Every finding on record at East Carolina Home Health Agency, LLC

An unannounced on-site complaint investigation was conducted on February 26, 2024. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, complaint log review, staff interviews, and patient interview the agency failed to document and investigate the existence of a complaint and the resolution for 1 of 3 patients with a clinical record review. (patient #2) Findings included: A policy [agency name] My home health resources booklet, My rights and responsibilities (not dated) was received on 02/26/2024 at 9:35 A.M. from the agency branch director. The policy stated, “As a patient of the agency, you have the right to… Voice grievances about care which is or is not provided…have grievances investigated by the Company.” Patient #2 was admitted on 12/20/2023 with a diagnoses of NONDISP SIMP SUPRCNDL FX W/O INTERCNDL FX R HUMER (fracture of arm) and UNSP FX UPPER END OF TIBIA (leg fracture). The plan of care for 12/20/2023-02/17/2024 included orders for skilled nurse visits 1 time a week for 1 week, 1 every 2 weeks for 2 weeks, and 1 time a week for 1 week, physical therapy (PT) visits 1 time a week, and occupational therapy (OT) visits 1 time a week for 1 week. For the PT visit of 01/04/2024 there was no evidence of patient #2 reporting a complaint. For the OT visit of 01/11/20/24 there was no evidence of patient #2 reporting a complaint. A review of the agency complaint log was conducted on 02/26/2024 at approximately 9:30 A.M. There was no evidence of complaint or investigation for patient #2. An interview was conducted on 02/26/2024 at approximately 9:00 A.M. with patient #2. Patient #2 stated, “I complained to everyone [agency staff] that came to my house [after the admission visit] about the delay in therapy.” An interview was conducted on 02/26/2024 at approximately 2:00 P.M. with PT #3. PT #3 stated, “I do remember her [patient #2] … She might have been expecting us sooner. It wasn’t really a serious complaint, I told her that I understood her concern. No, I didn’t report her concern to the office. If it’s really a serious complaint or they [patient] are irate we report to the manager and have a case conference.” An interview was conducted on 02/26/2024 at approximately 2:08 P.M. with OT #4. OT #4 stated, “Yes [patient #2 voiced a complaint] … her concern was that she felt like she didn’t get what she needed. [COTA name] called me and reported the concern. I made an attempt to call my supervisor but could not get through. I would [normally] contact [clinical manager’s name] and document it.” An interview was conducted on 02/26/2024 at approximately 2:10 P.M. with the branch director. The branch director stated, “We expect them to notify their supervisor [of a complaint/concern] so we can follow up.”

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, patient interview, and staff interviews the agency failed to complete physical therapy (PT) and occupation therapy (OT) comprehensive assessments within 5 days for 1 of 2 patients with orders for PT and OT. (patient #2) Finding included: A policy, Initial and Comprehensive Assessments (revises 04/2023) was received on 02/26/2024 at approximately 2:30 P.M. from the clinical supervisor. The policy stated, “The initial comprehensive assessment must be completed in a timely manner consistent with the patient’s immediate needs but no later than 5 calendar days after the start of care…” Patient #2 was admitted on 12/20/2023 with a diagnoses of NONDISP SIMP SUPRCNDL FX W/O INTERCNDL FX R HUMER (fracture of arm) and UNSP FX UPPER END OF TIBIA (leg fracture). The plan of care for 12/20/2023-02/17/2024 included orders for skilled nurse visits 1 time a week for 1 week, 1 every 2 weeks for 2 weeks, and 1 time a week for 1 week, physical therapy (PT) visits 1 time a week effective 12/24/2023, and occupational therapy (OT) visits 1 time a week for 1 week effective 12/31/2023. The PT comprehensive assessment was conducted on 01/04/2024, 15 days after the admission and 12 days after the physician’s order. The OT comprehensive assessment was conducted on 01/11/2024, 22 days after the admission and 11 days after the physician’s order. An interview was conducted on 02/26/2024 at approximately 9:00 A.M. with patient #2. Patient #2 stated, “Someone came to admit me and then no therapist came or called for weeks.” An interview was conducted on 2/26/2024 at approximately 1:50 P.M. with the clinical manager. The clinical manager stated, “Normally we communicate a delay in assessment with the patient, if we are aware that there will be a delay the patient should be notified at admission.”

An unannounced, onsite complaint investigation was conducted on 5/15/23-5/16/23. The allegations were substantiated and standard level deficiencies to the Medicare CoP were identified.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on clinical record review and staff and patient interview, the agency failed to provide written notice when terminating on-going care for 1 of 3 patients [#1]. The findings included: Patient # 1 had a Start of Care date of 1/3/23 and admitting diagnosis of encounter of orthopedic aftercare following a surgical amputation. Review of the Plan of Care [POC] for the certification period 3/4/23 to 5/2/23 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week and “Skilled nurse to perform/teach pressure ulcer care to left lateral foot. Leave foam pad placed by podiatry intact. Cleanse with normal saline. Apply calcium alginate with silver. Windowpane wound with foam dressing. Secure with rolled gauze and tubigrip using clean/aseptic technique. Change dressing 2 times weekly…” Review of the clinical record revealed RN # 1 made a routine visit on 4/11/23 and documented the following information, “…Patient is no longer homebound and will be discharged from agency on 4/17/23. Patient aware of dc [discharge] but states ‘no one ever told me I had to stay home. My niece is going to do the wound care while I am there. Who is going to do the care when I get back?’…” During an interview with the patient on 5/15/23 at 4:30 pm, the patient stated, “I did not get a formal discharge paper. No one mailed anything and no one brought anything by.” During an interview with the clinical manager on 5/16/23 at approximately 10 am, the clinical manager confirmed the patient did not receive any written notice of the pending discharge.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to attempt to investigate a patient related concern/complaint within 3 business days for 1 of 1 patient [#1]. The findings included: The policy, Complaint Management [revised date of 5/2023] was provided by the clinical manager on 5/15/23 at approximately 12:30 pm. The policy stated, “…All complaints made by patients, family or the patient’s responsible part either verbally or in writing will be reviewed, evaluated and forwarded to the appropriate manager for resolution…Actions and resolution will be documented in the complaint log…The Home Health Agency must investigate complaints made by a patient…to the following topics: Treatment or care that is or fails to be furnished…Attempts will be made to resolve complaints at the local level within three business days…” Patient # 1 had a Start of Care date of 1/3/23 and admitting diagnosis of encounter of orthopedic aftercare following a surgical amputation. Review of the Plan of Care [POC] for the certification period 3/4/23 to 5/2/23 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week and “Skilled nurse to perform/teach pressure ulcer care to left lateral foot. Leave foam pad placed by podiatry intact. Cleanse with normal saline. Apply calcium alginate with silver. Windowpane wound with foam dressing. Secure with rolled gauze and tubigrip using clean/aseptic technique. Change dressing 2 times weekly…” Review of the clinical record revealed RN # 1 made a routine visit on 4/11/23 and documented the following information, “…Patient is no longer homebound and will be discharged from agency on 4/17/23. Patient aware of dc [discharge] but states ‘no one ever told me I had to stay home. My niece is going to do the wound care while I am there. Who is going to do the care when I get back?’…” During an interview with the patient on 5/15/23 at approximately 4:30 pm, the patient stated, ”I wanted to speak with the administrator. I asked the nurses to have the administrator call me, I called the office and asked ______ [name of receptionist] to have the administrator call me. I wanted to voice my concerns to the administrator about what an adverse effect this discharge was going to have on my mental health because of the worry and stress I had to go through worrying about who would do my dressing changes. She never called me back.” During an interview with the area vice president on 5/16/23 at approximately 11:30 am, the vice president confirmed the administrator never returned the patient’s call to investigate his concerns.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, interview with staff and patient, the agency failed to document the existence of a complaint and the resolution of the complaint for 1 of 1 patients [#1]. The findings included: The policy, Complaint Management [revised date of 5/2023] was provided by the clinical manager on 5/15/23 at approximately 12:30 pm. The policy stated, “…All complaints made by patients, family or the patient’s responsible either verbally or in writing will be reviewed, evaluated and forwarded to the appropriate manager for resolution…Actions and resolution will be documented in the complaint log…The Home Health Agency must investigate complaints made by a patient…to the following topics: Treatment or care that is or fails to be furnished…Attempts will be made to resolve complaints at the local level within three business days…” Patient # 1 had a Start of Care date of 1/3/23 and admitting diagnosis of encounter of orthopedic aftercare following a surgical amputation. Review of the Plan of Care [POC] for the certification period 3/4/23 to 5/2/23 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week and “Skilled nurse to perform/teach pressure ulcer care to left lateral foot. Leave foam pad placed by podiatry intact. Cleanse with normal saline. Apply calcium alginate with silver. Windowpane wound with foam dressing. Secure with rolled gauze and tubigrip using clean/aseptic technique. Change dressing 2 times weekly…” Review of the clinical record revealed RN # 1 made a routine visit on 4/11/23 and documented the following information, “…Patient is no longer homebound and will be discharged from agency on 4/17/23. Patient aware of dc [discharge] but states ‘no one ever told me I had to stay home. My niece is going to do the wound care while I am there. Who is going to do the care when I get back’…” During an interview with Patient # 1 on 5/15/23 at approximately 4:30 pm, the patient stated, “I asked the nurses to have the administrator call me, I called the office and asked ______ [name of receptionist] to have the administrator call me. I wanted to voice my concerns to the administrator about what an adverse effect this discharge was going to have on my mental health because of the worry and stress I had to go through worrying about who would do my dressing changes. She never called me back. I told _____ [name of receptionist] the last time I called I was going to file a formal complaint.” A review of the agency complaint log on 5/15/23 at approximately 2 pm, revealed no entry related to patient # 1’s concerns. During an interview with the clinical manager on 5/16/23 at approximately 11:30 am, the clinical manager stated, “I guess we should have documented his concerns on the complaint log.”

An onsite, unannounced complaint investigation was conducted on 01/24/22. Deficiencies to the Medicare Conditions of Participation were identified and the allegation is substantiated. -MHB

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, caregiver interview, and staff interview the agency failed to provide timely notification of discharge and did not coordinate discharge with the patient or the patient’s caregiver for 1 of 3 clinical records reviewed (Patient #2). Findings included: Policy Discharge or Transfer, included in the Patient’s Guidebook for Home Healthcare, and revised 11/2021 was received from the agency director on 01/24/22 at 11:00 AM. This policy revealed, “…The patient’s continuing care, treatment and service needs will be reassessed at discharge for purposes of planning for and/or recommending appropriate services; identifying the need for continuing services; and setting up alternative care plans. The patient/family will be provided with discharge teaching/instructions…” and “The Home Health Agency must do the following before it discharges a patient for cause: a) Advise the patient, representative (if any), the physician(s) or other authorized practitioner(s) issuing orders for the home health plan of care, and the patient’s primary care practitioner or other healthcare professional who will be responsible for providing care and services to the patient after discharge from the Home Health Agency (if any) that a discharge for cause is being considered…c) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care…” Policy 03-09 Patient Rights/Notice of Privacy Practices, revised 08/2021, was received from the agency director on 01/24/22 at 11:30 AM. This policy revealed, “…As a patient of the Company, patients have a right to…Voice grievances about care which is or is not provided, recommend policy/service changes, have grievances investigated by the Company and make complaints without fear of reprisal or unreasonable interruption of care…Receive timely notice of impending discharge or transfer to another organization or to a different level of intensity of care, and to be advised of the consequences and alternatives to such transfers.” Patient #2 was admitted to the agency on 11/03/20 with diagnoses including laceration (a deep cut) to the left lower leg and lymphedema (a build-up of fluid in the soft tissue with the presence of swelling). Plan of Care from 10/29/21 to 12/27/21 revealed orders for skilled nursing services 2 times per week for 8 weeks and 1 time per week for 1 week. Wound care orders included on the Plan of Care revealed, “SKILLED NURSE TO PERFORMED [sic] WOUND CARE TO LEFT LOWER ANTERIOR (front) LEG. CLEANSED [sic] AREA WITH MILD SOAPY WATER OR SALINE APPLY SIKVER [sic] (silver-used in wounds for where infection is present or likely) CONTACT LAYER THEN DRAWTEC [sic] (Drawtex-brand name of absorbent dressing), IF AREA BECOMES MACERATED (a condition that occurs when skin is exposed to excess moisture) RESUME PREVIOUS ORDERS. (PRISMA-brand name absorbent dressing)/ROLL GAUZE, UNNA BOOT (brand name compression wrap often used for lymphedema). WRAPPED [sic] WITH UNNA BOOT AND COBAN (brand name self-adherent wrap dressing) 2 X WEEK [sic].” Narrative of Employee #3’s, nurse case manager, skilled nursing visit of 12/26/21, revealed, “…PT (patient) REQUESTS TO RECEIVE UNNA BOOTS ‘LIKE THE WOUND CLINIC. PTS WIFE STATES, ‘THEY ARE ONLY ORDERING [agency’s medical supply company] PRODUCTS BECAUSE ITS CHEAPER.’ [Patient #2’s caregiver] LOOKS AT RN (registered nurse) AND SAYS, ‘YOU SHOULD ORDER WHAT IS BEST FOR THE PATIENT NOT WHAT IS CHEAPER. YALL [sic] ARE JUST TRYING TO MAKE AS MUCH MONEY AS YOU CAN.’ RN EXPLAINS THAT RN CAN ONLY ORDER SUPPLIES OFF OF FORMULARY. SUPPLIES OFF OF FORMULARY HAVE TO BE ORDERED BY MANAGEMENT. [Patient #2’s caregiver] STATES, ‘WHATEVER [Employee #3], JUST KEEP ON TALKING.’ RN STATES, ‘[Patient #2’s caregiver] I AM SORRY BUT I AM ONLY TRYING TO HELP YOU UNDERSTAND.’ WHEN PERFORMING WOUND CARE, [Patient #2’s caregiver] STATES IT IS HARDER FOR HIM TO MOVE HIS LEGS WHILE HE IS SITTING UP, SO WRAPPING LEGS WILL BE DIFFICULT. [Patient #2] EXPLAINS THAT IS WHY HE LIKES 800AM TO 830AM VISITS. RN MADE [Patient #2] AWARE THAT [agency] WOULD DO THE BEST THEY CAN TO ACCOMMODATE BUT VISIT TIMES CANT [sic] BE PROMISED. [Patient #2’s caregiver] STATES, ‘YEAH YEAH [Employee #3]. IM [sic] NOT LAYING HIM BACK DOWN SO YOULL JUST HAVE A HARD TIME." RN PERFORMED WOUND CARE WITH PT SITTING UP. PT TOLERATED WELL.” Coordination Note of 12/28/21 was written by Employee #1, the agency director, and revealed, “SPOKE WITH (Patient #2’s caregiver) YESTERDAY 12/27/2021 TO DISCUSS WOUND SUPPLIES FOR [Patient #2]. [Patient #2’s caregiver] VERBALIZED UNHAPPINESS ABOUT THE [agency’s medical supply company] SUPPLIES SHE HAD RECEIVED. SHE VERBAILZED WHAT SUPPLIES SHE WAS REQUESTING AND WAS INFORMED THAT IT WOULD BE ORDERED BY A MANAGER. [Patient #2’s caregiver] WAS YELLING AND ENDED THE CALL BY HANGING UP ABRUPTLY. WHEN FOLLOWING UP WITH RN THAT LAST SAW [Patient #2]- IT IS DOCUMENTED THAT [Patient #2’s caregiver] WAS VERBALLY ABUSIVE TO THE RN. TODAY- 12/28/2021 I LEFT A MESSAGE WITH…[name of wound care clinic registered nurse], RN AT [wound care clinic] FOR A CALL BACK. AT 2;00 [sic] PM I SPOKE WITH [name of wound care clinic registered nurse] JUST NOW AND SHE INFORMED THAT [Patient #2’s caregiver] WAS REQUESTING DISCHARGE AND WANTED ANOTHER AGENCY. I INFORMED HER THAT IT WOULD BE COMPLETED TODAY AND THE BEHAVIOR OF [Patient #2’s caregiver] WAS DISRESPECTFUL TO THE STAFF- SO THE DISCHARGE WAS MUTUAL. WOUND CARE SUPPLIES WERE ORDERED TODAY SO [Patient #2] WOULD HAVE SUPPLIES UNTIL ANOTHER AGENCY COULD START CARE. CASE MANAGER WAS INFORMED.” Discharge Summary note of 12/28/21 was written by Employee #3, and revealed, “REASON FOR DISCHARGE: PTS WIFE REQUESTS NEW AGENCY/[agency] AGREES. PLEASE SEE [Employee #1’s], DIRECTOR, NOTE…EVALUATION OF GOALS: PT HAS LACERATION ON LEFT SHIN. PT SEES THE WOUND CLINIC. WOUND CLINIC WILL REFER PT TO ANOTHER HOME HEALTH AGENCY.” Narrative Note of 12/30/21 was written by Employee #1 and revealed, “PHYSICIAN CONTACTED AND APPROVED ORDERS IN PLAN…ATTEMPTED TO CALL [wound care clinic] TO LEAVE MESSAGE FOR [wound care registered nurse]. I SPOKE WITH [Patient #2’s caregiver] AND SHE WAS SAYS SHE DID NOT REQUEST DISCHARGE. I WAS UNBALE TO LEAVE MESSAGE ON THE CALL BACK LINE TO DISCUSS. IN MY CONVERSATION WITH [Patient #2’s caregiver] SHE WAS YELLING AND I POINTED IT OUT- SHE REPLIED SHE WAS ON A SPEAKER PHONE. [Patient #2’s caregiver] CONTINUES TO BE UPSET ABOUT [agency’s medical supply company] SUPPLIES. At the time of survey, there was no further documentation in the clinical record related to discharge conversations or coordination with Patient #2 or Patient #2’s caregiver prior to 12/28/21 or after 12/30/21. In a telephone interview on 01/24/22 at 11:50 AM, Patient #2’s caregiver stated “I was notified of discharge when I contacted [agency] to follow up on supplies…I did say something to the wound care clinic about wishing I could change companies because with [agency] there was always an issue with supplies…I would not have asked for a discharge to be done without things being in order with another company first…It was 3 weeks before we were able to get another company out here.” The following interviews occurred on 01/24/22 between 3:00 PM and 4:45 PM with Employee #1, the agency director. Employee #2, the clinical manager, was also present during these interviews. Employee #1 was asked if there was any additional documentation in the clinical record following the 12/30/21 Narrative Note and stated, “[Wound care clinic registered nurse], the nurse called me back. I believe it was the 30th…She informed me that she was doing what [Patient #2’s caregiver] asked her to do…On the 27th, I had a conversation with [Patient #2’s caregiver] and she was derogatory regarding my staff. On Tuesday (the next day) I got a call from [wound care clinic registered nurse]…I thought she (the wound care clinic registered nurse) was returning my call but she said that [Patient #2’s caregiver] told her that she was dissatisfied with our services and the [agency’s medical supply company] supplies and that she had been looking at other agencies…I told [wound care clinic registered nurse] that that was fine because [Patient #2’s caregiver] was making it difficult to continue services. [Patient #2’s caregiver] called back a couple of days later and said that she didn’t ask to be discharged. I told her that’s what [wound care clinic registered nurse] told me.” When asked if the agency would typically verify a third-party reported desire of a patient to discontinue services directly with the patient and/or caregiver, Employee #1 stated, “Typically we would follow up…[Patient #2’s caregiver] was making it difficult to provide care for [Patient #2].” Employee #1 stated that there were additional conversations that occurred with the both the wound care clinic registered nurse and Patient #2’s caregiver related to Patient #2’s discharge and stated those conversations would be added to the clinical record as late entries. Employee #1 confirmed that there was no evidence in the clinical record of a prior notice of discharge or a notice of impending discharge for cause of Patient #2 at the time of survey. Employee #1 also confirmed that there was no evidence in the clinical record of Patient #2 or Patient #2’s caregiver being provided with contact information for other agencies or providers who may be able to provide care.