Every finding on record at Chilex Home Care Services Inc

Purpose of visit: Recertification survey Entrance: 04/30/2021 at 11:45 AM Agency census: L&C-4 LHHS-0 PAS-0 Exit: 05/06/2021 at 2:00 PM An entrance conference was conducted on 04/30/2021 at 11:45 AM with the Alternate Administer. The agency was provided the form, "What to expect during your Agency's Survey." An exit conference was conducted on 05/06/2021 at 2:00 PM with the Administrator and Alternate Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided to the Administrator for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies.

Purpose of visit: Recertification survey Entrance: 04/30/2021 at 11:45 AM Agency census: L&C-4 LHHS-0 PAS-0 Exit: 05/06/2021 at 2:00 PM An entrance conference was conducted on 04/30/2021 at 11:45 AM with the Alternate Administer. The agency was provided the form, "What to expect during your Agency's Survey." An exit conference was conducted on 05/06/2021 at 2:00 PM with the Administrator and Alternate Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided to the Administrator for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviation List: L&C- Licensed and Certified LHHS - Licensed Home Health Services PAS-Personal Assistance Services POC- Plan of Care DON- Director of Nurses SN- Skilled Nurse SOC- Start of Care

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health staff in 3 (Patients #1, #2 and #3) of 3 patients' home folders reviewed during home visits. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availably of the patients. FINDINGS INCLUDE: Patient #1: Record review of the clinical record contained a POC with a SOC date of 05/16/2015 and a certification period of 02/13/2021-04/13/2021. The POC included a principal diagnosis of Contracture, left hand and the following additional diagnosis of other intellectual disabilities. The POC contained the following physician orders: SN to visit once a week for 9 weeks. Review of the record revealed no evidence that a visit schedule had been provided to Patient #1. On 05/06/2021 at approximately 3:20 PM, a home visit was conducted with Patient #1 and his caregiver. Patient #1 was non-verbal and lived in a Group Home. The patient's home folder was reviewed. The surveyor asked the caregiver if any paperwork had been removed from the patient's home folder. The caregiver stated nothing had been removed. The surveyor asked if a written visit schedule to show when the SN would be visiting was provided to Patient #1. The caregiver stated, "(Agency Administrator/DON) comes every weekend." The surveyor asked if the agency had provided a written schedule showing when they were going to visit? Caregiver for Patient #1 stated, "No." Patient #2: Review of the clinical record contained a POC with a SOC date of 12/13/2014 and a certification period of 01/10/2021 to 03/10/2021. The POC included a principal diagnosis of Dysphasia and the following additional diagnoses: Dysarthria, anarthria (a severe form of dysarthria. Dysarthria is a motor speech disorder that occurs when someone can't coordinate or control the muscles) and Contracture. The POC contained a physician order for the SN to visit once a week for nine weeks. Review of the record revealed no evidence that a visit schedule had been provided to Patient #2. On 05/06/2021 at approximately 3:45 PM, a home visit was conducted with Patient #2 and his caregiver. Patient #2 was non-verbal and lived in a Group Home. The patient's home folder was reviewed. The surveyor asked the caregiver if any paperwork had been removed from the patient's home folder. The caregiver stated nothing had been removed. The surveyor asked if a written visit schedule to show when the SN would be visiting was provided to Patient #2. The caregiver stated, "she (Administrator/DON) comes on Saturdays." The surveyor asked if the agency had provided a written schedule showing when they were going to visit? Caregiver for Patient #2 stated, "No." Patient #3: Review of the clinical record contained a POC with a SOC date of 03/22/2019 and a certification period of 01/10/2021 to 03/10/2021. The POC included a principal diagnosis of Unspecified Dementia without behavioral disturbance and the following additional diagnoses: Major depressive disorder and Hallucinations. The POC contained a physician order for the SN to visit once a week for nine weeks. Review of the record revealed no evidence that a visit schedule had been provided to Patient #3. On 05/06/2021 at approximately 2:30 PM, a home visit was conducted with Patient #3 and her caregiver. The patient's home folder was reviewed. The surveyor asked if any paperwork had been removed from the patient's home folder. Patient #2 and her caregiver stated not that they were aware of. The surveyor asked Patient #3 and her caregiver if the agency had provided a written visit schedule to show when the SN would be visiting? Patient #3 did not answer, the caregiver stated, "we know she'll (Administrator/DON) be here on Saturdays." The surveyor asked if the agency had provided a written schedule showing when they were going to visit? The caregiver stated, "No." In an interview with the Administrator/DON on 05/06/2021 at approximately 1:00 PM, the surveyor reviewed the findings from the home visits. The surveyor asked why the agency failed to provide written visit schedules to Patient #1, 2 and 3. The Administrator/DON stated, "they know I'm coming, we have it (schedule) on the 485 (POC) and we give that to them (group home) in the home folder." Admin stated, "I do all visits on Saturdays."