Every finding on record at Fatima Home Care

During the recertification survey conducted on 04/26/2022 to 04/28/2022 at Fatima Home Care, Inc., a Home Health Agency, Emergency Preparedness was reviewed. Fatima Home Care, Inc. is in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 04/26/2022 to 04/28/2022 at Fatima Home Care, Inc. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to ensure that the Registered Nurse (RN) conducted a supervisory visit of the Home Health Aide (HHA) while the HHA is providing patient care, no less frequently than every 60 days, who is not receiving skilled care service in 3 out of 10 Sample Patients (SP). SP#1, SP#3 and SP#4 Findings include: Clinical records review of SP#1 conducted on 04/26/22 to 04/27/22 showed that SP#1 is actively receiving home health aide services for assistance with personal care. Further review of the clinical record revealed supervisory visits were conducted on 12/28/21 and then on 02/28/22, which is an interval of 62 days. Clinical records review of SP#3 conducted on 04/26/22 to 04/27/22 showed that SP#3 is actively receiving home health aide services for assistance with personal care. Further review of the clinical record revealed supervisory visits were conducted on 02/02/22 and then on 04/04/22, which is an interval of 61 days. Clinical records review of SP#4 conducted on 04/26/22 to 04/27/22 showed that SP#4 is actively receiving home health aide services for assistance with personal care. Further review of the clinical record revealed supervisory visits were conducted on 12/29/21 and then on 02/28/22, which is an interval of 61 days. The Alternate Administrator, Director of Nursing and Alternate Director of Nursing on 04/28/22 at 11:48 AM acknowledged findings made by the surveyor, the provider failed to perform an on-site 60 days supervision.

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: This CONDITION is not met as evidence by: Based on interview, facility record review and clinical record review, it was determined that the Home Health Agency (HHA) failed to have skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis; and failed to show that services were provided by direct employees (G982). The effect of the systemic practice resulted in the agency's inability to ensure that the patient's skilled care needs would be met.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to have skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis. Findings include: Review of the licensure application dated 01/06/22 revealed the agency chose (5) Nursing and (1) Occupational Therapy as the direct service. On 04/26/22 at 10:47 am the Alternate Director of Nursing stated that no new admission for skilled nursing service have occurred in the past 12 months. On 04/26/22 at 12:34 pm an interview was conducted with the Alternate Director of Nursing and Alternate Administrator. As per Alternate Director of Nursing and Alternate Administrator, the provider last serviced a skilled care in July 2021 for Physical Therapy care only and has not provided any Skilled Nursing service. Clinical records review of skilled care conducted on 04/26/22 and 04/27/22 revealed that Sampled Patient (SP)#6 and SP#7 were admitted to service on 05/05/21 and 06/16/21, providing Physical Therapy service only and discharged as of 06/21/21 and 07/23/21 respectively.