Every finding on record at Carestaff Ohio Home Health Services LLC

Extended Substantial Allegation Survey Substantial Allegation 71394 The following deficiencies are based upon substantial allegation 71394 completed on 09/01/22. CareStaff Ohio Home Health Services LLC 369131, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. CareStaff Ohio Home Health Services LLC is precluded from providing its own home health aide training and competency testing or competency evaluation program for a period of two years from the date of the receipt of the deficiency report (2567) for this survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure that patients received home health services as written in the plan of care for one of four patients reviewed (Patient #1). This could affect all patients receiving services from the agency. The agency census was 14 patients. Findings include: Review of Patient #1’s medical record included home health aide (HHA) time sheets, the plan of care and the service plan. Review of the patient’s start of care revealed on 06/08/20 the patient began services at the agency with diagnoses including stroke, diabetes and depression. Review of Patient #1’s plan of care dated 06/02/22 revealed Patient #1 was to receive 40 hours of HHA services per week for assistance with activities of daily living. Review of HHA time sheets dated 04/01/22 through 08/04/22 revealed the HHA service hours had not been provided as planned. Review of the weeks dated 06/12/22 through 08/07/22 revealed 24 HHA hours or less were provided to Patient #1. Review of the HHA time sheets revealed missed visits due to “aide not available” were reported and documented on 04/01/22, 04/04/22, 04/08/22, 04/11/22, 04/15/22, 04/18/22, 04/22/22, 04/25/22, 04/29/22, 05/02/22, 05/06/22, 05/10/22, 05/13/22, 05/16/22, 05/20/22, 05/23/22, 05/27/22, 05/30/22, 06/03/22, 06/06/22, 06/10/22, 06/13/22, 06/17/22, 06/20/22, 06/24/22, 06/27/22, 07/01/22, 07/04/22, 07/08/22, 07/11/22, 07/18/22, 07/22/22, 07/26/22, 08/02/22, 08/03/22, and 08/04/22. There was no documentation in the patient's record that the physician was notified that services were not provided as ordered. Interview with Staff B on 08/31/22 at 3:07 PM revealed the primary HHA staff for Patient #1 had reduced their hours from full time to part time in February 2022 and the agency had been unable to locate another aide to cover the case’s hours. Staff B confirmed the agency had not been able to fulfill the HHA hours planned for Patient #1. This deficiency substantiates Substantial Allegation 71394.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, record review and staff interview, the agency failed to ensure a governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation (G942). The agency failed to ensure the Administrator was responsible for all day-to-day operations (G948). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' needs would be met.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure a governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation. This could affect all patients receiving services from the agency. The agency's census was 14 patients. Findings include: Review of agency records revealed there were no governing body minutes or structure of an advisory group at the agency. Interview with Staff B on 08/31/22 at 3:20 PM revealed there was not a governing body established yet as the ownership change was still in transition. Staff B said Staff A, the current owner, was out of the country at this time and Staff B offered no time frame for the transition to be final nor any information about the final documentation of the agency’s new ownership. Staff B offered no additional information about the transaction of change of ownership or the documentation of address change.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, record review and staff interview, the agency failed to ensure the Administrator failed to be responsible for all day-to-day operations. This could affect all patients receiving services from the agency. The agency census was 14 patients. Findings include: At the time of the survey, it was discovered that the agency had moved to 104 Brown Street, Dayton, Ohio 45402. Review of agency records revealed there was no approved Centers for Medicare & Medicaid (CMS) form 855A documenting any changes in address since 2018 that were available for review during the survey dates of 08/30/22 to 09/01/22. Interview with Staff D on 08/30/22 at 3:15 PM revealed a prospective owner, Staff B, was in the process of acquiring the agency from an owner identified as Staff A. Staff D said the agency was relocated from 65 Tahlequah Trail, Springboro, Ohio to 19 West Main Street New Lebanon Ohio 45345, effective 09/15/19. Staff D said after the sale of the agency to Staff A, effective date 05/17/20, the agency was relocated to 4428 North Dixie Dr, Dayton Ohio 45414, where Staff A also had a transportation company. Staff D could not provide any official paperwork regarding the address changes since 05/17/20 when the agency was purchased by Staff A and was located at 19 West Main Street New Lebanon OH 45345. Interview with Staff F on 08/31/22 at 9:10 AM revealed there were plans to relocate the agency from the 104 Brown Street location due to the poor quality of the office suite environment, i.e. falling debris and construction noise/activity at the building. Interview with Staff B on 08/31/22 at 3:04 PM confirmed the agency had moved to the 104 Brown Street location approximately nine months ago and there were plans to relocate soon. This deficiency substantiates Substantial Allegation 71394.