Every finding on record at Four Seasons Home Health Services Inc

An Emergency Preparedness Recertification Survey was initiated with the Administrator on 08/25/2023 at 10:30 AM. Census: Licensed and Certified- 8 Licensed Home Health- 2 Personal Assistance Services- 7 An exit conference was conducted with the Administrator on 09/01/2023 at 11:00 AM. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. The agency was found to be in substantial compliance with the Medicare Conditions of Participation, no deficiencies were cited.

A Recertification Survey was initiated with the Administrator on 08/25/2023 at 10:30 AM. Census: Licensed and Certified- 8 Licensed Home Health- 2 Personal Assistance Services- 7 An exit conference was conducted with the Administrator on 09/01/2023 at 11:00 AM. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Acronyms: Hha- home health aide DON- Director of Nurses

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, record review and interviews, the agency failed to provide written notice of the agency's transfer and discharge policy for 3 (Patients #1, 2 and 4) of 3 patients who received home visits from the surveyor. This failure did not conform to the patients right to be provided information regarding the criteria used to determine if the patient could be discharged or transferred from agency services. The failure placed the patients at risk to have their patient rights violated related to their possible discharge or transfer. FINDINGS INCLUDE: On 08/25/2023 at 12:00 PM, the surveyor reviewed the agency sample home folder. The folder did not include the agency’s transfer and discharge policy. Patient #1: On 08/30/2023 at 10:15 AM, the surveyor conducted a home visit and reviewed the home folder provided by the agency. The surveyor asked Patient #1 if anything was missing from the folder or removed. Patient #1 stated, “no.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. Patient #2: On 08/30/2023 at 10:05 AM, the surveyor conducted a home visit and reviewed the home folder provided by the agency. The surveyor asked Patient #2 if anything was missing from the folder or removed. Patient #2 stated, “not that I know of.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. Patient #4: On 08/30/2023 at 11:10 AM, the surveyor conducted a home visit and reviewed the home folder provided by the agency. The surveyor asked Patient #4 if anything was missing from the folder or removed. Patient #4 stated, “no, don’t think so.” Review of the agency home folder contained no evidence a written notice of the agency's transfer and discharge policy had been provided. During an interview with the Administrator/DON on 08/31/2023 at 2:30 PM, the surveyor reviewed the findings and asked why the agency did not provide written notice of the agency’s transfer and discharge policy. The Administrator/DON stated, “we didn’t know we were supposed to do that, when we discharge, we give them 5-day notice.” Agency policy, dated 11/29/2029, quoted in part, “PE.6 Patient Discharge/Discharge Planning, Purpose: To coordinate the discharge plan to the greatest degree possible to assure a smooth transition in accordance with patient preferences. To provide continuity of care as well as appropriate and timely post-discharge care and documentation…. To give patient other options for coverage when Medicare Covered Service end…. Policy, … G. Agency will provide appropriate discharge planning and notification per regulations….”

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each of the hha tasks listed at 484.80(b)(3)(iii) and (ix)(D) (training topics/tasks) were evaluated by observation of the hha performance of the tasks for 1 (Employee B) of 1 hha personnel record reviewed. This failure potentially placed any future patients with assigned hha services at risk for receiving substandard or unsafe care from the home health aide. FINDINGS INCLUDE: Personnel record, hha B: Review of the personnel file for hha B revealed an In-service record with a hire date of 08/01/2019. A form titled, “HOME HEALTH AIDE SKILLS COMPETENCY CHECKLIST” was completed with the Administrator/DON and dated 08/01/2019. The form did not include, “Respirations and Nail and Skin care” marked as evaluated for competency. Review of the entire hha personnel record did not demonstrate evidence that the hha performed or was observed providing all the required tasks for a competency evaluation. In an interview on with the Administrator/DON on 08/31/23 at approximately 11:30 AM, the surveyor reviewed the findings and asked why the Administrator/DON did not conduct a competency evaluation of all the required hha tasks. The Administrator/DON stated he thought it (the competency) was complete. The surveyor asked why respirations and nail and skin care were not completed with the competency for the hha, B. The Administrator/DON stated, “the hha last worked in 2021 and those tasks were not done, I concentrated on the big one (tasks).”