Every finding on record at Epsilon Health Solutions LLC

An unannounced on-site survey, authorized by the Centers for Medicare and Medicaid Services (CMS), was conducted on 4/24/23. The Condition of Participation reviewed was Patient Rights. The survey was prompted by complaint intake WY96618.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on medical review, staff interview, case manager interview and review of agency policy, the agency failed to provide all services outlined in the plan of care for 1 of 6 sample patients (#4). The findings were: Review of the medical record for patient #4 showed a signed agreement dated 2/9/23 between the client, the agency and the community choice waiver case manager for the agency to provide 1 nurse visit per month and 5 aide visits per week. The following concerns were identified: 1. Review of communication notes in the medical record of patient #4 showed the following: The agency canceled 8 home visits in the month of February (1st, 3rd, 7th, 9th, 14th, 21st, 22nd, 23rd) and canceled 2 scheduled home visits during the month of March. Further review showed 3 of the cancellations during this time frame were related to weather. The others were related to inadequate staffing. 2. Interview with the business office manager on 4/24/23 at 3:49 PM confirmed she had called the client several times in the past few months to adjust the schedule because of staffing or the weather. 3. Interview with the patient's case manager on 5/1/23 at 2:56 PM revealed the case manager had received complaints from patient #4 in February related to the number of times the agency canceled or rescheduled her visits and the patient was "upset" and "frustrated" about not receiving home visits because there was "not enough staff." 4. Review of the agency policy titled " Clients Rights and Responsibilities," no date, showed: "These Rights and Responsibilities will be followed by all employees that provided care/services to you in your residence... You have the right to exercise these rights any time without fear of reprisal or discrimination in care/services...7. Receive all services outlined in the plan of care."

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 medical record review, staff interview, case manager interview, and policy review, the agency failed to ensure patients, patient representatives, and physicians were notified a discharge for cause was being considered for 1 of 6 patients (#4) reviewed. The findings were: Review of the medical record for patient #4 showed s/he was admitted to the agency on 7/19/21. Review of the “Client Financial Authorization” most recently signed on 2/9/23 showed the agency was to provide 1 nurse visit per month, and 5 home health aide visits per week. Review of the 30-day discharge notice dated 2/24/23, addressed to the patient and signed by the agency administrator showed “We regret to inform you that this letter will serve as a termination of services effective 03/26/23, due to violation of agency policy ‘Clients Receiving Services Have the Responsibility to Refrain from Verbally or Physically Abusing Caregivers.’ Unfortunately, there have been several documented instances of verbally abusive behavior towards staff members, particularly the agency’s business office manager. Multiple reports have been made to case manager [name of case manager] detailing concerns.” The following concerns were identified: a. Interview with the agency administrator on 4/24/23 at 3:51 PM revealed the patient’s telephone conversation with the business office manager on 2/23/23 created a “hostile work environment”. However, the administrator could not describe what was said or how it created a hostile work environment. Further, the administrator could not provide any other examples of the patient, either in the home or over the telephone, creating a hostile work environment. The administrator confirmed she had not talked to the patient regarding any complaints or the patient’s concerns. b. Review of the patient’s medical record showed no evidence of notification to the patient, the patient’s representative, or the patient’s physician that a discharge for cause was being considered. c. Interview with the patient’s case manager on 5/1/23 at 2:56 PM revealed the case manager had received complaints from the patient in February 2023 related to the number of times the agency canceled or rescheduled her visits, and the patient was upset and frustrated about not receiving the home visits because the agency did not have enough staff. The case manager further revealed she had not been notified by the agency of any inappropriate behavior displayed by the patient, and was unaware a discharge for cause was being considered until the discharge notice was issued. d. Review of the agency policy “Transfer/Discharge Policy”, undated, showed “The Agency may only transfer the Client from the Agency if:…The Agency determines, under a policy set by the Agency for the purpose of addressing ‘discharge for cause’ that meets the DISCHARGE FOR CAUSE REQUIREMENTS below, that the Client’s behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the client or the ability of the Agency to operate effectively is seriously impaired…DISCHARGE FOR CAUSE REQUIREMENTS:…Make efforts to resolve the problem(s) presented by the Client’s behavior…Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records…”

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, case manager interview, review of the CMS State Operation Manual, and policy review, the agency failed to make efforts to resolve problems presented by the patient’s behavior for 1 of 6 patients (#4) reviewed. The findings were: Review of the medical record for patient #4 showed s/he was admitted to the agency on 7/19/21. Review of the “Client Financial Authorization” most recently signed on 2/9/23 showed the agency was to provide 1 nurse visit per month, and 5 home health aide visits per week. Review of the 30-day discharge notice dated 2/24/23, addressed to the patient and signed by the agency administrator showed “We regret to inform you that this letter will serve as a termination of services effective 03/26/23, due to violation of agency policy ‘Clients Receiving Services Have the Responsibility to Refrain from Verbally or Physically Abusing Caregivers.’ Unfortunately, there have been several documented instances of verbally abusive behavior towards staff members, particularly the agency’s business office manager. Multiple reports have been made to case manager [name of case manager] detailing concerns.” The following concerns were identified: a. Review of communication notes in the patient’s medical record showed the agency canceled 2 scheduled visits in the month of January 2023 (on the 2nd, and 30th ), and changed the time for 4 scheduled visits (on the 13th, 26th, 27th, and 31st ). During the month of February 2023, the agency canceled 8 scheduled visits, (on the 1st, 4th, 8th, 10th, 14th, 21st, 22nd, and 23rd ), and changed the time of the scheduled visits 5 times (on the 2nd, 10th, 16th, 17th, and 28th ). Review of the documentation related to calls to the patient revealed the patient was “agreeable” to the changes except on 1/31/23, when the patient was documented as saying, “This is getting ridiculous” and told the business office manager the agency needed to get its act together, and on 2/1/23 when the patient stated, “that will not work, I need groceries” and “I need an aide every day”. b. Further review of communication documentation showed a 2/24/23 entry by the OT #1: “After discussing client’s recent verbally abusive behavior towards staff members, it was determined the client would be issued a 30-day termination notice for violation of agency policy: Client’s (sic) Receiving Services Have the Responsibility to Refrain from Verbally or Physically Abusing Caregivers.” c. Interview with the business office manager on 4/23/23 at 3:49 PM revealed she had called the patient “several times” in the past few months to adjust the schedule due to weather or staffing concerns. She further revealed the patient became “upset” on 2/23/23 when notified the home health aide visits for the next two days were to be canceled due to weather, and she interpreted the patient’s response to the cancellations as verbal abuse and notified the clinical director and the agency administrator. The business office manager was unable to describe how the conversation was abusive. d. Interview with the agency administrator on 4/24/23 at 3:51 PM revealed the patient had a telephone conversation with the business office manager on 2/23/23 that created a “hostile work environment”. However, the administrator could not describe what was said or how it created a hostile work environment. Further, the administrator could not provide any other examples of the patient, either in the home or over the telephone, creating a hostile work environment. The administrator confirmed she had not talked to the patient regarding any complaints or the patient’s concerns. e. Review of the CMS State Operations Manual, appendix B showed the following definition: “Disruptive, abusive behavior” includes verbal, non-verbal or physical threats, sexual harassment, or any incident in which agency staff feel threatened or unsafe, resulting in a serious impediment to the agency’s ability to operate safely and effectively in the delivery of care. f. Interview with the patient’s case manager on 5/1/23 at 2:56 PM revealed the case manager had received complaints from the patient in February 2023 related to the number of times the agency canceled or rescheduled her visits, and the patient was upset and frustrated about not receiving the home visits due to agency staffing issues. The case manager further revealed she had not been notified by the agency of any inappropriate behavior displayed by the patient, and was unaware a discharge for cause was being considered until the discharge notice was issued. g. Review of the agency policy “Transfer/Discharge Policy”, undated, showed “The Agency may only transfer the Client from the Agency if:…The Agency determines, under a policy set by the Agency for the purpose of addressing ‘discharge for cause’ that meets the DISCHARGE FOR CAUSE REQUIREMENTS below, that the Client’s behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the client or the ability of the Agency to operate effectively is seriously impaired…DISCHARGE FOR CAUSE REQUIREMENTS:…Make efforts to resolve the problem(s) presented by the Client’s behavior…Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records…”

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and review of agency policy, the agency failed to ensure problems and efforts made to resolve them were documented and entered into the clinical record for 1 of 6 sample (#4) sample patients. The findings were: Review of the medical record for patient #4 showed s/he was admitted to the agency on 7/19/21. Review of the 2/9/23 agreement signed by the patient, the agency, and the patient’s case manager showed the agency was to provide 1 nurse visit per month, and 5 home health aide visits per week. Review of communication notes in the patient’s medical record showed the agency canceled 2 scheduled visits in the month of January 2023 (on the 2 nd , and 30 th ), and changed the time for 4 scheduled visits (on the 13th, 26th, 27th, and 31st ). During the month of February 2023, the agency canceled 8 scheduled visits, (on the 1st, 4th, 8th, 10th, 14th, 21st, 22nd, and 23rd), and changed the time of the scheduled visits 5 times (on the 2nd, 10th, 16th, 17th, and 28th). Review of the documentation related to calls to the patient revealed the patient was “agreeable” to the changes except on 1/31/23, when the patient was documented as saying, “This is getting ridiculous” and told the business office manager the agency needed to get its act together, and on 2/1/23 when the patient stated, “that will not work, I need groceries” and “I need an aide every day”. Further review of communication documentation showed a 2/24/23 entry by the OT #1: “After discussing client’s recent verbally abusive behavior towards staff members, it was determined the client would be issued a 30-day termination notice for violation of agency policy: Client’s (sic) Receiving Services Have the Responsibility to Refrain from Verbally or Physically Abusing Caregivers.” Interview with the business office manager on 4/23/23 at 3:49 PM revealed she had called patient #4 “several times” in the past few months to adjust the schedule due to weather or staffing concerns. She further revealed the patient became upset on 2/23/23 when notified the home health aide visits for the next two days were canceled due to weather, and she interpreted the patient’s response to the cancellations as verbal abuse and notified the clinical manager and the agency administrator. The following concern were identified: a. Interview with the agency administrator on 4/24/23 at 3:51 PM revealed the patient’s telephone complaint on 2/23/23 created a “hostile work environment”. However, the administrator could not describe what was said or how it created a hostile work environment. Further, the administrator could not provide any other examples of the patient, either in the home or over the telephone, creating a hostile work environment. The administrator confirmed she had not talked to the patient regarding any complaints or the patient’s concerns. The administrator could not produce any documentation of previous instances of abusive behavior by the patient, nor any documentation of agency efforts to resolve complaints or issues. b. Review of the agency policy “Transfer/Discharge Policy”, undated, showed “The Agency may only transfer the Client from the Agency if:…The Agency determines, under a policy set by the Agency for the purpose of addressing ‘discharge for cause’ that meets the DISCHARGE FOR CAUSE REQUIREMENTS below, that the Client’s behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the client or the ability of the Agency to operate effectively is seriously impaired…DISCHARGE FOR CAUSE REQUIREMENTS:…Make efforts to resolve the problem(s) presented by the Client’s behavior…Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records…”