Every finding on record at Duhaney Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey, from 6/21/20223 to 6/23/2023 at the new and unapproved location: 6060 West Manchester Ave., Suite 312, Los Angeles, CA, 90045. Old Address: 360 N Pacific Coast Hwy, Suite 1022, El Segundo, CA, 90245 New Address: 6060 West Manchester Ave., Suite 312, Los Angeles, CA, 90045 Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor # 36459 Health Facilities Evaluator Nurse, Surveyor # 44749 Unduplicated Admissions - 14 Active Patients - 4 Sample Size - 7 Patients Home Visits – 2 The following Conditions of Participation (COP) were not met: 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care 484.105 Condition of Participation: Organization and Administration of Services

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the HHA’s staffs lack of knowledge to readily and effectively respond during an emergency or crisis situation. Findings: On 6/23/23, at 6:10 pm., a review of the agency's emergency preparedness program indicated no documented evidence that training was being conducted for staff regarding emergency or crisis situations. On 6/23/23, at 6:15pm., an interview was conducted with the ADM/DPCS designee in the agency's office. ADM/DPCS designee could not produce documentation for any emergency drills conducted throughout the year or show that the emergency plan was updated within the last 2 years. A review of the agency’s policy entitled “Emergency Management Plan” with a revised date of April 2016, indicated Organization leadership will provide for orientation and education of all personnel regarding participation in the emergency management plan. Education will be provided during orientation and annually thereafter. Education to include: A. Specifics of organization’s emergency management plan B. Information on developing their family’s emergency response plan C. Information regarding accessing housing and transportation for staff if necessary

The following reflects the findings of the California Department of Public Health during a Recertification Survey, from 6/21/20223 to 6/23/2023 at the new and unapproved location: 6060 West Manchester Ave., Suite 312, Los Angeles, CA, 90045. Old Address: 360 N Pacific Coast Hwy, Suite 1022, El Segundo, CA, 90245 New Address: 6060 West Manchester Ave., Suite 312, Los Angeles, CA, 90045 Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor # 36459 Health Facilities Evaluator Nurse, Surveyor # 44749 Unduplicated Admissions - 14 Active Patients - 4 Sample Size - 7 Patients Home Visits – 2 The following Conditions of Participation (COP) were not met: 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care 484.105 Condition of Participation: Organization and Administration of Services

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to maintain the current medication profiles for two of seven sampled patients (Patient 1 and Patient 4). The deficient practice had the potential to put patients at risk for medication errors and adverse drug reactions which can be life threatening. b. A review of Patient 4's clinical record indicated a Start of Care (SOC) date of 02/05/2023, with a diagnoses of sequelae (residual effects or conditions produced after the acute phase of an illness or injury has ended) of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). A review of Patient 4 's Plan of Care (POC) for certification period 04/06/2023 to 06/04/2023, indicated an order for a Skilled Nurse (SN) to visit the patient one time a week for nine weeks. On 06/22/2023, at 12:45 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 4’s residence. A review of Patient 4’s Medication Profile, indicated that patient had an order for Olanzapine 10 mg daily (milligrams – unit of measurements) and Olanzapine 2.5 mg every night at bedtime. Further review of Patient 4’s Medication Profile, indicated that Aripiprazole 15 mg daily was discontinued on 03/01/2023. A review of Patient 4’s current medication from the assisted living indicated that Olanzapine 10 mg and Olanzapine 2.5 mg were not on the list of current medications. Further review of Patient 5’s current medication from the assisted living indicated that patient was still taking Aripiprazole 15 mg. During an interview with the Medication Technician at the Assisted Living, on 06/22/2023 at 1:33 p.m., she stated that Patient 4 was not taking Olanzapine. Medication Technician further stated that Patient 4 is currently taking Aripiprazole and not discontinued. During a telephone interview with the Director of Patient Care Services (DPCS), on 06/23/2023 at 1:13 p.m., she stated that medication reconciliation should be observed and done every visit. A review of agency’s policy and procedure titled, “Safe and Effective Use of Medication” undated, indicated that each RN (Registered Nurse) and LVN are required to review and update each patient’s medications on a weekly basis and that includes all new medications, changes in medications and discontinuance of medications. a.On 6-22-23, a review of PT 1’s clinical record indicated PT 1 was admitted to the home health agency on 7-13-22 with a primary diagnosis listed as encounter for fitting and adjustment of urinary device. A review of the Plan of Care for certification period 3-10-23 to 5-8-23 indicated Skilled Nurse visits of 2 times per week for 9 weeks. On 6-22-23 at 10:45am during home visit, five (5) medications were identified as being at the facility, but not listed on the care plan or med profile. Three (3) medications listed on care plan/med profile but not at facility (discontinued). 1) Pregabalin 200mg capsule take one capsule by mouth 2 times a day At facility, not on care plan or med profile 2) Trazodone 50 mg tablet 0.5 tabs oral nightly At facility, not on care plan or med profile 3) Loperimide 2 mg capsule 1 caps oral Q2H, PRN At facility, not on care plan or med profile 4) Ondansetron HCL 4mg Tablet 1 tabs Oral every 8 Hrs as needed At facility, not on care plan or med profile. 5) Levothyroxine 100mcg Tablet 1 tabs Oral Qday 100mcg on medication label, 112mcg on care plan and med profile. 1) Sennosides 8.6mgTab oral 2 tablets at night medications listed on care plan/med profile but not at facility (discontinued). 2) Tolterodine tartrate 2mg tabs oral 1 tab 2x daily medications listed on care plan/med profile but not at facility (discontinued). 3) Ferrous sulfate 325mg oral 1 table medications listed on care plan/med profile but not at facility (discontinued). On 6-22-23 at 1050am an interview was conducted with LVN1, she stated the medication profile and care plan was not updated for these (5) medications and (3) discontinued medications. LVN1 stated the medication profiles and care plan should always be updated and current to reflect exactly what the physician orders for the patient. On 6-23-23 at 10:35am an interview was conducted with ADM/DPCS designee in the agency conference room. ADM/DPCS designee stated medication reconciliation should be done with each SN visit to ensure that the medications the patient is receiving is current and up to date with what the physician has ordered. A review of the agency’s policy entitled “Safe and Effective use of Medications” undated, indicated each RN and LVN are required to review and update each patient’s medications on a weekly basis. This includes all new medications, changes in medications, discontinuance of medications, etc.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, Quality of Care was met as follows: The HHA failed to ensure to develop and update the patient's Plans of Care (POC) for three of seven sample patients (Patient 1, Patient 4, and Patient 5). The deficient practice has the potential for lack of care and services to meet the patients' care goals that could result in the patient's decline or progress of their health status. (Refer G572). The HHA failed to obtain a physician's discharge order for one of seven sampled patients (Patient 6). The deficient practice has the potential for the patient's health status and treatment not coordinated that could result in non-continuity of patient care and services. (Refer to G580). The HHA failed to ensure to communicate and coordinate the patients' care and services for two of seven sampled patients (Patient 4 and Patient 5). For Patient 4, the HHA did not coordinate with the physician, when the patient has right knee pain and has no pain medication order and the patient insulin (hormone created by pancreas that controls the amount of glucose in the bloodstream at any given moment) medication was discontinued and the patient has type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). For Patient 5, HHA did not coordinate with the physician when the patient has a diagnosis of type 2 diabetes mellitus and has no order to manage diabetes mellitus. This deficient practice has the potential to delay provision of care and services identified in the assessment that could impact the patient's health status and wellbeing. (Refer to G600). The cumulative effect of these systemic practices resulted in the home health agency's failure to deliver statutorily mandated compliance with Federal regulations for Care planning, Coordination, and Quality of care to ensure the highest quality of care are provided to certified patients receiving the home health benefits. .

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 interview and record review the Home Health Agency (HHA) failed to ensure to develop and update the patient's Plans of Care (POC) for three of seven sample patients (Patient 1, Patient 4, and Patient 5). The deficient practice has the potential for lack of care and services to meet the patients' care goals that could result in the patient's decline or progress of their health status. Findings: b. A review of Patient 4's clinical record indicated a Start of Care (SOC) date of 02/05/2023, with a diagnoses of sequelae (residual effects or conditions produced after the acute phase of an illness or injury has ended) of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). A review of Patient 4 's Plan of Care (POC) for certification period 04/06/2023 to 06/04/2023, indicated an order for a Skilled Nurse (SN) to visit the patient one time a week for nine weeks. A review of Patient 4’s clinical record on 06/21/2023 indicated that there was no current POC for the certification period 06/05/2023 to 08/03/2023. c. A review of Patient 5's clinical record indicated a Start of Care (SOC) date of 07/18/2022, with a diagnosis of rheumatic heart failure (condition in which the heart valves have been permanently damaged by rheumatic fever) A review of Patient 5 's Plan of Care (POC) for certification period 03/15/2023 to 05/13/2023, indicated that there was no order of frequency for SN visits. Further review of the POC indicated that the section DME supplies, safety measures, nutritional requirements, allergies, functional limitations, activities permitted, mental status, prognosis, orders for discipline and treatment and goals/rehabilitation potential/discharge plan where all blank. A review of Patient 5’s clinical record on 06/21/2023 indicated that there was no current POC for the certification period 05/14/2023 to 07/12/2023. During an interview with Office Staff, on 06/21/2023 at 2:54 p.m. and 3:17 p.m., she stated that Patient 5 does not have a current 485 (Plan of Care) and latest was 03/15/2023 to 05/13/2023. Office Staff stated that Patient 4 did not have a current 485 and the latest was 04/06/2023 to 06/04/2023. Office Staff further stated that Patient 4 and Patient 5 did not have current plan of care because the Director of Patient Care Services (DPCS) has been on vacation and has not finalized them. During a telephone interview with the Director of Patient Care Services (DPCS), on 06/23/2023 at 1:13 p.m., she stated that she completed and finalized Patient 4 and Patient 5’s 485 Wednesday night. DPCS stated that 485 should be competed and available within seven days after data is generated from the OASIS (Outcome and Assessment Information Set, a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) and nothing should be left blank. DPCS further stated that it is important to have a current plan of care because it translates whatever was in the OASIS and tells the nurse what was ordered and what to do. A review of agency’s policy and procedure titled, “Physician Orders/Plans of Care” undated, indicated that the purpose of the policy and procedure is to outline the requirements for complete, individualized diagnostic and therapeutic orders. The policy and procedure further indicated that each plan of care musty be re-evaluated on a periodic basis by the RN (Registered Nurse). Additionally, the policy and procedure indicated that the contents of the diagnostic and therapeutic (plan of care) will include: a. The patient’s diagnosis b. A description of the treatment and/or procedure to be done, including when appropriate, the type, frequency and duration c. Who is to perform the treatment and procedure d. A description of equipment, if any, necessary in the provision of care e. A description of current medications, including name, dose, frequency and route of each medication f. A description of any medical, physical, psychosocial or environmental precautions or limitations that affect the implementation of the plan of care A review of agency’s policy and procedure titled, “Reassessment/Recertification” undated, indicated that the plan of care must be renewed at least every 62 days or more often as warranted by the condition of the patient. The policy and procedure indicated that two weeks prior to the recertification date, the Director of Patient Care Services or designee will alert the clinician about the need for a review and update of the plan of care and possible recertification. The policy and procedure further indicated that the clinician completes the required documentation for recertification in a timely manner: a. OASIS Recertification Assessment: day 56 to 60 day i.e., the last five days of the current recertification period b. Plan of Care, revised c. Physician orders if not included in plan of care a.On 6-22-23, a review of PT 1’s clinical record indicated PT 1 was admitted to the home health agency on 7-13-22 with a primary diagnosis listed as encounter for fitting and adjustment of a urinary device. A review of the Plan of Care for certification period 3-18-23 to 5-8-23 indicated the care plan was not current and up to date. It further indicated Skilled Nurse visits of 2 times per week for 9 weeks. On 6-21-23 at 3:30pm an interview was conducted in the agency office with office staff, she stated that the Plan of care dated 3-16-23 to 5-8-23 was the most current for PT1. She further stated that the DPCS has not updated the care plan for this patient and is currently on vacation. A review of the agency’s policy entitled “reassessment/Recertification” undated, indicated the plan of care must be renewed at least every 62 days or more often as warranted by the condition of the patient. Two weeks prior to the recertification date, the Director of Patient Care Services or designee will alert the clinician about the need for a review and update of the plan of care and possible recertification. The clinician completes the required documentation for recertification in a timely manner: OASIS recertification assessment day 56to 60 days i.e, the last 5 days of the current recertification period.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to obtain a physician's discharge order for one of seven sampled patients (Patient 6). The deficient practice has the potential for the patient's health status and treatment not coordinated that could result in non-continuity of patient care and services. Findings: A review of Patient 6's clinical record indicated a Start of Care (SOC) date of 2/06/2023 with a diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar) and altered mental status. A review of Patient 6's Plan of Care (POC) for certification period 4/06/2023 to 6/04/2023, indicated an order for a Skilled Nurse (SN) to visit the patient two times a week for nine weeks. A review of Patient 6’s OASIS Transfer (Outcome and Assessment Information Set, a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) dated 2/26/2023, indicated that patient was transferred to an inpatient facility and discharged from agency. There no physician's order of Patient 6's transfer to the hospital and discharge. A review of Patient 6’s skilled nursing visit note on 2/27/2023, indicated patient was transferred to the hospital due to a fall on 02/26/2023. A review of Patient 6’s Communication Order dated 3/01/2023, indicated to hold PT (Physical Therapy) as of 3/01/2023 secondary to inpatient admission and resume PT when discharged from the hospital. A review of Patient 6’s Patient Missed Visit Order dated 3/06/2023, indicated that skilled nursing was missed and reason for missed visit indicated that patient continues to be in the hospital. During an interview with Office Staff, on 6/23/2023 at 4:06 p.m., she stated that there was no discharge order for Patient 6. During an interview with the Director of Patient Care Services Designee (DPCSD), on 6/23/2023 at 6:15 p.m., she stated that when a patient is discharge there should be a discharge order from the doctor. A review of agency’s policy and procedure titled, “Patient Transfer Information” undated, indicated that the physician will be notified of any transfer of patients from the agency to another organization (i.e., hospital). The policy and procedure further indicated that documentation completed for discharge includes discharge summary, OASIS Discharge and physician order sent to the physician for signature.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure to communicate and coordinate the patients' care and services for two of seven sampled patients (Patient 4 and Patient 5). For Patient 4, the HHA did not coordinate with the physician, when the patient has right knee pain and has no pain medication order and the patient insulin (hormone created by pancreas that controls the amount of glucose in the bloodstream at any given moment) medication was discontinued and the patient has type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). For Patient 5, HHA did not coordinate with the physician when the patient has a diagnosis of type 2 diabetes mellitus and has no order to manage diabetes mellitus. This deficient practice has the potential to delay provision of care and services identified in the assessment that could impact the patient's health status and wellbeing. Findings: a. A review of Patient 4's clinical record indicated a Start of Care (SOC) date of 2/05/2023, with a diagnoses of sequelae (residual effects or conditions produced after the acute phase of an illness or injury has ended) of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). A review of Patient 4 's Plan of Care (POC) for certification period 4/06/2023 to 6/04/2023, indicated an order for a Skilled Nurse (SN) to visit the patient one time a week for nine weeks. On 6/22/2023, at 12:45 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 4’s residence. Patient 4 was observed in a wheelchair with a knee brace to his right knee. Patient 4 complained of pain to the right knee at a level of 8/10 (severe) but patient stated he did not need pain medication. LVN 1 stated that she would apply ice pack to the knee to help with the pain. A review of Patient 4’s Medication Profile, indicated that patient did not have an order for pain medication. A review of Patient 4’s clinical record from the assisted living facility indicated that there was an order for Tramadol (for pain) 50 mg (milligram – unit of measurement) dated 6/09/2023. A review of Patient 4’s clinical record indicated that there was no follow-up or communication notes to the physician regarding the patient’s Tramadol order that was ordered on 6/09/2023. A review of Patient 4’s clinical record indicated that patient had a diagnosis of type 2 diabetes mellitus but medication profile indicated that Insulin Lispro 100 unit/ml (milliliter -unit of measurement) was discontinued on 03/01/2023. Further review of Patient 4’s clinical record indicated that there was no other order for diabetic medications and no follow-up or communication notes to the physician to discuss if another diabetic medication was needed. During an interview with the Medication Technician at the Assisted Living, on 06/22/2023 at 1:33 p.m., she stated that Patient 4 does not have any current pain medications and that they are still waiting for the Tramadol. b. A review of Patient 6's clinical record indicated a Start of Care (SOC) date of 02/06/2023 and discharge date unknown, with a diagnoses of type 2 diabetes mellitus and altered mental status. A review of Patient 6's Plan of Care (POC) for certification period 04/06/2023 to 06/04/2023, indicated an order for a Skilled Nurse (SN) to visit the patient two time a week for nine weeks. A review of Patient 6’s clinical record indicated that patient had a diagnosis of type 2 diabetes mellitus but medication profile indicated that there was no order for diabetic medication. Further review of Patient 6’s clinical record indicated that there was no follow-up or communication notes to the physician to discuss if Patient 6’s needed diabetic medication. During a telephone interview with the Director of Patient Care Services (DPCS), on 06/23/2023 at 1:13 p.m., she stated that since Patient 4 and Patient 5 were both diagnosed with diabetes then nurse should have followed up with the doctor to discuss diabetic medication since both patients were no taking any. During an interview with the Director of Patient Care Services Designee (DPCSD), on 06/23/2023 at 6:15 p.m., she stated that coordination of care is important because staff need to know what is going on with the patient and communicate with the doctor any issues or concerns. A review of agency’s policy and procedure titled, “Care Coordination” undated, indicated that the purpose of the policy and procedure is to ensure that individual care and services of all disciplines is coordinated.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview, and record review, the Home Health agency (HHA) failed to provide documented evidence the Quality Assurance Performance Improvement (QAPI) program was maintained and actively implemented to enable the HHA to assess processes of care, services, and operations. This deficient practice denied all active patients the benefit of an effective QAPI program, which is designed to improve the agency’s performance, and ultimately provide better patient care. Findings: On 6/23/23, at 6:15 pm., an interview was conducted with the ADM/Designee in the agency's office. During a concurrent interview the QAPI program was requested, however the ADM/Designee was unable to provide the documented evidence. The ADM/Designee stated the agency does not have a performance improvement project (PIP). Further review indicated there was no policy and procedure in place for the QAPI program.

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 interview and record review, the Home Health Agency (HHA) failed to develop and implement policies and procedures for COVID-19 (corona virus disease - highly contagious respiratory disease caused by a virus that can spread from person to person) policy and procedure. The deficient practice had the potential to put the patients and staff at risk for infection. Findings: On 6/23/2023, requested policy and procedure for COVID-19 from the Administrator but unable to provide. During an interview with the Administrator/Director of Patient Care Services Designee (ADM/DPCSD), on 6/23/2023 at 6:03 p.m., she stated that there was no COVID-19 policy and procedure at the agency. ADM/DPCSD further stated that the policy and procedure was in storage.

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, interview and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Organization and Administration of Services as follows: 1. The HHA failed to ensure the HHA has functioning governing body to assume full legal authority and responsibility for the daily operations of the agency. (Refer G942) 2. The HHA failed to ensure the HHA has a qualified Administrator responsible for all day-to-day operations and management of the agency. (Refer to G944) The cumulative effect of these systemic practices resulted in the home health agency's failure to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of services to ensure highest quality of care is provided to patients certified to receive home health benefits. .

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 interview and record review the home health agency (HHA) failed to ensure the agency's governing assume full legal authority and responsibility for the daily operations of the agency. This failure had the potential affect the provision of the agency’s home health services, its operational plans, and its quality assessment and performance improvement program will not be addressed and reviewed which can impact the quality of patient care provided to all the patients certified to receive home health services. Findings: On 6/23/23, at 6 pm., during a record review of the agency’s governing indicated no documented evidence they met at a regular basis. There were no meeting minutes provided when requested. On 6/23/23 at 6:15pm., and interview was conducted with the ADM(Administrator)/DPCS (Director of Patient Care Services) designee stated that no governing body meeting minutes could be provided because everything was still in the storage. Agency policy was requested and could not be provided.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the Administrator had the appropriate training and experience and must be responsible for all day-to-day operations and management of the HHA. The deficient practice has the potential to result of the HHA to be mismanaged by unqualified administrator or personnel that could impact the quality of care and quality of life to the patients certified to receive home health benefits. Findings: On 06/23/2023, the Administrator’s employee record was requested to be reviewed. During an interview with the Office Staff, on 6/23/2023, at 1:40 p.m., Office Staff stated the Administrators employee file was not available and was in storage. On 6/23/2023 at 1:43p.m., it was also observed that one of the offices inside the HHA 's suite was occupied by a Caregiver Agency. During an interview with the Patient Care Services from the Caregiver Agency, on 6/23/2023, at 12:40 p.m., stated agency moved to the current office two weeks ago. The Patient Care Services from the caregiver agency stated that they were using the office while they wait for an available suite in the same building. Patient Care Services from the caregiver agency further stated that the owner of the caregiver agency was the same person as the owner of the HHA. A review of agency’s job description titled, “Administrator” undated, indicated that summary of job responsibilities included being responsible to plan, coordinate, manage and direct all activities and programs of the home health agency.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed ensure that there was a discharge summary for one of seven sample patients (Patient 6). The deficient practice has the potential for the patient's health status and treatment will not be coordinated resulting to non-continuity of patient care and services. Findings: A review of Patient 6's clinical record indicated a Start of Care (SOC) date of 2/06/2023 with a diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar) and altered mental status. A review of Patient 6's Plan of Care (POC) for certification period 4/06/2023 to 6/04/2023, indicated an order for a Skilled Nurse (SN) to visit the patient two times a week for nine weeks. A review of Patient 6’s OASIS Transfer (Outcome and Assessment Information Set, a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) dated 2/26/2023, indicated that Patient 6 was transferred to an inpatient facility and was discharged from agency. A review of Patient 6’s Discharge Order/Summary dated 2/23/2023, indicated that the sections reason for terminating services, describe extent to which treatment goals where obtained, services rendered to patient, instructions to patient/caregiver, patient has advance directive and equipment left at home where all blank. During an interview with the Director of Patient Care Services Designee (DPCSD), on 6/23/2023 at 6:15 p.m., she stated that when a patient is discharged from the agency a discharge summary is completed and sent to the physician. A review of agency’s policy and procedure titled, “Discharge from Services” undated, indicated that the purpose of the policy and procedure is to define the requirements for documentation of patient discharge from the agency. The policy and procedure further indicated that the discharge summary is completed and submitted to the organization within a week of discharge from the agency and a copy of the discharge summary will be provided to the patient’s physician when home health services are discontinued.