Every finding on record at Genesis Home Health Inc

A Complaint Survey for complaint #2020003858, was conducted on May 06, 2021 at Genesis Home Health Inc. The Home Health Agency was not in compliance with 42 CFR 484 Subpart A-C requirements for Home Health Agencies.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the Home Health Agency failed to investigate the complaints made by 1 out of 3 Sampled Patients (SP)'s relative. SP#1 Findings Include: Review of SP#1's record revealed she was admitted on 12/12/2019 to receive Home Health Aide (HHA) services. Further record review revealed SP#1 received HHA services from Staff B from 12/12/20219 to 01/21/2020. Additional record review revealed SP#1 was discharged on 06/20/2020. During an interview conducted on 05/06/2021 at 2:13 PM, SP#1's relative stated that her mother's neighbor told her that she overheard Staff B scream and yell at the patient. SP#1's relative stated that she immediately notified the agency of the incident and requested a new HHA. A review of the agency's policy and procedure manual revealed a form titled "Patient Concerns/Grievances" which contained the following "Any concern/grievance received from a patient or family will be forwarded in writing to the Director of Nursing/Administrator or his/her designee within thirty (30) days of the date the person filing the grievance becomes aware of the action. The concern/grievance investigation shall commence within 48 hours of receipt of the written complaint. The Director of Nursing is responsible for evaluating, reviewing, and investigating all patient concerns/grievances and for giving feedback to the patient and Administration. A record of the concern/grievance, investigation, follow-up action and response to the patient will be documented, using the Patient Complaint Form, and will be retained by Administration in a Patient Complaint file. The investigation shall be completed within thirty (30) days unless circumstances prevent finalization within that time period and a decision rendered by the Director of Nursing." During an interview conducted on 05/06/2021 at 2:45 PM, Registered Nurse/ Staff E acknowledged the above findings and stated that she was not working at the agency at that time. Furthermore, Registered Nurse/ Staff E reviewed and acknowledged that the complaint log and SP#1's record did not contain documentation to demonstrate that the agency investigated the complaint made by SP#1's relative.

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 record review, interview and policy review, the Home Health Agency failed to document both the existence and the resolution of the complaint made by 1 out of 3 Sampled Patients (SP)'s relative. SP#1 Findings include: R Review of SP#1's record revealed she was admitted on 12/12/2019 to receive Home Health Aide (HHA) services. Further record review revealed SP#1 received HHA services from Staff B from 12/12/20219 to 01/21/2020. Additional record review revealed SP#1 was discharged on 06/20/2020. During an interview conducted on 05/06/2021 at 2:13 PM, SP#1's relative stated that her mother's neighbor told her that she overheard Staff B scream and yell at the patient. SP#1's relative stated that she immediately notified the agency of the incident and requested a new HHA. A review of the agency's policy and procedure manual revealed a form titled "Patient Concerns/Grievances" which contained the following "Any concern/grievance received from a patient or family will be forwarded in writing to the Director of Nursing/Administrator or his/her designee within thirty (30) days of the date the person filing the grievance becomes aware of the action. The concern/grievance investigation shall commence within 48 hours of receipt of the written complaint. The Director of Nursing is responsible for evaluating, reviewing, and investigating all patient concerns/grievances and for giving feedback to the patient and Administration. A record of the concern/grievance, investigation, follow-up action and response to the patient will be documented, using the Patient Complaint Form, and will be retained by Administration in a Patient Complaint file. The investigation shall be completed within thirty (30) days unless circumstances prevent finalization within that time period and a decision rendered by the Director of Nursing." During an interview conducted on 05/06/2021 at 2:45 PM, Registered Nurse/ Staff E acknowledged the above findings and stated that she was not working at the agency at that time. Furthermore, Registered Nurse/ Staff E reviewed and acknowledged that the complaint log and SP#1's record did not contain documentation to demonstrate that the agency investigated the complaint made by SP#1's relative.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that 1 out 3 Sampled Patients (SP)'s record contained all the Home Health Aide (HHA) notes for the services provided by the agency. SP#3 Findings Include: On 05/06/2021 at 11:55 AM, SP#3's complete file was requested from Registered Nurse/ Staff E. A review of SP#3's record revealed she was admitted on 06/05/2020. Further review of SP#3's record revealed no documentation that the agency provided the HHA services after 04/03/2021. During an interview conducted on 05/06/2021 at 2:56 PM, Staff D/Registered nurse acknowledged that SP#3's record did not contain documentation to demonstrate that the agency provided HHA services after 04/03/2021. Registered Nurse/ Staff E stated that the HHA notes are probably in the payroll department. On 05/06/2021 at 3:05 PM, while the surveyor was already in her vehicle, Registered Nurse/ Staff E brought SP#3's HHA notes for the personal care services for the week of 04/04/2021 to 04/10/2021. Further review of the HHA notes revealed no documentation that the agency provided the homemaker services to SP#3 during the week of 04/04/2021 to 04/10/2021. Additional review of the HHA notes revealed no documentation that the agency provided personal care services to SP#3 on Thursday (04/15/2021) and Friday (04/16/2021); and no homemaker services on Tuesday (04/13/2021), Thursday (04/15/2021), and Friday (04/16/2021).