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, CR#7, CR#8, CR#9, and CR#10 . Findings include: On June 23, 2022 at approximately 10:30 AM, a review of the Patient Admission Packet, which includes the Agency's Patient Handbook (provided to the patient at the time of admission) and the Client's Bill of Rights (located in the Patient Handbook) found that the complaint hotline telephone number being provided to the patient (1-800-222-0989) is an incorrect phone number (page3,#18). There was no evidence in the Admission Packet, Patient Handbook, or any other documents that the correct telephone number for the State toll free home health telephone complaint hotline (1-800-254-5164) was provided to the patient. A review of the agency's policy C-380 Home Care Bill of Rights/Grievance Procedure, page 3, #11 found that the telephone number listed in the policy (1-800-222-0989) to communicate complaints to the "State Department of Health" was also an incorrect phone number. A review of clinical records (CR) was conducted on June 21, 2022 starting at 2:00 PM and again on June 22, 2022 starting at 9:10 AM. The start of care (SOC) is indicated below. CR#1 SOC 06/01/2022 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#2 SOC 05/28/2022 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#3 SOC 09/06/2019 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#4 SOC 05/23/2022 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#5 SOC 05/23/2022 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#6 SOC 01/06/2022 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#7 SOC 01/21/2022 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#8 SOC 04/13/2022 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#9 SOC 03/30/2022 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. CR#10 SOC 09/30/2021 did not contain evidence that the patient received the correct home health telephone complaint hot line phone number. An interview with the administrator and the director of nursing conducted on June 23, 2022 starting at 4:45 PM confirmed the above findings.

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 a review of clinical records (CR), agency documents and an interview with the administrator, the agency failed to provide evidence that the patient was 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, and (iv) Aging and Disability Resource Center for ten (10) of ten (10 CR reviewed: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, CR#7, CR#8, CR#9, and CR#10. Findings include: On June 21, 2022 at approximately 10:30 AM, a review of the Admission Packet/Folder that is provided to the patient at time of admission which includes the Patient Handbook, Admission Service Agreement, Better Home Care Phone Numbers, Admission Checklist, Emergency Preparedness Information and other documents found that the names, addresses, and telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center were not provided to the patient. There were no other documents to support that this information was provided to the patient. A review of clinical records (CR) was conducted on June 21, 2022 starting at 2:00 PM and again on June 22, 2022 starting at 9:10 AM. The start of care (SOC) is indicated below. CR#1 SOC 06/01/2022 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#2 SOC 05/28/2022 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#3 SOC 09/06/2019 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#4 SOC 05/23/2022 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#5 SOC 05/23/2022 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#6 SOC 01/06/2022 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#7 SOC 01/21/2022 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#8 SOC 04/13/2022 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#9 SOC 03/30/2022 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. CR#10 SOC 09/30/2021 did not contain evidence that the patient received the names, addresses, or telephone numbers of the following federally-funded and State-funded entities that service the area where the patient resides: 1) Agency on Aging; 2) Center for Independent Living, 3) Protection and Advocacy Agency, and 4) Aging and Disability Resource Center. An interview conducted with the administrator and director of nursing on June 23, 2022 starting at 4:45 PM confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of personnel files (PF), agency policies and an interview with the administrator, the agency failed to demonstrate the presence of the following: initial competency evaluation/skills assessment, and/or annual performance evaluation for two (2) of ten (10) personnel files reviewed: PF#1, and PF#5. Findings include: A review of the following agency policies took place on June 22, 2022 starting at approximately 2:00 PM: Policy D-260 Performance Evaluations states on page 1, "A competency-based performance evaluation will be conducted for all employees after one (1) year of employment and at least annually thereafter;' and "A criteria-based performance evaluation will be conducted at least annually by the appropriate supervisor;" Policy D220 Competency Evaluation of Home Care Staff states on page 2, "All new employees will be assessed for competency based on the expected requirements for the position;" and "Professional staff will be evaluated by supervisors/peers who have demonstrated competencies in the areas in question." A review of personnel files took place on June 23, 2022 starting at approximately 09:20 AM. The date of hire (DOH) is indicated below. PF#1 DOH 11/16/2020 contained a completed annual performance review signed by the employee and administrator, but there was no date on the review as to when it was conducted. PF#5 DOH 04/18/2022 contained a completed Speech Therapy (ST) Skills Proficiency Self Evaluation that was signed by the employee and dated 04/18/2022, and a ST Skills Proficiency Evaluation that was signed by the employee and dated 04/18/2022 but there was no supervising signature contained on the ST Skills Proficiency Evaluation. An interview conducted with the administrator and director of nursing on June 23, 2022 starting at 4:45 PM confirmed the above findings.