Every finding on record at Caretenders of Cleveland, Inc

Emergency Preparedness Survey At the time of the Emergency Preparedness Survey completed on 06/14/21, Caretenders is in compliance with the provisions of 42 CFR Part 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Extended Recertification Survey COVID 19 Focused Infection Control Survey An entrance conference was conducted on 06/07/21 at 9:00 AM with the Administrator. An exit conference was conducted on 06/14/21 at 4:00 PM with administrative staff. The following deficiencies are based on the extended recertification survey completed 06/14/21. Caretenders 367548, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B,C for Home Health Agency. 36Q7548001 - 1225 E. Waterloo Road, Akron, OH 44306 36Q7548002 - 18000 Jefferson Park Rd., Suite 103, Middleburg Heights, OH 44130-3486 36Q7548003 - 397 Churchill Hubbard Road, Suite 4, Youngstown, OH 44505-1375 36Q7548005 - 2602 Hubbard Road, Madison, OH 44057 36Q7548006 - 20600 Chagrin Blvd, Suite 290, Shaker Heights, OH 44122-5344 A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at 42 CFR Part 484.70 related to Infection Control. Caretenders 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 medical record review and staff interview, the agency failed to provide the home health services as written in the plan of care for two of 17 medical records reviewed (Patients #8 and #13). The agency census was 1137. Findings include: 1. Review of the medical record for Patient #8 revealed a plan of care dated 04/03/21 to 06/01/21 with orders for five home health aide visits per week for two hours each visit. The medical record lacked documentation of any home health aide visits after 04/27/21. The patient was discharged from the agency on 06/02/21. The medical record lacked documentation of physician notification that services were not provided as ordered. This was verified in an interview on 06/10/21 at 3:30 PM by Staff A. 2. Review of the medical record for Patient #13 revealed a plan of care dated 04/09/21 to 06/07/21 with orders for a speech therapy evaluation effective 04/11/21. The medical record contained a physician order dated 05/04/21 for a speech therapy evaluation the week of 05/03/21, with a calendar frequency for speech therapy of two visits every two weeks times two. The medical record contained an order dated 05/12/21 for a speech therapy evaluation the week of 05/10/21, with a calendar frequency of one speech therapy visit effective 05/16/21. The medical record contained a resumption of care order dated 05/28/21 for a speech therapy evaluation the week of 05/30/21. The medical record contained a coordination note dated 06/07/21 that the physician's office was okay with the speech therapy evaluation to be the week of 06/07/21, but lacked an order for this change. The medical record lacked documentation of any speech therapy evaluations, physician notification the evaluations had not yet been completed, or reasons why the speech therapy evaluations were not completed. This was verified in an interview on 06/10/21 at 1:15 PM by Staff A.

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 record review and staff interview, the parent home health agency failed to provide direct support and administrative control of all five branch locations (G974). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' needs would be met.

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the parent home health agency failed to provide direct support and administrative control of all five branch locations. This could affect all patients receving services from the agnecy. The census was 1137. Findings include: The agency had five approved branch locations: 36Q7548001 - 1225 E. Waterloo Road, Akron, Ohio 44306; 36Q7548002 - 18000 Jefferson Park Rd., Suite 103, Middleburg Heights, Ohio 44130; 36Q7548003 - 397 Churchill Hubbard Road, Suite 4, Youngstown, Ohio 44505; 36Q7548005 - 2602 Hubbard Road, Madison, Ohio 44057; and 36Q7548006 - 20600 Chagrin Blvd, Suite 290, Shaker Heights, Ohio 44122. 1. On 06/08/21 at 9:00 AM, Staff A, the Executive Director at the parent office, was interviewed at the Parma/Middleburg Heights Branch (Medicare side). Staff A stated the Clinical Director position for this location was currently not filled and he/she was acting as Interim Clinical Director at this time. Staff A stated that each branch did their own interviewing, hiring, orientation, and maintained their own personnel files. Each branch had their own emergency preparedness manual and did their own exercises. Staff A stated there was a weekly phone call to each branch and he/she made a quarterly visit to each branch. The Cleveland West/Middleburg Heights office/branch (Medicaid side) was connected to this suite and had their own staff and supplies. On 06/08/21 at 2:00 PM, Staff A stated there was a weekly quality call with all locations and the corporate office. The Corporate Quality Assessment and Performance Improvement Coordinator worked with each location for all quality activities. All contracts were handled at the corporate office with involvement with staff from the location for each specific contract. Human Resources was directed from the corporate office with a designated person at each location for human resource duties. Each location accepted their own referrals. 2. On 06/09/21 at 11:30 AM, Staff E, the Regional Quality Coordinator for Ohio, Kentucky and Wisconsin, stated the Executive Director position for the Cleveland West/Middleburg Heights Branch (Medicaid side) was currently not filled and the Area Executive Director was covering this position at this time. The Executive Director at the branch was responsible for both clinical and operational matters, including interviewing and hiring staff. All staff completed their orientation electronically through i-Train for all locations and in all states. The Cleveland West/Middleburg Heights branch provided both skilled care and non-skilled care through Medicaid. The Cleveland West/Middleburg Heights branch did their own separate emergency preparedness. Staff E confirmed through email on 06/09/21 at 3:49 PM, that he/she could not find documentation of a tabletop exercise for the last two years for the Cleveland West/Middleburg Heights branch. 3. Review of the Job Description for Staff A revealed the title of Executive Director for location Home Health. The job description listed Supervisor's Title as Area or Regional Vice President/Area Executive Director. The Job Summary stated, "The Executive Director serves as the Administrator of the home health provider and is responsible for the administration of the day to day operations of the home care provider. This includes: coordinating and completing assigned projects to effectively support the immediate and long range objectives of the company; oversight of the eligibility of patients referred to home care services, planning for the services to be provided to patients and supervising their total home health care; implementing and maintaining administrative practices, agency philosophy, goals, and policies which assure compliance with applicable state and federal regulations; enhancing the profitability of the agency; and providing motivation and retention of a qualified staff and assure the quality of services delivered. This position also acts as a liaison with management staff and other departments throughout the company." 4. Review of the Job Description for the Clinical Director position for the Parma/Middleburg Heights Branch revealed the title of Clinical Director for location Home Health. The job description listed Supervisor's Title as Executive Director. The Job Summary stated: "The Clinical Director is responsible for overseeing and directing the patient care operations of the home care facility. This includes: coordinating and completing assigned projects to effectively support the immediate and long range objectives of the company; oversight of the eligibility of patients referred to home care services, planning for the services to be provided to patients and supervising their total home health care; implementing and maintaining administrative practices, agency philosophy, goals, and policies which assure compliance with applicable state and federal regulations; enhancing the profitability of the agency; and providing motivation and retention of a qualified staff and assure the quality of services delivered. This position also acts as a liaison with management staff and other departments throughout the company." The Essential Functions section listed the following, "Supervises the maintenance and accuracy of patient care and employee records. Performs staff conferences as needed and mandatory in-services, including but not limited to monthly staff/safety meeting....Provides and oversees orientation for personnel. Provides timely performance evaluation of personnel....Ensures that only qualified personnel are hired. Verifies licensure, certification, and credentialing as required by law and policy prior to employment and annually thereafter. On an on-going basis, ensures maintenance of records to support competency of all personnel." The job description lacked direction to work with or under the direction of the Administrator of the home health provider. 5. Review of the Job Description for the Executive Director position for the Cleveland West/Middleburg Heights Branch revealed the title of HCBS Executive Director II for location Home Community Based Services. The job description area listing Supervisor's Title was blank. The Job Summary stated, "The Home & Community Based Services Executive Director II is responsible for the administration of the day to day operations of the community based services business line. This includes: coordinating and completing assigned projects to effectively support the immediate and long range objectives of the company, responsible for eligibility and admission of the client and supervision of care provided, implementing and maintaining administrative practices, agency philosophy, goals, and policies which assure compliance with applicable state and federal regulations and enhancing the profitability of the agency. Providing motivation and retention of a qualified staff and assure the quality of services delivered. This position also acts as a liaison with management staff and other departments throughout the agency." The Essential Functions section listed the following: "Ensures that only qualified personnel are hired and that there are adequate staff to meet the clients needs...Verifies licensure, certification, background checks and credentialing as required by law and policy prior to employment and annually thereafter. On an on-going basis, ensures that staff meet all in-service and educational requirements annually and ensure maintenance of records to support competency of all personnel. Ensure the training and use of E.V.V. (Electronic Visit Verification) by the appropriate staff to achieve the compliance with State requirements and Company goals. Ensures that all staff are orientated to all aspects of their position and monitors for compliance with performance expectations....Ensures that performance evaluations are completed timely....Ensures that client and employee records are maintained in compliance with regulations and policy and ensures confidentiality and security of client records." The job description lacked direction to work with or under the direction of the Administrator of the home health provider. 6. Review of the Job Description titled, Administrator for the Clinical Director for the Medicare side of the Akron branch (Staff I) revealed he/she reported to the Regional Operations Director/Vice-President/Governing Body. The job description was signed in 2018. The Job Summary indicated the Administrator is responsible for planning, coordinating, managing and directing all activities and programs of agency. The Administrator has the authority from Governing Body to perform responsibilities for operating the agency. Per interview on 06/08/21 at 4:15 PM Staff I stated he/she oversaw all audits, Infection Control, budget, Quality Improvement, scheduling, staff, scheduler, clinical managers and reviewed all complaints and incidents. Staff I also oversaw competencies, annual reviews and annual training. Staff I stated personnel files were kept at the branch and they did their own hiring and firing of employees and all training and in-services were done at the branch unless on computer. Staff I stated he/she maintained the Emergency Preparedness manual for the Medicare side of the branch and did not include the Medicaid side of the branch as they have different policies. 7. Review of the Job Description titled, Home and Community Based Services Executive Director II with Department Supervisor's Title blank revealed this job description was for Staff H. The job description was signed on 11/10/2020. Further review revealed the Home and Community Based Services Executive Director II was responsible for administration of day to day operations of Community Based Service business line, the Medicaid side of the Akron branch. Per interview on 06/08/21 at 3:00 PM Staff H stated he/she oversaw intake, scheduling, field staff, training, billing, hiring and firing. There was a Human Resource person at this branch that maintained the personnel files and did the initial screening process of new hires. The Emergency Preparedness manual was incomplete and Staff H stated no assistance or guidance was received from the parent location or the Home and Community Based Service (HCBS) Regional Quality Coordinator or HCBS Quality Manager. Staff H stated that he/she could not find documentation of a tabletop exercise for the last two years for the Medicaid side of the Akron branch. 8. Review of the Job Description for the Clinical Director position for the Madison Branch revealed the title of Clinical Director for location Home Health. The job description listed Supervisor's Title as Executive Director. The Job Summary stated: "The Clinical Director is responsible for overseeing and directing the patient care operations of the home care facility. This includes: coordinating and completing assigned projects to effectively support the immediate and long range objectives of the company; oversight of the eligibility of patients referred to home care services, planning for the services to be provided to patients and supervising their total home health care; implementing and maintaining administrative practices, agency philosophy, goals, and policies which assure compliance with applicable state and federal regulations; enhancing the profitability of the agency; and providing motivation and retention of a qualified staff and assure the quality of services delivered. This position also acts as a liaison with management staff and other departments throughout the company." The Essential Functions section listed the following, "Supervises the maintenance and accuracy of patient care and employee records. Performs staff conferences as needed and mandatory in-services, including but not limited to monthly staff/safety meeting....Provides and oversees orientation for personnel. Provides timely performance evaluation of personnel....Ensures that only qualified personnel are hired. Verifies licensure, certification, and credentialing as required by law and policy prior to employment and annually thereafter. On an on-going basis, ensures maintenance of records to support competency of all personnel." The job description lacked direction to work with or under the direction of the Administrator of the home health provider. Interview with the Branch Director of the Madison branch, Staff J, on 06/09/21 at 4:44 PM revealed that the branch did run their own Emergency Preparedness community drills/tabletop drills, specific to the hazards in the branch location. The branch maintained their staffing levels as directed from the parent location and completed their own hiring and firing as needed. All personnel files were maintained and held at the branch location.

Substantial Allegation Survey Substantial Allegation OH00121258 An entrance conference was conducted on 04/27/21 with the Clinical Director, and an exit conference was conducted on 04/30/21 with the Clinical Director. The following deficiencies are based upon substantial allegation OH00121258 completed on 04/30/21. Caretenders 367548, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the physician was notified of changes in the patient's condition for one three patients reviewed (Patient #3). This could affect all patients receiving services from the agency. The census was 123. Findings include: Review of Patient #3's record revealed the patient was admitted on 01/19/21 with diagnoses including unstageable pressure ulcer to the sacral region, dementia, hypertension, chronic obstructive pulmonary disease, anxiety, and contracture. Review of the physician ordered plan of care for the certification period dated 01/19/21 to 03/19/21 revealed orders for skilled nursing three times a week for one week, two times a week for one week and one time a week for seven weeks. The skilled nurse was to perform wound care to the sacrum twice a week. Irrigate with normal saline wound cleanser, apply alginate (provides a moist cover to prevent the wound from drying out and allowing the wound to heal more quickly), cover with foam dressing using clean technique. Instruct patient/caregiver on signs and symptoms of wound infection and proper disposal of dressings. Review of wound assessments on visit sheets completed by Staff B (Registered Nurse (RN), C (Licensed Practical Nurse (LPN), and D (RN) dated 01/19/21, 01/21/21 and 01/25/21, respectively, all revealed: depth of wound description-partial thickness (loss of layer of tissue just below the skin presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister), no exudate, necrotic tissue type-yellow, necrotic eshar (dead tissue that sheds or falls off) 0-25%, necrotic slough (yellow/white usually wet material in wound bed, contains dead white blood cells and fibrin) 76-100%, necrotic tissue amount-none, skin around the wound-normal. The measurements of the wound for 01/19/21, 01/21/21 and 01/25/21 were as follows: length/width/depth - 4 centimeters (cm) by 6 cm by 0 cm, 4 cm by 6 cm by 0.5cm, and 4 cm by 5.5 cm by 0.5 cm, respectively. Review of the wound assessment on visit sheet completed by Staff E (RN) dated 01/28/21 revealed the following changes: no measurements taken as they were not due, depth of wound description - necrotic (dead tissue), small amount of serosanguinous exudate, necrotic tissue type-firm on both sides, necrotic eshar increased to 51-75%, necrotic tissue amount increased to 50-<75%, skin around the wound - bright red, change in wound - none. Review of the wound assessment on visit sheet completed by Staff C (LPN) dated 02/02/21 revealed the following changes: measurements were 4 cm by 5.5 cm by 0.5 cm, necrotic tissue type - yellow, change in wound - none. Review of wound assessment on visit sheet completed by Staff F (RN) dated 02/09/21 revealed the following changes: measurements were 2.5 cm by 3.5 cm by 0.2 cm, wound description - deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues), small amount of serosanguinous exudate, skin color around the wound - normal, change in wound - none. Review of a Communication Note dated 02/10/21 revealed Patient #3's caregiver called the agency to report the patient's wound looked worse, redness and blister like area on the corner. The caregiver was present at the nursing visit on 02/09/21 but the wound did not have these changes at that time. The caregiver stated there was no increase in drainage or warmth to the area; however, it was difficult to keep the area clean due to incontinence of urine. The doctor was called for a change in products used, placed order and will provide education to caregiver at next visit. A call was made to the doctor's office (no time indicated), message left. At 3:10 PM, a second call was made to the doctor's office. Message sent to the doctor. At 5:30 PM there was no update from the doctor. The caregiver was called to provide follow up on request to doctor and plan for extra visit once orders were received. Report was given to Staff F on condition change of patient and request to doctor for visit. On 02/11/21 at 11:20 AM, the doctor's office called. A verbal order was received for three as needed wound visits and to change wound care to the following: skilled nursing to perform and educate caregiver on wound care to sacral wound twice weekly and as needed for soilage of dressing, cleanse wound with normal saline, apply calcium alginate to wound bed and cover with thin duoderm or waterproof foam dressing to prevent soilage during incontinence. Staff F was called and updated for the visit on 02/11/21. Review of the wound assessment on visit sheet per Staff F (RN) dated 02/11/21 revealed: no measurements taken as they were not due, necrotic tissue type - white, necrotic slough increased to 51-75%, necrotic eshar increased to 51-75%, necrotic tissue amount increased to 50-<75%, skin around the wound - bright red, change in wound - none. Staff F also assessed the wound on 02/09/21. Review of the wound assessment on visit sheet per Staff C (LPN) dated 02/16/21 revealed: wound measured 5 cm by 6 cm by 0.4 cm, depth of wound description - full thickness (skin loss involves damage to, or necrosis of, subcutaneous tissue that may extend down to and through underlying fascia all the way down to the bone), odor - faint, skin around the wound -white, change in wound - none. There was no documentation that the physician was notified of changes to the patient's wound. The physician was notified of changes on 02/10/21 only after the patient's caregiver called and reported them. Per interview on 04/30/21 at 10:07 AM the Clinical Director confirmed there was no other documentation of follow up or physician notification of changes to the patient's wound. This deficiency substantiates Substantial Allegation OH00121258.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure all entries in the medical record were timed for one of three patient records reviewed (Patient #3). The census was 123. Findings include: Review of agency policy titled, "Home Care Record" effective date 05/15/99 and last revised 03/01/19, revealed patient home care record shall contain signed, dated and timed clinical notes and progress notes. 1. Review of the medical record for Patient #3 revealed Communication Notes dated 01/26/21 by Staff D with no time of communication with the caregiver regarding signs and symptoms of infection and techniques to keep the wound clean. 2. Review of the medical record for Patient #3 revealed Communication Notes dated 02/10/21 by Staff G with no time of call from caregiver who reported worsening wound condition. 3. Review of the medical record for Patient #3 revealed Communication Notes dated 02/22/21 by Staff A with no time of call to family to give Tylenol every four hours for fever. Per interview on 04/30/21 at 10:20 PM Staff A confirmed these entries were not timed per policy.