Every finding on record at Home Health of Kansas LLC

On behalf of the Centers for Medicare and Medicaid Services (CMS) an unannounced on-site Recertification and Complaint Survey, 5F9C9-H1, 95013 at the above-named Home Health Agency (HHA) from 03/13/23 to 03/16/23 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

On behalf of the Centers for Medicare and Medicaid Services (CMS) an unannounced on-site Recertification and Complaint Survey 5F9C9-H1, 95013 conducted at the above-named Home Health Agency (HHA) from 03/13/23 to 03/16/23 resulted in noncompliance with one Condition of Participation, 42 CFR 484.50, Patient Rights, respective to applicable CoP under 42 CFR 484, Subpart A through C and the following standard-level deficiencies cited.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on document review, policy review, record review, review of the agency's governing body minutes, and interview, the above-named Home Health Agency, failed to ensure Patient Rights were promoted and protected for 2 of 12 (Patient 2 and 12) patients reviewed. This deficient practice has the potential to place patients at risk for unmet care needs and services. Findings Include: 1. The Home Health agency failed to protect 1 of 12 patients (Patient 2) from neglect related to services and care not being provided as indicated in the plan of care. (Refer to tag G0430) 2. The Home Health agency failed to ensure home health aide (HHA) visits were completed as outlined in the plan of care and authorized by the Veterans Administration (VA) for 2 of 12 patients (Patient (P)2 and P12). Refer to tag G0436) 3. The Home Health agency failed to develop policies or take any direct action to prevent further Violations and ensure that 2 of 12 patients (Patient (P)2 and P12) were receiving needed services while a complaint was being investigated. (Refer to tag G0486)

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the Home Health agency failed to protect 1 of 12 patients (Patient 2) from neglect related to services and care not being provided as indicated in the plan of care. This deficient practice has the potential to place patients at risk for unmet needs and services. Findings Include: Review of the agency's policy titled, "Assessment of Possible Abuse/Neglect," dated December 2022 revealed, "The organization will investigate complaints regarding treatment or care, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the organization …Neglect: Failure of a caretaker to supply the patient with the necessary food, clothing, shelter, health care, or supervision; or the absence or likelihood of an absence of the necessary food, clothing, shelter, health care, or supervision for a patient." Review of an untitled agency complaint document dated 12/01/22 showed that Registered Nurse (RN)1 submitted a written complaint which identified that Home Health Aide (HHA)2 was not present at the home of patient (P)2 on 11/30/22 from 12:00 PM to 2:00 PM as HHA2 documented on the visit note. RN1 stated he/she was at the home of P2 from 12:15 PM to 1:41 PM on 11/30/22 and that P2 had stated HHA2 had called and told P2's mother that he/she was at home with a sick child and would not be able to complete the scheduled visit on 11/30/22. The agency complaint document also showed, "documentation reviewed and compared signature from other clinicians visits identied [sic] as being signed by patient after the documented visit: 11/4 visit 1310 [1:00 PM] – 1510 [3:10 PM], signed [electronically by patient] at 2204 (10:04 PM), 11/28 visit 1130 [11:30 AM] – 1330 [1:30 PM], signed [electronically by patient] at 2301 [11:01 PM], 11/30 visit 1200 [12:00 PM] – 1400 [2:00 PM], signed [electronically by patient] at 1717 [5:17 PM]. Patient signatures from [HHA2] visits do not match signatures obtained by previous clinicians" … Review of P2's "Aide Visit Note[s]" in the electronic medical record (EMR) located in the "Visits" section confirmed the above and additionally showed the following: On 12/02/22 (two days after the complaint) HHA 2 documented the visit start time as 11:00 AM and end time as 1:00 PM. The document showed the patient as having electronically signed at 9:07 PM and HHA2 electronically signed at 9:08 PM. On 12/07/22 (seven days after the complaint) HHA2 documented the visit start time as 1:00 PM and end time as 3:00 PM. The document showed the patient as having electronically signed at 10:17 PM and HHA2 electronically signed at 10:17 PM On 12/12/22 (12 days after the complaint) HHA2 documented the visit start time as 11:00 AM and end time as 1:00 PM. The document showed the patient as having electronically signed at 1:33 PM and HHA2 electronically signed at 1:33 PM. Review of P2's "HHA Care Plan" indicated that the HHA assists with transfers, assists with meal preparation and feeding, checks vital signs and weight, reminds the patient to take medications, assists with bath using a shower chair, assists with dressing, changes bed linens, patient uses an electronic wheelchair, and ambulates only with assistance. During an interview with the Administrator and HR Representative on 03/14/23 at 11:30 AM, the Administrator stated the time stamp associated with the patient signature accurately reflects the time it was signed automatically by the software program. The Administrator also stated that the time for the start and the end of the visit is entered by the assigned staff person and is not automatically registered by the software. When asked whether the staff devices used to access the EMR has GPS (Global Positioning System), the Administrator stated they had it turned off because it was interfering with the tracking of mileage. The HR Representative stated the agency felt that it could not prove neglect because HHA2 would not say anything during the meeting. During an interview on 03/15/23 at 3:45 PM, the Administrator confirmed the agency's belief that HHA2 did not complete the visits as assigned and that the HHA2 appeared to have forged the patient signature.

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 record review, agency complaint document review, policy review, and interview, the Home Health agency failed to ensure home health aide (HHA) visits were completed as outlined in the plan of care and authorized by the Veterans Administration (VA) for 2 of 12 patients (Patient (P)2 and P12). The failure to complete all visits as authorized and included in the plan of care has the potential for patients to not receive the services identified and could affect all patients receiving care from the agency. Findings Include: Review of the agency's policy titled, "Contents of Clinical Record," dated December 2022 revealed, "The clinical record will …accurately document care provided and results in detail … All entries in the medical record should be reflective of actual time or noted as a late entry … The clinical record for patient receiving only personal care and/or support/chore services contains the following information … Plan of service including schedule of services." Patient 2 Review of an untitled agency complaint document dated 12/01/22 showed that Registered Nurse (RN)1 submitted a written complaint which identified that Home Health Aide (HHA)2 was not present at the home of patient (P)2 on 11/30/22 from 12:00 PM to 2:00 PM as HHA2 documented on the visit note. RN1 stated he/she was at the home of P2 from 12:15 PM to 1:41 PM on 11/30/22 and that P2 had stated HHA2 had called and told P2's mother that he/she was at home with a sick child and would not be able to complete the scheduled visit on 11/30/22. The agency complaint form also showed, "documentation reviewed and compared signature from other clinicians visits identied [sic] as being signed by patient after the documented visit: 11/4 visit 1310 [1:00 PM] – 1510 [3:10 PM], signed [electronically by patient] at 2204 (10:04 PM), 11/28 visit 1130 [11:30 AM] – 1330 [1:30 PM], signed [electronically by patient] at 2301 [11:01 PM], 11/30 visit 1200 [12:00 PM] – 1400 [2:00 PM], signed [electronically by patient] at 1717 [5:17 PM]. Patient signatures from [HHA2] visits do not match signatures obtained by previous clinicians"... Review of P2's "HHA Care Plan" indicated the HHA assists with transfers, assists with meal preparation and feeding, checks vital signs and weight, reminds the patient to take medications, assists with bath using a shower chair, assists with dressing, changes bed linens, patient uses an electronic wheelchair, and ambulates only with assistance. During an interview on 03/15/23 at 3:45 PM, the Administrator confirmed the agency's belief that HHA2 did not complete the visits as assigned. Patient 12 Review of two untitled documents involving P12 showed the following: Review of an untitled agency complaint document dated 11/16/22 revealed, "Pt [patient] called VA [Veterans Administration] to complain that the HHAs [home health aides] that come out have not been staying the full hours. Pulled HHAs time to verify how many hours they are doing when they are with [him/her]. Also pull VA authorization to verify hours. Educated HHAs to make sure they are staying with patient 2.5 [two and one-half] hours instead of 2 [two] hours. To make sure they are documenting any visits that patient has not let them stay the full time." Review of an untitled agency complaint document dated 12/07/22 showed P12 called the agency and stated that the "VA [Veterans Administration] had approved 7.5 hours a week" but sated [he/she] was only being seen by home health aides for "1 [one] hour 3 [three] times a week … HH [home health] DON [Director of Nursing] called pt who reports HHAs are not staying for the full 2.5 hours – confirmed by time sheets." Review of P12's printed "Aide Visit Note[s]" since 12/07/22 showed the following: On 12/09/22 the HHA documented "Time In" as 9:00 AM and "Time Out" as 11:00 AM for a total of 2 hours. On 12/12/22 the HHA documented "Time In" as 8:15 AM and "Time Out" as 10:26 AM for a total of 2 hours and 11 minutes. On 12/14/22 the HHA documented "Time In" as 8:45 AM and "Time Out" as 11:00 AM for a total of 2 hours and 15 minutes. On 12/15/22 the HHA documented "Time In" as 8:30 AM and "Time Out" as 10:40 AM for a total of 2 hours and 10 minutes. On 12/21/22 the HHA documented "Time In" as 08:30 AM and "Time Out" as 10:35 AM for a total of 2 hours and 5 minutes. On 12/23/22 the HHA documented "Time In" as 8:35 AM and "Time Out" as 10:45 AM for a total of 2 hours and 10 minutes. On 12/26/22 the HHA documented "Time In" as 8:30 AM and "Time Out" as 10:45 AM for a total of 2 hours and 15 minutes. On 12/28/22 the HHA documented "Time In" as 8:30 AM and "Time Out" as 10:45 AM for a total of 2 hours and 15 minutes. On 12/30/22 the HHA documented "Time In" as 7:45 AM and "Time Out" as 9:51 AM for a total of 2 hours and 6 minutes. Review of P12's"HHA Care Plan" includes: assisting patient with home exercise program, assist with positioning, repositioning, alignment, checking bottom of feet for skin breakdown, assist with meal preparation, change linens, cleaning, laundry, assist patient with dressing, assist with shower, denture care, oral care, medication reminders, remind patient to check blood sugar, and check blood pressure, pulse, respiration, and weight. During an interview on 03/15/23 at 4:00 PM, Billing Staff confirmed the documentation, and that the VA approval was for two hours and 30 minutes three times per week.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on record review, document review, policy review, and interview, the Home Health agency failed to develop policies or take any direct action to prevent further violations and ensure that 2 of 12 patients (Patient (P)2 and P12) were receiving needed services while a complaint was being investigated. This failure has the potential to affect all patients who received care from this agency. Findings Include: Review of the agency's policy titled, "Assessment of possible abuse/neglect," dated December 2022 and the agency policy titled, "Complaint/Grievance Process," dated November 2017 showed the policies failed to address taking action to prevent further violations while the complaint is being investigated. Patient 2 Review of an untitled agency complaint document dated 12/01/22 showed that Registered Nurse (RN)1 submitted a written complaint which identified that Home Health Aide (HHA)2 was not present at the home of patient (P)2 on 11/30/22 from 12:00 PM to 2:00 PM as HHA2 documented on the visit note. RN1 stated he/she was at the home of P2 from 12:15 PM to 1:41 PM on 11/30/22 and that P2 had stated HHA2 had called and told P2's mother that he/she was at home with a sick child and would not be able to complete the scheduled visit on 11/30/22. The agency's complaint form also showed, "documentation reviewed and compared signature from other clinicians visits identied [sic] as being signed by patient after the documented visit: 11/4 visit 1310 [1:00 PM] – 1510 [3:10 PM], signed [electronically by patient] at 2204 (10:04 PM), 11/28 visit 1130 [11:30 AM] – 1330 [1:30 PM], signed [electronically by patient] at 2301 [11:01 PM], 11/30 visit 1200 [12:00 PM] – 1400 [2:00 PM], signed [electronically by patient] at 1717 [5:17 PM]. Patient signatures from [HHA2] visits do not match signatures obtained by previous clinicians … Resolution/Response/Intervention: Education being created to be provided at next HHA visit regarding expectations. Meeting with [HHA2] being scheduled to review concerns and provide education/disciplinary action." Review of P2's "Aide Visit Note[s]" in the electronic medical record (EMR) located in the "Visits" section confirmed the above. HHA2 continued to be assigned to P2 and further visits showed the following: On 12/02/22 (two days after the complaint) HHA 2 documented the visit start time as 11:00 AM and end time as 1:00 PM. The document showed the patient as having electronically signed at 9:07 PM and HHA2 electronically signed at 9:08 PM. On 12/07/22 (seven days after the complaint) HHA2 documented the visit start time as 1:00 PM and end time as 3:00 PM. The document showed the patient as having electronically signed at 10:17 PM and HHA2 electronically signed at 10:17 PM On 12/12/22 (12 days after the complaint) HHA2 documented the visit start time as 11:00 AM and end time as 1:00 PM. The document showed the patient as having electronically signed at 1:33 PM and HHA2 electronically signed at 1:33 PM. Patient 12 Review of an untitled agency complaint document received from P12 dated 12/07/22 revealed, "Patient called and stated that the VA [Veterans Administration] had approved him for 7.5 hours a week but he is only being visited for 1 [one] hour 3 [three] times a week … HH [Home Health] DON [Director of Nursing] call pt [patient] who reports …[HHA2] never allows [him/her] to sign after [his/her] visits and when [P12] asks about it [HHA2] gives excuses such as iPad died, or that [he/she] doesn't need to sign …[P12] stated, 'I think [HHA2] is padding her time a lot and I'd like to request [he/she] not come back." Review of P12's "Aide Visit Notes" showed that HHA2 was assigned to P12 on 12/07/22, six days after the complaint was received involving P2 and before an investigation was completed on 12/14/22. During an interview on 03/15/23 at 3:45 PM, the Administrator confirmed the agency's belief that HHA2 did not complete the visits as assigned and that HHA2 appeared to have forged the patient signature. The Administrator confirmed the agency had not removed HHA2 from being assigned to P2 until an investigation could be completed after the complaint was received on 12/01/22. HHA2 also continued to see other patients, in addition to P2 and P12, between 12/01/22 and 12/14/22 when an investigation was completed and HHA2's employment was terminated.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on observation, record review, policy review, and interview, the agency failed to ensure the patients' plan of care (POC) and the medication list were accurate and updated for 2 of 3 patients (Patient (P)4 and P5) reviewed during joint home visit with staff. Failure to update the medication list and obtain current orders from the physician has the potential to lead to medication errors. Finding Include: Review of the agency's policy titled, "Medication Profile," dated December 2022, revealed, "Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications … Based on review of the medication profile as well as the written material, changes in the plan of care may be required … The medication lists should be reviewed at each skilled visit to ensure it is accurate. If at anytime there is a discrepancy, the clinician will contact the provider for clarification and reconciliation." Patient 4 During P4's home visit with the Occupational Therapist (OT) on 03/14/23 at 11:30 AM, P4's medication bottles were reviewed with P4's son. P4's son reported what the patient was currently prescribed and taking against the printed medication list, revealed the following: P4 was taking Calcium 600 milligrams (mg) twice a day, not once a day as written on the medication list. P4 was taking folic acid (supplement used to prevent sores in mouth and nose caused by taking methotrexate) 1 mg daily, not 0.4 mg as written on the medication list. P4 was taking gabapentin (used for nerve pain) 300 mg one capsule at bedtime, not one capsule three times a day as written on the medication list. P4 was taking methotrexate (used to treat rheumatoid arthritis by decreasing the activity of the immune system) 2.5 mg tablets four tablets once a week, not six tablets once a week as written on the medication list. During an interview on 03/14/23 at 12:30 PM, the OT stated that he/she usually asks if there were any medication changes but does not review the medication list with the patient or look at the medication bottles in the home. Patient 5 During P5's home visit with the Physical Therapist (PT) on 03/14/23 at 2:00 PM, review of patients' medication bottles, what P5 stated he/she was currently taking with the agency medication list revealed the following: P5 reported that he/she was taking Benfotiamine (and over-the-counter version of B1 supplement used for nerve pain) which was not on the medication list. P5 stated his/her physician recommended it. During an interview on 03/15/23 at 3:45PM, the Administrator stated it is the expectation that medications are reviewed during the first nurse or clinician visit of the week. The medication list in the electronic medical record should then be updated, and the practitioner or physician should be contacted for corresponding orders.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, policy review, and interview, the agency failed to provide 3 of 3 patients (Patient (P)2, P4, and P5) seen during a home visit with a medication list that included the medication name, dosage, and frequency. The failure to provide patients with accurate and up-to-date medication lists has the potential to contribute to medication errors for all patients receiving home health services. Findings Include: Review of the agency's policy titled, "Medication Profile," dated December 2022 revealed, "During subsequent visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen." Patient 2 Review of P2's current POC showed a SOC date of 09/01/20. During a visit to the home of P2 on 03/15/23 at 11:30 AM, the Registered Nurse (RN)/Director of Nursing (DON) provided the patient with a "Medication Profile." The RN/DON confirmed P2 did not have a medication list in his/her home and skilled nursing sets up P2's medication in medication boxes for two weeks at a time during the nursing visit. The RN/DON stated the nurse used the list of medications in their electronic device to access the EMR. Patient 4 Review of P4's current plan of care (POC) showed a start of care (SOC) date of 02/17/23. During a visit to the home of P4 with the Occupational Therapist (OT) on 03/14/23 at 11:30 AM, the OT provided the patient with a "Medication Profile" printed from the electronic medical record (EMR) and placed it in the agency admission file in the home. During an interview on 03/14/23 at 12:00PM, P4's son stated they had not received a medication list from the agency prior to that day. Patient 5 Review of P5's current POC showed a SOC date of 02/10/23. During a visit to the home of P5 on 03/14/23 at 2:00 PM, the Physical Therapist (PT) asked P5 if he/she had any medication changes. During an interview, after the PT had left the home, on 03/14/23 at 2:45 PM, P5 stated the PT had brought the "Medication Profile" list to the home that day and that the agency had not provided a list prior to 03/14/23. Reviewed of the medication list with P5, who stated that in addition to the medications listed he/she has also been taking Benfotiamine (an over-the counter version of B1 supplement). During an interview on 03/15/23 at 3:45 PM, the Administrator confirmed that staff were given the medication list to bring along on the joint visits and the agency was aware that the "Medication Profiles" were not being provided to patients as required.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on document review, policy review, review of the agency's governing body minutes, and interview, the Home Health agency's governing body and executive team failed to report a complaint involving a staff person not completing patient visits as documented for 1 patient (Patient (P)2) of 12 patients reviewed and failed to ensure those visits were not billed. This failure has the potential for ongoing neglect of all patients' care needs and the potential for incorrect billing practices. Findings Include: Review of the agency's policy titled, "Assessment of Possible Abuse/Neglect," dated December 2022 revealed, "The organization will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations … The Executive Director/Administrator will … submit reports to the proper authorities." Review of an untitled agency complaint document dated 12/01/22 showed Registered Nurse (RN)1 submitted a written complaint which identified that Home Health Aide (HHA)2 was not present at the home of patient (P)2 on 11/30/22 from 12:00 PM to 2:00 PM as HHA2 documented on the visit note. RN1 stated in the report that he/she was at the home of P2 from 12:15 PM to 1:41 PM on 11/30/22 and that P2 had stated HHA2 had called and told P2's mother that he/she was at home with a sick child and would not be able to complete the scheduled visit on 11/30/22. The agency complaint form also showed, "documentation reviewed and compared signature from other clinicians visits identied [sic] as being signed by patient after the documented visit: 11/4 visit 1310 [1:00 PM] – 1510 [3:10 PM], signed [electronically by patient] at 2204 (10:04 PM), 11/28 visit 1130 [11:30 AM] – 1330 [1:30 PM], signed [electronically by patient] at 2301 [11:01 PM], 11/30 visit 1200 [12:00 PM] – 1400 [2:00 PM], signed [electronically by patient] at 1717 [5:17 PM]. Patient signatures from [HHA2] visits do not match signatures obtained by previous clinicians" … Review of P2's "Aide Visit Note[s]" in the electronic medical record (EMR) located in the "Visits" section confirmed the above and additionally showed the following: On 12/02/22 (two days after the complaint) HHA 2 documented the visit start time as 11:00 AM and end time as 1:00 PM. The document showed the patient as having electronically signed at 9:07 PM and HHA2 electronically signed at 9:08 PM. On 12/07/22 (seven days after the complaint) HHA2 documented the visit start time as 1:00 PM and end time as 3:00 PM. The document showed the patient as having electronically signed at 10:17 PM and HHA2 electronically signed at 10:17 PM. On 12/12/22 (12 days after the complaint) HHA2 documented the visit start time as 11:00 AM and end time as 1:00 PM. The document showed the patient as having electronically signed at 1:33 PM and HHA2 electronically signed at 1:33 PM. During an interview with the Administrator and HR Representative on 03/14/23 at 11:30 AM, the Administrator stated that the time stamp associated with the patient signature accurately reflects the time it was signed automatically by the software program. The Administrator also stated that the time for the start and the end of the visit is entered by the assigned staff person and is not automatically registered by the software. The HR Representative stated the agency did not report the complaint to the appropriate authorities in accordance with applicable state regulations because they felt that it could not prove neglect because HHA2 would not say anything during the meeting. During an interview on 03/15/23 at 3:45 PM, the Administrator confirmed the agency's belief that HHA2 did not complete the visits as assigned and that the HHA2 appeared to have forged the patient signature. Review of billing documents showed that the Veterans Administration was billed for the visits identified in the complaint for P2. During an interview on 03/16/22 at 11:15 AM, Billing stated that he/she was not aware of the situation or told that billing for the services should not occur. Review of "governing body minutes" for the fourth quarter 2022 failed to show that any action was taken with regard to notification of the appropriate agencies at the state offices or Veterans Administration.