Every finding on record at Hhcs, Inc

Emergency Preparedness Survey At the time of the emergency preparedness survey completed on 08/26/22, Heritage Health Care Services is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Extended Recertification Survey An entrance conference was conducted with the Director of Operations at 10:00 AM on 08/22/22, and an exit conference was completed with the Lima Branch Administrator at 3:45 PM on 08/26/22. The following deficiencies are based on the extended recertification survey completed 08/26/22. Heritage Health Care Services 367587, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies. Heritage Health Care Services is precluded from offering its own aide training and/or competency evaluation program for a period of two years from the exit date of this survey.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on medical record review, policy review, observation and staff interview, the agency failed to ensure patients received the home health services as written in the plan of care (G572). The agency failed to ensure the plans of care included prognosis, risk and interventions to prevent emergency department/hospital readmission, education and training to facilitate discharge, and advance directives (G574). The agency failed to ensure all patient care orders were recorded in the plan of care (G576). The agency failed to promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered (G590). The cumulative effect of these systemic practices resulted in the agency's inability to ensure patients' care needs would be met.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure patients received the home health services as written in the plan of care for three of 17 medical records reviewed (Patient #7, #8, and #16). This could affect all patients receiving services from the agency. The agency census was 151. Findings include: 1. Review of the medical record for Patient #7 revealed a physical therapy plan of care dated 07/25/22 with orders for physical therapy twice a week. Review of the medical record for the week of 07/25/22 revealed only one physical therapy visit. The medical record lacked documentation of physician notification that services were not provided as ordered. The findings were verified in an interview with Staff B on 08/25/22 at 10:11 AM. 2. Review of the medical record for Patient #8 revealed a physician ordered plan of care dated 01/23/22 to 03/23/22 with orders for skilled nursing twice the first week and then weekly. The medical record lacked documentation of any skilled nursing visits the week of 01/23/22 and 01/30/22. There was a note on 01/26/22 and on 02/02/22 for missed visits due to no authorization. The medical record lacked documentation of physician notification that services were not provided as ordered. The findings were verified in an interview with Staff B on 08/23/22 at 12:16 PM. 3. Review of the medical record for Patient #16 revealed a plan of care dated 07/29/22 to 09/26/22 with orders for occupational therapy evaluation. Review of the medical record lacked documentation of any occupational therapy evaluation. The medical record lacked documentation of physician notification that services were not provided as ordered. The findings were verified in an interview with Staff B on 08/23/22 at 11:40 AM.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on medical record review, policy review, and staff interview, the agency failed to ensure the plans of care included prognosis, risk and interventions to prevent emergency department/hospital readmission, education and training to facilitate discharge, and advance directives for one of 17 medical records reviewed (Patient #8). This could affect all patients receiving services from the agency. The agency census was 151. Findings include: Review of the medical record for Patient #8 revealed a physician ordered plan of care dated 01/23/22 to 03/23/22. The plan of care lacked documentation of prognosis, risk and interventions to prevent emergency department/hospital readmission, education and training to facilitate discharge, and advance directives. The findings were verified in an interview with Staff B on 08/25/22 at 10:25 AM. Review of the policy titled, "Plan of Care," original date 11/2011, revealed the policy did not list risk and interventions to prevent emergency department/hospital readmission, education and training to facilitate discharge, or advance directives under the content of the plan of care.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review, policy review, and staff interview, the agency failed to ensure all patient care orders were recorded in the plan of care for one of 17 patients reviewed (Patient #14). This could affect all patients receiving services from the agency. The agency census was 151. Findings include: Review of the agency policy titled, "Coordination of Service," with an original date of 11/2011 revealed professional staff coordinated services with the physician by developing the plan of care in consultation with the physician, the patient and/or family, and others involved in care or the patient as appropriate, alerting the physician promptly to any changes which suggest a need to modify the plan of care, reviewing the plan of care with the physician as often as the severity of the patient's condition requires at least once every 60 days, and initiating revisions in the plan of care. Review of the Patient #14's medical record revealed a start of care date of 01/18/22. The patient was admitted with diagnoses which included history of Parkinson’s Disease, hypertension and low back pain. The certification period under review was 05/18/22 through 07/16/22. The patient had a physician telephone order dated 05/23/22 for an occupational therapy consultation and treatment and social services consult for care needs. Review of the medical record revealed the agency was unable to provide documentation these services were completed. Interview with Staff B and Staff D on 08/25/22 at 2:25 PM revealed Staff D was responsible for reviewing telephone messages and new orders. Staff D verbalized she did not read each message but just spot checked. The agency’s home healthcare software program permitted staff to activate a new order by clicking a computer button manually, this would generate the workflow. Staff B confirmed during this interview that Patient #14’s order for occupational therapy and social services consult was never activated and the plan of care was not updated nor was scheduling ever alerted to schedule these clinicians and hence the patient never received these ordered services.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review, policy review, observations and staff interview, the agency failed to promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered for one of 17 patients reviewed (Patient #13). This could affect all patients receiving services from the agency. The agency census was 151. Findings include: Review of the agency policy titled, "Coordination of Service," with an original date of 11/2011 revealed professional staff coordinated services with the physician by developing the plan of care in consultation with the physician, the patient and/or family, and others involved in care or the patient as appropriate. Alerting the physician promptly to any changes which suggest a need to modify the plan of care. Reviewing the plan of care with the physician as often as the severity of the patient's condition requires, at least once every 60 days, and initiating revisions in the plan of care. Observations during a home visit on 08/24/22 at 11:00 AM revealed Patient #13 verbalized to therapy Staff F that she had fallen the previous day on 08/23/22 which necessitated the local fire department being summoned to assist the patient off the floor and back into the chair. The patient further verbalized to Staff F that she really needed physical therapy to regain her mobility. She further stated the fire department told her that the fire department could not continue to come to the patient’s home to assist her after falls. Patient #13 stated, “I need my therapy!” Review of Patient #13's medical record revealed a start of care date of 08/04/22. The patient was admitted with diagnoses which included diabetes mellitus, hypertension, chronic obstructive pulmonary disease, dependance on nicotine, and dependance on supplemental oxygen. The certification period under review was 08/04/22 through 10/02/22. The patient had a physician order for physical therapy at the frequency of once per week for one week, three times per week for one week, two times per week for two weeks and once per week for one week. Review of Staff F’s therapy progress notes dated 08/24/22 documented the patient reported a fall when trying to ambulate yesterday afternoon, her lower extremities gave out. There was no documentation the physician was notified of this fall. Interview with Staff B on 08/26/22 at 1:30 PM confirmed the agency was unable to provide documentation the physician was timely notified that Patient #13 had fallen.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, staff interview and policy review, the agency failed follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases for one patient observed with a dressing change (Patient #4). The total sample was 17. This could affect all patients receiving services from the agency. The agency census was 151. Findings include: The medical record for Patient #4 was reviewed on 8/23/22. Patient #4 had a start of care of 05/20/22 with diagnoses including Type 2 diabetes with a pressure ulcer to the right heel. The certification periods reviewed were for 05/20/22 through 07/18/22 and 07/19/22 through 09/16/22. Skilled nursing visits were ordered for three times per week. Physician orders were received on 08/23/22 to cleanse the left lower leg with normal saline (NS), pat dry, apply Alginate (used to absorb drainage) to the reddened areas, wrap with kerlix (gauze dressing) and coban (self adherent elastic wrap) from toes to two inches below the knee. Orders for the right heel were to apply iodoflex (wound cleaning dressing) to the wound, cover with gauze and ABD (thick absorbent dressing) pad. Apply Alginate to this lateral leg, wrap with kerlix and coban from toes to two inches below the knee and to paint toes with betadine as needed. A home visit was completed on 08/24/22 at 10:00 AM. Staff D entered the home and received information from Patient #4 regarding new dressing changes from the wound clinic. Staff D reviewed the new order, applied gloves, removed the right leg dressing which included the heel dressing, and irrigated the heel with normal saline and gauze. Staff D then requested to use Patient #4's scissors off the desk. The Alginate was cut with the patient's desk scissors which were not cleaned prior to use. Staff D then changed gloves without performing hand hygiene, applied new gloves and applied iodiflex to the right heel, then gauze and the coban bandage. Staff D removed her gloves without performing hand hygiene, applied new gloves and removed the left leg dressing, cleansed the red patchy areas with normal saline, placed a large square of Alginate to the left leg then wrapped it with kerlex and coban. Staff D did not change gloves after removing the old dressing and prior to applying a new dressing on the left leg. A request was made to Staff E for a policy related to dressing changes. Staff E provided a policy on 08/24/22 at 1:00 PM titled, "Wound Dressing Application, Home Care," revised 02/18/22. This policy described Alginate dressings as one used for wounds with heavy exudate, tunneling or minor bleeding. This policy instructed staff to organize equipment and supplies on a clean surface, perform hand hygiene, apply gloves, remove the old dressing, inspect the drainage, remove gloves and perform hand hygiene. This policy then instructed staff to put on new gloves assess the wound, obtain appropriate measurements, clean the wound with normal saline or another prescribed wound cleanser, discard the soiled gauze, remove gloves perform hand hygiene, apply new gloves place ordered dressing and cover with gauze then remove gloves and use hand sanitizer. The findings of not following the facility policy titled, "Wound Dressing Application, Home Care," revised 02/18/22, in regard to not changing gloves after removing the dressing and not completing hand hygiene prior to re-applying gloves was verified in an interview with Staff E on 08/24/22 at 1:00 PM.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on personnel file review, policy review and staff interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that included a method for identifying infectious and communicable disease problems for seven personnel files reviewed (Staff C, D, H, I, J, K, and M). This could affect all patients receiving services from the agency. The agency census was 151. Findings include: The personnel file for Staff D was reviewed on 08/25/22. Staff D was hired on 04/14/11 with no documentation of tuberculosis (TB) testing on file. A health questionnaire was on file dated 01/13/22. The personnel file for Staff C was reviewed on 08/25/22. Staff C had a hire date of 8/22/22 with no documentation of skin testing just a health questionnaire. A request was made to Staff B on 08/25/22 at 2:30 PM for the agency policy related to TB testing and for a Centers for Disease Control (CDC) risk assessment for this county. Staff B stated in an interview at that time, "they were informed by the higher ups that we do not need to do TB testing anymore". The facility policy titled, "TB Guidelines for all Field Staff," effective 01/01/05, was provided and reviewed on 08/25/22. This policy directed the agency for new hires to provide proof of having a purified protein derivative (PPD) skin test within the previous 12 months. New staff will also receive a one step PPD upon hire. If they are unable to provide proof they will receive a 2-step PPD, provided by Heritage Health Care Services upon hire. A request was made to Staff B for when this policy changed. Staff B provided a CDC risk assessment on 08/25/22 at 3:55 PM which was partially filled out stating, "no idea when this assessment was completed since no date was on the form but I know it was recent". Staff B also stated, "We now realize we were not correct in our process for completing skin tests; we should have been doing them upon hire". Five additional Personnel files (Staff H, I, J, K and M) were reviewed on 08/25/22 with no documentation of TB skin testing completed upon hire. There was just a screening questionnaire for the Field Staff. No Personnel file was able to be located for Staff L to verify TB status. The findings of not completing TB skin testing as required was verified in an interview with Staff B on 08/25/22 at 3:55 PM.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on medical record review, policy review and staff interview, the agency failed to provide home health supervisory visits by a skilled professional no less frequently than every 14 days for patients receiving skilled services for three of three patients reviewed who were receiving home health aide services and skilled services (Patient #1, #9 and #14). The total sample was 17. This could affect all patients receiving services from the agency. The agency census was 151. Findings include: Review of the agency's policy titled, "Home Health Aide Supervisory Visits," effective 11/2011 stated when skilled nursing care is also furnished to a patient, a registered nurse must make a supervisory visit to each patient’s residence at least 14 days (either when the aide is present to observe and assist, or when the aide is absent) to assess relationship and determine whether goals are being met. 1. Review of Patient #1's medical record for the certification period dated 07/30/22 through 09/27/22 revealed orders for skilled nursing services every other week for five weeks and home health aide services one day per week. The agency was unable to provide documentation supervisory visits were conducted by a Registered Nurse at least every 14 days. 2. Review of Patient #14's medical record for the certification period dated 03/19/22 through 05/17/22 revealed orders for skilled nursing every other week and home health aide services one day per week. The plan of care for the certification period dated 07/17/22 through 09/14/22 revealed orders for physicial therapy services every week and then every other week and home health aide services one day per week. The agency was unable to provide documentation supervisory visits were conducted by a Registered Nurse or Physical Therapist at least every 14 days. 3. Review of the medical record for Patient #9 revealed orders for skilled nursing and home health aide visits three times per week. Review of the documentation from 11/14/21 through 01/14/22 revealed no documentation of supervisory visits for the home health aide. The above findings were verified in an interview with Staff A on 08/24/22 at 9:45 AM. Staff A stated that licensed practical nurses performed all home health aide services so supervision was not needed.

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: Based on personnel file review, policy review, document review, review of governing body meeting minutes and staff interview, the agency failed to ensure the governing body assumed the full legal authority and responsibility for the agency's overall management and operation (G942). The agency failed to ensure an Administrator was appointed by the governing body (G946). The agency failed to ensure an Administrator was responsible for all day to day operations of the home health agency (G948). The agency failed to ensure the agency employs qualified personnel (G952). The agency failed to ensure when the Administrator was not available, that there was a predesignated person authorized in writing by the Administrator and the governing body to assume the Administrator's responsibilities and obligations (G954). The agency parent location failed to provide direct support and administrative control of it's branch (G974). The agency failed to ensure the home health agency, under the direction of the governing body, prepared an overall plan and budget that included an annual operating budget and capital expenditure plan that was reviewed and updated at least annually by a committee consisting of representatives of the governing body, administrative staff, and medical staff of the agency under the direction of the governing body (G988). The cumulative effect of these systemic practices resulted in the agency's inability to ensure the administration of services would be met.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on review of governing body meeting minutes and staff interview, the agency failed to ensure the governing body assumed the full legal authority and responsibility for the agency's overall management and operation. This could affect all patients receiving services from the agency. This agency census was 151. Findings include: On 08/25/22 at 1:45 PM, Staff A stated in an interview that the governing body for Heritage met annually with one meeting for all locations and provider numbers. The governing body had not designated one Administrator for this agency, but an Administrator for each location, Toledo and Lima. The Administrator for the Toledo office was only responsible for the Toledo office. The Administrator for the Lima office was responsible for the Lima office. The governing body had not designated in writing the Administrator or the back up Administrator. Review of the governing body meeting minutes for 2020, 2021, and 2022 revealed one meeting on 05/07/21. The meeting minutes documented the Emergency Preparedness Plan was reviewed and the Quality Assessment and Performance Improvement documents were reviewed. Two performance improvement plans were also reviewed. The meeting minutes lacked discussion or review of any other topics. On 08/26/22 at 10:21 AM, Staff B stated in an interview there were no additional governing body meeting minutes for the last two years.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on document review and staff interview, the agency failed to ensure an Administrator was appointed by the governing body. This could affect all patients receiving services from the agency. The agency census was 151. Findings include: Review of information as part of the offsite process for the survey revealed the agency's main location was at 1745 Indian Wood Circle, Suite 252, Maumee, Ohio 43537 and the agency had an approved branch location at (36Q7587001) 3478 Elm Street West, Lima, Ohio 45807. Review of the organizational charts revealed the Administrator for the "Toledo Branch" (Maumee) was Staff C and the Administrator for the "Lima Branch" was Staff B. Review of the Governing Body meeting minutes lacked documentation of approval of the Administrator. On 08/25/22 at 1:45 PM, Staff A stated in an interview that there was no documentation of the governing body appointment of the Administrator. There was an Administrator for each location, not one Administrator over both locations.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on document review and staff interview, the agency failed to ensure an Administrator was responsible for all day to day operations of the home health agency. This could affect all patients receiving services from the agency. The agency census was 151. Findings include: Review of information as part of the offsite process for the survey revealed the agency's main location was at 1745 Indian Wood Circle, Suite 252, Maumee, Ohio 43537 and the agency had an approved branch location at (36Q7587001) 3478 Elm Street West, Lima, Ohio 45807. Review of the organizational charts revealed the Administrator for the "Toledo Branch" (Maumee) was Staff C and the Administrator for the "Lima Branch" was Staff B. On 08/25/22 at 1:45 PM, Staff A stated in an interview that the governing body for Heritage met annually with one meeting for all locations and provider numbers. The governing body had not designated one Administrator for this agency, but an Administrator for each location, Toledo and Lima. The Administrator for the Toledo office was only responsible for the Toledo office and the Administrator for the Lima office was responsible for the Lima office. The governing body had not designated in writing the Administrator or the back up Administrator. On 08/25/22 at 2:15 PM, Staff B stated in an interview that the Administrator for the Toledo office had the same job description as the Administrator for the Lima office. Staff B stated the Administrator for the Lima office handled the day to day operations for that location and did not report to the Toledo office.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on personnel file review, policy review and staff interview, the agency failed to ensure the agency employs qualified personnel for nine of nine personnel files reviewed (Staff C, D, H, I, J, K, L, M and N). This could affect all patients receiving services from the agency. The agency census was 151. Findings include: During the entrance conference with Staff A on 08/22/22, Staff A stated that staff were assessed for competency upon hire and as needed. Staff B stated in an interview on 08/25/22 at 12:30 PM that each branch kept a "soft folder. The staff licenses and competencies were kept with the main personnel folder kept at the Corporate Office in Lima. Nine personnel files were reviewed on 08/25/22 for Staff C, D, H, I, J, K, L, M and N. Six of the nine files (I, J, K, L, M and N) lacked evidence of any orientation or skills checklist and five (I, J, K, L and N) did not have any performance evaluations . Staff B stated in an interview on 08/25/22 at 12:30 PM that the personnel file for Staff L could not be located in the "soft file drawer". Staff B further stated in an interview on 08/25/22 at 4:10 PM that the Corporate Office in Lima could not locate orientation, skills checklist or any information for Staff L. The personnel file for Staff D from Lima was the only file that had documentation of orientation, skills checklist and an annual evaluation. The agency policy titled, "Personnel Folder," effective 11/2011, was reviewed on 08/26/22. This policy listed what was required in all personnel files. Personnel files should include: Name, current address, proof of license (eg. RN/LPN), yearly physical, TB skin test results, hepatitis B vaccination or refusal, receipt of employee handbook and skills checklist. The agency policy titled, "Orientation," effective 11/2011, listed under purpose that the agency provides an orientation program in order to provide qualified care which enables clients to remain independent in their home and to provide quality health care services. Orientation consists of videos with discussion related to the control of infectious disease, Universal precautions, documentation in home care, skill proficiencies demonstrated on a live participant and Passport orientation. The policy titled, "Performance Evaluation, effective 11/2011, was reviewed on 08/26/22. This policy stated that all personnel will be evaluated at periodic intervals based on their job description as follows. During the probationary/introductory period of a position of the first ninety days of employment, annually and within 90 days of promotion. These evaluations will be documented on the applicable form and discussed between the individual and their supervisor. Staff B verified in an interview on 08/26/22 at 12:30 PM that this agency was not following the policies, titled "Orientation", "Personnel Folder," or "Performance Evaluation" based on the lack of required documents for the personnel files reviewed.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on document review and staff interview, the agency failed to ensure when the Administrator was not available, that there was a predesignated person authorized in writing by the Administrator and the governing body to assume the Administrator's responsibilities and obligations. This could affect all patients receiving services from the agency. The agency census was 151. Findings include: Review of information as part of the offsite process for the survey revealed the agency's main location was at 1745 Indian Wood Circle, Suite 252, Maumee, Ohio 43537 and the agency had an approved branch location at (36Q7587001) 3478 Elm Street West, Lima, Ohio 45807. Review of the organizational charts revealed the Administrator for the "Toledo Branch" (Maumee) was Staff C and the Administrator for the "Lima Branch" was Staff B. No alternate Administrator was listed. Review of the Governing Body meeting minutes revealed no documentation of appointment of a predesignated person authorized in writing by the Administrator and the governing body to assume the Administrator's responsibilities and obligations in the Administrator's absence. On 08/25/22 at 1:45 PM, Staff A stated in an interview that there was no documentation of the governing body appointment of who would act in the Administrator's absence.

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: Based on document review and staff interview, the agency parent location failed to provide direct support and administrative control of it's branch. This could affect all patients receiving services from the agency. The agency census was 151. Findings include: 3) Review of the agency’s policy titled, "Responsibilities of the Administrator,"with an original date of 11/2011 Review of the admission packet for the agency revealed the agency had developed two separate admission packets, one for its Maumee location (parent) and another for its branch location located in Lima, Ohio. Review of the packets revealed there were two separate Administrators of the agency listed along with their individual contact information for each location (Maumee and Lima). Additionally, the admission packet failed to include the back page of the required CMS Home Health Agency Outcome and Assessment Information (OASIS) Statement of Privacy Rights provided to patients at the start of care. The notice informed patients of their rights in relation to the OASIS assessment documentation and instructed patients that they could see review, copy, or correct this health information and to refer to the back of this notice for contact information. The admission packets also failed to include the Home Health Agency OASIS Notice About Privacy for Patients Who Do Not Have Medicare or Medicaid Coverage. The CMS Form 10280 Home Health Change of Care Notice (HHCCN) listed the individual offices rather than the main agency location in Maumee, Ohio. The admission packets contained a flier which included a map of Ohio that indicated this agency had branch locations in Mansfield, Chillicothe, Piqua as well as two offices in Pennsylvania for a total of seven branches. The flier also indicated the agency serviced approximately one half of the state of Ohio from north to south or approximately 50 of Ohio’s 88 counties from this location. The website information also contained this same information and instructed the agency had seven branch offices to serve the public. Interview on 08/26/22 11:23 AM with Staff A and Staff B confirmed these deficient practices 2. On 8/24/22 at 11:55 AM Staff O stated they had worked in the Lima office for four months. Staff O stated their job was to upload orders, put therapy notes into the electronic medical record software, fax things to the physician and call to get signatures for the plans of care from the physician. Staff O further stated they did all of the on boarding for new employees such as background checks, drug screening, getting copies of drivers licenses and COVID-19 testing for the Lima office staff. On 8/25/22 at 11:45 AM Staff E stated they were in charge of hiring and scheduling the registered nurses (RN) and licensed practical nurses (LPN) for the Lima branch. Staff E stated they reported to Staff A who was the Director of Operations with Heritage having branches in Lima, Toledo, Piqua, Mansfield and Allegheny (Pennsylvania). The Lima branch saw patients from Wood County and south with the Maumee branch covering north of Wood County. 1. Review of information as part of the offsite process for the survey revealed the agency had a parent location at 1745 Indian Wood Circle, Suite 252 Maumee, Ohio 43537 and an approved branch location (36Q7587001) 3478 Elm Street West, Lima, Ohio 45807. Review of the organizational charts during the survey revealed the Administrator for the "Toledo Branch" was Staff C and the Administrator for the "Lima Branch" was Staff B. On 08/25/22 at 1:45 PM, Staff A stated in an interview that the governing body for Heritage met annually with one meeting for all locations and provider numbers. The governing body had not designated one Administrator for this agency, but instead there was an Administrator for each location in Maumee and Lima. The Administrator for the Maumee office was only responsible for the Maumee office and the Administrator for the Lima office was responsible for the Lima office. The governing body had not designated in writing the Administrator or the back up Administrator. On 08/25/22 at 3:00 PM, Staff C stated that he/she would be at the corporate office in Lima on 08/26/22 as he/she needed to meet with the human resources department for orientation and to sign additional documents. Staff C stated that 08/22/22 was his/her first day. Review of the Quality Assessment and Performance Improvement (QAPI) documents revealed quality measures and outcomes were reviewed by location. The QAPI documents lacked an overall QAPI plan, quality measures, outcomes, and performance improvement projects for the agency as a whole.

Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This STANDARD is not met as evidenced by: Based on document review and staff interview, the agency failed to ensure the home health agency, under the direction of the governing body, prepared an overall plan and budget that included an annual operating budget and capital expenditure plan that was reviewed and updated at least annually by a committee consisting of representatives of the governing body, administrative staff, and medical staff of the agency under the direction of the governing body. This could affect all patients receiving services from the agency. The agency census was 151. Findings include: Review of the governing body meeting minutes for 2020, 2021, and 2022 revealed one meeting on 05/07/21. The meeting minutes lacked discussion or review of the annual operating budget and capital expenditure plan. Review of the Board of Directors HCF Management (corporate governing body) meeting minutes for 12/30/21 revealed the operating budget for calendar year 2022 was approved. On 08/26/22 at 11:23 AM, Staff A verified in an interview that the budget was reviewed and approved by the corporate governing body.