Every finding on record at Home Health Professionals, Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 06/28/2023. During the survey, it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

An extended survey for Medicare recertification for the home health was completed on 06/28/2023. The provider had 5 current patients. 4 condition-level deficiencies were identified during this survey. Condition-level deficiencies were identified at: -484.50 Condition of Participation: Patient Rights; -484.55 Condition of Participation: Comprehensive Assessment of Patients; -484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care; and -484.105 Condition of Participation: Organization and Administration of Services. A home health provider that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) – see Tag G788.

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 policy review, clinical record review, home visit observation, and interview, the home health provider failed to provide written notice that: - Must be understandable to persons who have limited English proficiency, and accessible to individuals with disabilities (G0412); - Contained the verbiage that the transfer and discharge policies could be provided to a patient-selected representative within 4 business days of the initial evaluation visit (G0422); - The patient be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property (G0430); - The patient receive all services outlined in the plan of care (G0436); - The agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR411.408(f [Requirement for use of HH advance beneficiary notices (ABNs), "including restrictions on who may receive the ABN on the patient's behalf"] (G0440); - The patient has the right to be advised of the state toll free home health telephone hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHA's (G0444); - The patient has the right to be advised of the names, addresses, and telephone numbers of the Quality Improvement Organization that serves the area where the patient resides (G0446); - The patient has the right to be informed of the right to access auxiliary aids and language services as described in paragraph (f) of the section, and how to access these services (G0450); The patient and representative (if any) have the right to be informed of the home health agencies (HHA's) policy for transfer or discharge. The HHA may only transfer or discharge the patient from the HHA if: - The HHA advised the patient, representative (if any), the physician(s) issuing orders for the home health plan of care, and the patient's primary practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered (G0464); - The HHA makes efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation (G0466); - The HHA provides the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care (G0468); - The HHA documents the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical record (G0470); - The patient dies (G0472); and - Information must be provided to patients in plain language and in a manner that is accessible and timely to - (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations (G0490). The cumulative effect of these deficient practices has the potential to affect the rights of all of the home health provider's patients.

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 policy review, record review, and interview, the home health provider failed to provide the written notice of patient rights (provided to all patients during the initial evaluation visit and in advance of furnishing care to the patient) that contained the verbiage that the notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities in three of seven records reviewed (Records/Patients #1, #3, and #7). This deficient practice has the potential to affect the rights of all the home health provider's patients. Findings included: Review of the home health provider policy titled, “Patient Bill of Rights,” dated 10/2014 showed that the policy contained the verbiage that the written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities. Review of the documents titled, “Patient’s Bill of Rights,” for Records/Patients #1, #3, and #7, with admission dates ranging from 03/29/2022 to 04/10/2023 showed that the document titled, “Patient’s Bill of Rights,” failed to contain the verbiage that the written notice of patient rights must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities. During an interview on 06/28/2023 at 12:46 PM, the administrator stated that the document, “Patient Bill of Rights,” provided to patients on admission, failed to contain the verbiage that the written notice of patient rights must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide 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 to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide a written notice of patient rights (provided to all patients during the initial evaluation visit and in advance of furnishing care to the patient) that contained the verbiage that the discharge and transfer policies are provided to a patient representative within four-business days of the initial evaluation visit in three of seven records reviewed (Records/Patients #1, #3, and #7). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: Review of the policy titled, “Patient Bill of Rights,” dated 01/13/2018 showed that the policy failed to contain the verbiage that the discharge and transfer policies are provided to a patient representative within four-business days of the initial evaluation visit. Review of the documents titled, “Patient’s Bill of Rights,” for Records/Patients #1, #3, and #7, with admission dates ranging from 03/29/2022 to 04/10/2023 showed that the document titled, “Patient’s Bill of Rights,” failed to contain the verbiage that the discharge and transfer policies are provided to a patient representative within four-business days of the initial evaluation visit. During an interview on 06/28/2023 at 12:46 PM, the administrator stated that the document, “Patient Bill of Rights,” provided to patients on admission, failed to contain the verbiage that the discharge and transfer policies are provided to a patient representative within four-business days of the initial evaluation visit.

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 policy review, record review, and interview, the home health provider failed to provide a written notice of patient rights (provided to all patients during the initial evaluation visit and in advance of furnishing care to the patient) that contained the verbiage that the patient had the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property in three of seven records reviewed (Records/Patients #1, #3, and #7). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: Review of the policy titled, “Patient Bill of Rights,” dated 01/13/2018 showed that the policy contained the verbiage that the patient had the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Review of the documents titled, “Patient’s Bill of Rights,” for Records/Patients #1, #3, and #7, with admission dates ranging from 03/29/2022 to 04/10/2023 showed that the document titled, “Patient’s Bill of Rights,” failed to contain the verbiage that the patient had the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. During an interview on 06/28/2023 at 12:46 PM, the administrator stated that the document, “Patient Bill of Rights,” provided to patients on admission, failed to contain the verbiage that the patient had the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property.

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 policy review, record review, and interview, the home health provider failed to provide written notice of patient rights (provided to all patients during the initial evaluation visit and in advance of furnishing care to the patient) that contained the verbiage that the patient had the right to receive all services outlined in the plan of care in three of seven records reviewed (Records/Patients #1, #3, and #7). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: Review of the policy titled, “Patient Bill of Rights,” dated 01/13/2018 showed that the policy failed to contain the verbiage that the patient had the right to receive all services outlined in the plan of care. Review of the documents titled, “Patient’s Bill of Rights,” for Records/Patients #1, #3, and #7, with admission dates ranging from 03/29/2022 to 04/10/2023 showed that the document titled, “Patient’s Bill of Rights,” failed to contain the verbiage that the patient had the right to receive all services outlined in the plan of care. During an interview on 06/28/2023 at 12:46 PM, the administrator stated that the document, “Patient Bill of Rights,” provided to patients on admission, failed to contain the verbiage that the patient had the right to receive all services outlined in the plan of care.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide written notice of patient rights (provided to all patients during the initial evaluation visit and in advance of furnishing care to the patient) that contained the verbiage that the agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR411.408(f) [Requirement for use of HH advance beneficiary notices (ABNs), "including restrictions on who may receive the ABN on the patient's behalf"], in three of seven records reviewed (Records/Patients #1, #3, and #7). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: Review of the policy titled, “Patient Bill of Rights,” dated 01/13/2018 showed that the policy failed to contain the verbiage that the agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR411.408(f) [Requirement for use of HH advance beneficiary notices (ABNs), "including restrictions on who may receive the ABN on the patient's behalf"]. Review of the documents titled, “Patient’s Bill of Rights,” for Records/Patients #1, #3, and #7, with admission dates ranging from 03/29/2022 to 04/10/2023 showed that the document titled, “Patient’s Bill of Rights,” failed to contain the verbiage that the agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR411.408(f) [Requirement for use of HH advance beneficiary notices (ABNs), "including restrictions on who may receive the ABN on the patient's behalf"]. During an interview on 06/28/2023 at 12:46 PM, the administrator stated that the document, “Patient Bill of Rights,” provided to patients on admission, failed to contain the verbiage that the agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR411.408(f) [Requirement for use of HH advance beneficiary notices (ABNs), "including restrictions on who may receive the ABN on the patient's behalf"].

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide the written notice of patient rights (provided to all patients during the initial evaluation visit and in advance of furnishing care to the patient) that contained the correct Missouri Adult Abuse Hotline telephone number and/or the correct hours of operation in three of seven records reviewed (Records/Patients #1, #3, and #7). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: Review of the policy titled, “Patient Bill of Rights,” dated 01/13/2018 showed that the policy contained the verbiage that the patient would receive, in writing, the telephone numbers for the state home health hotline and/or hours of operation. Review of the documents titled, “Patient’s Bill of Rights,” for Records/Patients #1, #3, and #7, with admission dates ranging from 03/29/2022 to 04/10/2023 showed that the document titled, “Patient’s Bill of Rights,” failed to contain the correct Missouri Adult Abuse Hotline number and/or the correct hours of operation. During an interview on 06/28/2023 at 12:46 PM, the administrator stated that the document, “Patient Bill of Rights,” provided to patients on admission, failed to contain the correct Missouri Adult Abuse Hotline number and/or the correct hours of operation.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, and interview, the home health provider failed to ensure the written notice of patient rights (provided to all patients during the initial evaluation visit and in advance of furnishing care to the patient) contained the verbiage that the patient be advised of the name, address, and phone number of the quality improvement organization that served the area where the patient resides in three of seven records reviewed (Records/Patients #1, #3, and #7). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: Review of the policy titled, “Patient Bill of Rights,” dated 01/13/2018 showed that the policy failed to contain the verbiage that the patient be advised of the names, addresses, and telephone numbers of federally funded entities that serve the area where the patient resides. During home visit observations of Records/Patients #1, #3, and #7, with observation dates ranging from 06/27/2023 to 06/28/2023 showed that the folders placed in the patient homes at the time of admission failed to contain the name, address, and telephone number for the Quality Improvement Organization that serves the area where the patient resided. During an interview on 06/28/2023 at 12:46 PM, the administrator stated that the folders placed in the patient homes at the time of admission failed to contain the name, address, and telephone number for the Quality Improvement Organization that serves the area where the patient resided.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to inform the patient of the right to access auxiliary aids and language services in one of one admission packet reviewed. This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the provider's policy titled, "Patient Bill of Rights," dated 10/2014, showed the patient bill of rights' purpose is to assist with fully understanding patient rights and the policy will be available to the organization personnel, patient, and his/her representatives. Review of the patient admission packet showed the home health provider's packet failed to include the verbiage of the patient's right to access auxiliary aids and language services. During an interview on 06/28/2023 at 2:30 PM, the home health administrator stated that he/she would expect the patient to be informed of all of his/her rights.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to provide written and verbal information to the patient regarding the transfer and discharge process including the right to be informed when the provider is considering a discharge for cause in one of one patient admission packets reviewed. This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the provider's policy titled, "Patient Bill of Rights," dated 10/2014, showed the patient has the right to be advised in advance of any change in the plan of care before the change is made. Review of the patient admission packet failed to show that the patient had the right to be notified of the consideration of discharge for cause. During an interview on 06/28/2023 at 2:30 PM, the home health administrator stated that he/she would expect the patient to be informed of all of their rights.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on policy review, admission packet review, and interview, the home health provider failed to inform the patient of the right to have efforts made by the home health provider to resolve the problems presented by the patient's behavior prior to a discharge for cause in one of one patient admission packet reviewed. This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the provider's policy titled, "Patient Bill of Rights," dated 10/2014, showed the home health provider would assist the patient with fully understanding patient rights and all policies would be available to the patients and his/her representatives. Review of the patient admission packet failed to include; the patient has the right to have efforts made by the home health provider to resolve the problems presented by the patient's behavior prior to a discharge for cause. During an interview on 06/28/2023 at 2:30 PM, the administrator stated that he/she would expect the patients to be informed of all of their rights.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on policy review, patient admission packet review, and interview, the home health provider failed to provide written and verbal information to the patient and representative regarding the transfer and discharge process including the right to receive contact information for other agencies or providers who may be able to provide care prior to discharge for cause in one of one patient admission packet reviewed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Patient Bill of Rights," dated 10/2014, showed the purpose of the policy was to assist the patient with fully understanding patient rights and all policies would be available to the patients and his/her representative. Review of the patient admission packet showed the agency failed to inform the patient of the right to receive contact information for other agencies or providers who may be able to provide care in the event of a discharge for cause. During an interview on 06/28/2023 at 2:30 PM, the home health administrator stated that he/she would expect the patient to be informed of all of their rights.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on policy review, patient admission packet review, and interview, the home health provider failed to provide written and verbal information to the patient regarding the right to have the problem and efforts made to resolve the problem documented prior to a discharge for cause in one of one patient admission packet reviewed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Patient Bill of Rights," dated 10/2014, showed the purpose of the policy was to assist the patient with fully understanding patient rights and all policies would be available to the patients and his/her representative. Review of the patient admission packet showed the home health provider failed to inform the patient of his/her right to have problems and efforts made to resolve the problem documented prior to a discharge for cause. During an interview on 06/28/2023 at 2:30 PM, the administrator stated that he/she would expect the patients to be informed of all of his/her rights.

Death of patient CFR(s): 484.50(d)(6) The patient dies; or This ELEMENT is not met as evidenced by: Based on policy review, patient admission packet review, and interview, the home health provider failed to provide the patient with the right to be informed of the provider's transfer and discharge policy regarding discharging the patient due to death in one of one patient admission packet reviewed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Patient Bill of Rights," dated 10/2014, showed the purpose of the policy was to assist the patient with fully understanding patient rights and all policies would be available to the patients and his/her representative. Review of the patient admission packet showed the provider failed to provide the patient with their right to be discharged in the event of death. During an interview on 06/28/2023 at 2:30 PM, the administrator stated that he/she would expect the patient to be informed of all of his/her rights.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on policy review, patient admission packet review, and interview, the home health provider failed to provide written and verbal information of the patient's right to receive information in plain language and in a manner that is accessible and timely to persons with disabilities and persons with limited English proficiency in one of one patient admission packet reviewed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Patient Bill of Rights," dated 10/2014, showed the purpose of the policy was to assist the patient with fully understanding patient rights and all policies would be available to the patients and his/her representative. Review of the patient admission packet showed the provider failed to provide the patient with information regarding receiving information in a plain language and in a manner that is accessible and timely to persons with limited English proficiency. During an interview on 06/28/2023 at 2:30 PM, the home health administrator stated that he/she would expect the patient to be informed of all of his/her rights.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on policy review, clinical record review, home visit observation, and interview, the home health provider failed to provide a comprehensive assessment that contained: - A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date (G0514); - The patient’s medical, nursing, rehabilitative, social, and discharge planning needs (G0534); and - A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effect, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy (G0536). The cumulative effect of these deficient practices has the potential to affect the comprehensive assessment of all of the provider's patients.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to provide an initial assessment that was completed within 48 hours of the referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date in two of seven records reviewed (Records/Patients #3 and #7). This deficient practice as the potential to affect the timely admission for all of the provider's patients. Findings included: Review of the agency’s policy titled, “Initial and Comprehensive Assessment,” dated 10/2014, showed that the comprehensive assessment will be completed within 48 hours of referral, the patient’s return home from an inpatient stay, or of the organization’s knowledge of the patient’s return from a 24-hour hospital admission for other than diagnostic testing. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/10/2023 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body causing symptoms like confusion, restlessness, difficulty breathing). The patient resided in their own home. Review of the patient’s referral information showed: - The referral for services was received on 04/07/2023; and - The patient was admitted to services on 04/10/2023. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that the admission was performed greater than 48 hours following an inpatient discharge. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 04/04/2023 with a primary diagnosis of osteoarthritis of the right shoulder with right shoulder surgery. The patient resided in their own home. Review of the patient’s referral information showed: - The referral for services was received on 3/30/2023; and - The patient was admitted to services on 04/04/2023. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that the admission was performed greater than 48 hours following an inpatient discharge.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to provide a comprehensive assessment that identified the patient’s medical and nursing needs in one of seven records reviewed (Record/Patient #2). This deficient practice has the potential to affect the comprehensive assessment of all the provider's patients. Findings included: Review of the provider's policy titled, “Initial and Comprehensive Assessment,” dated 10/2014, showed that the comprehensive assessment will contain: - The patient’s medical and psychosocial history, including pertinent diagnosis and prognosis; and - The patient’s pain status. Review of the provider's policy titled, “Pain Assessment,” and dated 10/2014 showed that: - During the initial assessment, the patient will be asked a general screening question regarding current or recent pain as part of the baseline data.; When the patient or the clinician identifies pain, the following in-depth pain assessment information should be obtained whenever possible, including, but not limited to: * Pain intensity using a rating scale; * Pain location; * Pain quality, patterns of radiation, and character; * Pain onset, duration, variations, and patterns; and * Pain management history. RECORD/PATIENT #2: Review of the initial comprehensive assessment dated 06/20/2023 failed to contain documentation of: - A complete pain assessment: * Documentation showed patient having pain in their leg and back, but failed to contain documentation of a comprehensive pain assessment; and - The individualized instruction provided to a patient receiving home infusion therapy including, but not limited to what was instructed and the outcome of the instruction. During and interview on 06/28/2023 at 12:45 PM, the administrator stated that there was no additional documentation on the comprehensive assessment and that they would expect the clinician to document an assessment according to the provider's policy.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, home visit observation, and interview, the home health provider failed to provide a comprehensive assessment that contained review of all medications the patient was currently using in three of seven records reviewed (Records/Patients #2, #3, and #7). This deficient practice has the potential to affect the medication management of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Initial and Comprehensive Assessment,” dated 10/2014, showed that the comprehensive assessment will contain a review of medication history, as applicable to care and service and current medication use, including prescription, over-the-counter medications, herbal medications, and identifying drug interactions, duplicative drug therapy, and noncompliance with therapy. Review of the provider’s policy titled, “Medication Monitoring,” dated 02/21/2022 showed that: - Ongoing patient medication monitoring will use a collaborative approach between clinicians, physicians, pharmacists, patients, and families/caregivers; - The clinician will assess the effect of medications on the patient. The assessment will identify potential contraindications, drug interactions, duplicative drug therapy, significant adverse reactions, and noncompliance with drug therapy. The drug interactions will be performed by a registered nurse at least three points of care (Start of Care, Resumption of Care, and Recertification). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/20/2023 with a diagnosis of pathological fracture (A broken bone caused by disease) of right ankle with intravenous antibiotic therapy. The patient resided in their own home. Review of the prescriber orders dated 06/16/2023 and received at time of referral showed the patient was to take: - Daptomycin (an antibiotic used to treat various bacterial infections) 425 milligrams (mg)/8.5 milliliter (ml) intravenous push every 24 hours; - Normal saline, 10 ml before and after infusion, and line maintenance; - Heparin (an anticoagulant medication used to keep intravenous access lines from forming blood clots) 10 units (u)/ml after normal saline and as needed for line maintenance; - The documentation did not contain orders for alprazolam (an antianxiety medication), oxycodone (an opioid pain medication), thiamine (a vitamin), carvedilol (a medication used to slow down the heart rate), and tizanidine (a medication used to relieve muscle spasms). Review of the Orthopedic Surgery Discharge Summary dated 6/16/23 and received at time of referral showed the patient was to take: - Daptomycin 400mg/50 ml intravenous piggyback every 24 hours; - Alprazolam four times per day; - Oxycodone every four hours as needed; - Thiamine infusion daily; and - The documentation did not contain orders for normal saline, heparin, tizanidine, or carvedilol. Review of the inpatient after visit summary dated 06/16/2023, and received at time of referral showed the patient was to take: - Daptomycin 422.5mg every 24 hours - Alprazolam four times per day - Carvedilol 25mg twice per day - The documentation did not contain orders for normal saline, heparin, carvedilol, oxycodone, tizanidine, and thiamine. Review of the plan of care dated 06/20/2023 showed that the patient was to take: - Daptomycin 422.5 mg; - Normal saline 10 ml once a day; - Heparin flush 5 ml every 24 hours; - Alprazolam three times per day; - Carvedilol twice per day - Tizanidine 2 caps three times a day as needed muscle spasms - The plan of care did not contain orders for oxycodone and thiamine. Review of the comprehensive assessment dated 06/20/2023 showed the assessment failed to contain documentation of the reconciliation of the medications between the multiple providers on the referral paperwork. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that the record did not contain documentation of the efforts to reconcile the medications between the multiple providers. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/10/2023 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body causing symptoms like confusion, restlessness, difficulty breathing). The patient resided in their own home. During a home visit observation on 06/27/2023 at 9:30 AM, this surveyor compared the current medication profile (CMP) to the medications in the patient’s home, the comparison showed that: - The CMP contained orders for oxygen continuously; the home visit showed that the patient used the oxygen on an as needed basis; - The CMP contained orders for losartan (a medication that relaxes blood vessels to lower blood pressure) once a day; the home visit showed that the patient was not taking the medication; - The CMP showed the patient was taking metoprolol (a medication used to treat high blood pressure and chest pain) capsules two times per day; the patient was not taking the medication; - The CMP failed to contain orders for Tylenol with codeine, the patient was taking the medication three times per day as needed for pain. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 04/04/2023 with a primary diagnosis of osteoarthritis of the right shoulder with right shoulder surgery. The patient resided in their own home. During a home visit observation on 06/27/2023 at 4:30 PM: - This surveyor compared the CMP to the medications in the patient’s home. The CMP failed to contain orders for trazadone (a medication used to treat depression), gabapentin (a medication used to treat seizures and nerve pain), potassium, and Sinemet (a medication used to control tremors associated with Parkinson’s disease); - A review of the patient’s home medications showed that the patient was taking trazadone, gabapentin, potassium, and Sinemet; and - The clinician asked the patient about the use of Sinemet to treat tremors. During an interview on 06/27/2023 at 4:30 PM, the clinician stated that he/she did not do anything with the reconciliation of the patient’s medications. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that the therapy staff are expected to notify the registered nurse of changes in the patient’s medications, and there was no documentation available for the communication between the registered nurse and the physical therapist.

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 policy review, clinical record review, home visit observation, and interview, the home health provider failed to develop a plan of care that contained: - Physician consultation to approve additions or modifications to the original plan (G0572); - The individualized plan of care must include the following: * The types of services, supplies, and equipment required; * All necessary interventions to address the underlying risk factors; and * Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient (G0574); - Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. (G0614); and - Name and contact information of the HHA clinical manager (G0622). The cumulative effect of these deficient practices has the potential to affect the care planning, coordination, and quality of care for all of the provider's patients.

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 policy review, record review, and interview, the home health provider failed to consult the physician to approve modifications to the original plan of care in two of seven full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Care Planning Process," dated 10/2014, showed the plan of care (POC) will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. Review of the clinical record showed: -Patient admitted to home health services on 04/07/2023 with a diagnosis of primary osteoarthritis of the right hip (a disease in which the cartilage within a joint begins to break down and the underlying bone begins to change); -Patient was schedule to receive physical therapy (PT) services two times a week for one week and one time a week for eight weeks; -Patient had a missed PT visit on 05/16/2023 due to patient being unavailable; and -The home health agency failed to notify the physician of the missed visit. During an interview on 06/28/2023 at 2:30 PM, the home health administrator stated he/she would expect the visit to be made up on another day and reported to the physician as a missed visit. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 03/29/2022 with a diagnosis of chronic obstructive pulmonary disease (COPD) (a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing). The patient resided in their own home. Review of the POCs dated 03/24/2023 and 05/23/2023 showed an order for home health aide (aide) services one time weekly. Review of the clinical record failed to contain physician notification of aide missed visit for 03/26/2023, 04/02/2023, and 06/18/2023. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that it is their expectation that clinicians notify the physician of missed visits, and they had no additional documentation to provide prior to the survey exit.

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 policy review, clinical record review, home visit observation and interview, the home health provider failed to develop a plan of care (POC) that included: - The types of services, supplies, and equipment required; - The frequency and duration of visits to be made; - All necessary interventions to address the underlying risk factors; - Patient and caregiver education and training to facilitate timely discharge; and - Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; in three of seven records reviewed (Records/Patients #2, #3, and #7). This deficient practice has the potential to affect the care planning and coordination of care for all of the provider's patients. Findings included: Review of the policy titled, “Care Planning Process,” dated 10/2014 showed that: - The clinical POC includes goals/outcomes to be achieved, orders for specific home health services and disciplines, treatments and procedures, including amount/frequency/durations, frequency and duration of visits; and - Changes in the plan of care will be noted with the following documentation: * Assessment; * Plan of care with clinical outcome goals; * Care plan with specific services/actions to be taken; * Clinical notes; and * Verbal orders. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/20/2023 with a diagnosis of pathological fracture (A broken bone caused by disease) of right ankle with intravenous antibiotic therapy. The patient resided in their own home. Review of the POC dated 06/20/2023 showed that the document: - Failed to contain: * Parameters for Clonidine (a blood pressure pill) to be taken as needed for hypertension; * Specific and individualized interventions for the care of the intravenous access dressing site once weekly; * Specific and individualized interventions for pain management for a patient with orders to report pain greater than 9 out of 10 to the physician; * Orders and goals for the management of the patient’s wound, including but not limited to, observation of a non-removable surgical dressing; and - Contained orders and interventions that were not applicable to the patient or conflicted with each other including: * Orders for the peripherally inserted central (PICC) line included the statement, “If peripheral (the order failed to contain which type of line i.e. central or intravenous), leave line in place until no longer functional or medication is complete;” and * Conflicting normal saline orders on the medication section (administer normal saline once daily) and the orders for disciplines and treatments section (normal saline before and after medication administration) of the POC. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/10/2023 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body causing symptoms like confusion, restlessness, difficulty breathing) and diabetes (a chronic, metabolic disease characterized by elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves). The patient resided in their own home. During a home visit observation on 06/07/2023 at 9:30 AM, the patient’s daughter reported that the granddaughter had medical power of attorney. The granddaughter prefills the medication planner and performs all activities related to medical management of the patient. During the observation visit, this surveyor noted the patient used a straight cane, rolling walker, bath seat, bedside commode, hospital bed, and glucometer. Review of the POC dated 06/09/2023 showed that the document failed to contain: - The DME associated with the patient’s care including a straight cane, rolling walker, bath seat, commode, hospital bed, glucometer, and medication planner; - Interventions and goals for the monitoring of the patient’s blood sugars; and - Interventions and goals identifying the management of the patient’s medications by a person who did not live in the patient’s home. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that: - They would expect medication planner, blood sugar management, and DME to be on the POC, and they had no further documentation to provide at the time of exit. RECORD/PATIENT #7: The patient was admitted on 04/04/2023 with a primary diagnosis of osteoarthritis of the right shoulder with right shoulder surgery. The patient resided in his/her own home with the assistance of his/her spouse and adult children. The comprehensive assessment dated 04/04/2023 showed the patient was prescribed opioid pain medication and a non-removable dressing to the right shoulder. During an interview on 06/27/2023 at 4:30 PM, the patient’s spouse stated that the provider's staff do not manage the patient's medications, and the patient has an in-home nurse that visits every two weeks to prefill the patient's medication planner. During a home visit observation on 06/27/2023 at 4:30 PM the patient's spouse provided this surveyor with a list of medications that the in-home nurse provided; and this surveyor compared the in-home nurse’s medication list to the medications in the medication planner, and they matched. Review of the POC dated 04/04/2023 showed the document failed to contain: - Specific interventions for managing the patient’s pain; - Specific interventions for managing the patient’s wound; and - Interventions addressing the involvement of another agency in the management of the patient’s medications and contact information of that agency. During an interview on 06/27/2023 at 4:40 PM the physical therapist stated that he/she does not manage the patient’s medications. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that: - They would expect all staff members to manage the patient’s medications; - Therapy staff notify the nurse of medication changes and the nurse performs medication reconciliation; - The POC should include all pertinent interventions for the care of the patient; and - They had no further documentation to provide prior to survey exit.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based clinical record review, home visit observation, and interview, the home health provider failed to provide patients with a written visit schedule, including frequency of visits by provider personnel and personnel acting on behalf of the provider in two of two applicable records reviewed (Records/Patients #3 and #7). This deficient practice has the potential to affect the scheduling communication for all of the provider’s patients. Findings included: RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/10/2023 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body causing symptoms like confusion, restlessness, difficulty breathing). The patient resided in their own home. During a home visit observation on 06/27/2023 at 9:30 AM, a review of the folder left in the patient’s home at the time of admission showed that the folder and home failed to contain a written schedule of clinician visits. During an interview on 06/27/2023 at 10:15 AM, the patient and family residing in the home stated that the provider staff had not left a written schedule of visits in the home or offered to leave a written schedule of visits. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 04/04/2023 with a primary diagnosis of osteoarthritis of the right shoulder with right shoulder surgery. The patient resided in their own home. During a home visit observation on 06/27/2023 at 4:30 PM, a review of the folder left in the patient’s home at the time of admission showed that the folder and home failed to contain a written schedule of clinician visits. During an interview on 06/27/2023 at 4:30 PM, the patient and family residing in the home stated that the provider staff had not left a written schedule of visits in the home or offered to leave a written schedule of visits. During an interview on 06/28/2023 at 12:45pm, the administrator stated they expect clinicians to leave written calendars in the patient homes.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, and interview, the home health provider failed to provide patients with the name and contact information of the provider's clinical manager in two of two records reviewed (Records/Patients #3 and #7). This deficient practice has the potential to affect the coordination of care for all the provider’s patients. Findings included: Review of the booklet, provided to patients at the time of admission, showed that the booklet failed to contain the name of the provider's current clinical manager. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/10/2023 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body causing symptoms like confusion, restlessness, difficulty breathing). The patient resided in their own home. During a home visit observation on 06/27/2023 at 9:30 AM, a review of the folder left in the patient’s home at the time of admission showed that the folder failed to contain the name of the current clinical manager. During an interview on 06/27/2023 at 10:15 AM, the patient and family residing in the home stated that the provider staff had not left an updated form listing the name of the current clinical manager. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 04/04/2023 with a primary diagnosis of osteoarthritis of the right shoulder with right shoulder surgery. The patient resided in their own home. During a home visit observation on 06/27/2023 at 4:30 PM, a review of the folder left in the patient’s home at the time of admission showed that the folder failed to contain the name of the current clinical manager. During an interview on 06/27/2023 at 4:30 PM, the patient and family residing in the home stated that the provider staff had not left an updated form listing the name of the current clinical manager. During an interview on 06/28/2023 at 12:45pm, the administrator stated they expect clinicians to leave the name of the current clinical manager in the patient homes.

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 nationally recognized standards, home visit observation, and interview, the provider failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in one of two applicable records (Record/Patient #3). This deficient practice has the potential to affect the infection prevention of all the provider’s patients. Findings included: Review of the product label for the provider’s disinfectant wipes showed that the product can be used on most hard, non-porous surfaces. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/10/2023 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body causing symptoms like confusion, restlessness, difficulty breathing). The patient resided in their own home. During a home visit observation on 06/27/2023 at 9:30 AM, the physical therapy assistant (PTA) used a cloth gait belt for patient safety during the visit. The PTA returned the used cloth gait belt to his/her vehicle and cleansed it using the agency’s disinfectant wipes. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that they would be changing their practice to leave the cloth gait belts at the patients home for single patient use.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on policy review, employee file review, and interview, the home health provider failed to ensure employees participated in home health sponsored in-service training in one of six employee files reviewed (Employee #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Personnel Record Contents," dated 10/2014, showed the personnel files for regular full or part time personnel will include counseling documents such as ongoing competency assessments, trainings, and award certificates. Review of the employee personnel files showed the following: EMPLOYEE #2: -Date of hire: 04/04/2022; and -The provider failed to provide proof of annual in-service training for the employee. During an interview on 06/28/2023 at 11:00 AM, the administrator stated that he/she would expect record of annual in-service training to be kept in the employee files.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to show how communication and oversight exist between the skilled professional and assistant regarding the patient in two of seven records reviewed (Records/Patients #3 and #7). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the policy titled, "Job Title/Position: Physical Therapist," and dated 10/2014 showed that the physical therapist (PT) supervises physical therapy assistants (PTA) according to organization policy and state regulations. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/10/2023 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body causing symptoms like confusion, restlessness, difficulty breathing). The patient resided in their own home. Review of the documentation showed that physical therapy services began on 04/11/2023. The PT documented 30-day re-evaluations on 05/09/2023 and 06/06/2023. The visit documentation for both dates failed to contain PTA supervision. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 04/04/2023 with a primary diagnosis of osteoarthritis of the right shoulder with right shoulder surgery. The patient resided in their own home. Review of the documentation showed that physical therapy evaluation was performed 04/04/2023. The PT performed a 30-day re-evaluation on 05/01/2023. The documentation failed to contain supervision of the PTA. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that they would expect the PT to perform supervisory visits on the PTA a minimum of every 30 days and that they were unable to provide documentation for the missed supervisory visits.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on employee file review, and interview, the home health provider failed to ensure a physical therapist was supervising a physical therapist in one of five employee files reviewed (Employee #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: EMPLOYEE #1: Review of the employee personnel file showed: -Employee was hired on 03/16/2020; -Employee was a licensed Physical Therapist; and -Employee's onboarding competencies were signed off by a Physical Therapy Assistant. During an interview on 06/28/2023 at 11:30 AM, the administrator stated that he/she would expect a Physical Therapist to be signed off by another Physical Therapist rather than a Physical Therapy Assistant.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with four Conditions of Participation: Patient rights; Comprehensive Assessment of Patients; Care Planning, Coordination of Services, and Quality of Care; and Organization and Administration of Services, the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 06/28/2025. .

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review and interview, the home health provider failed to provide home health aides with written patient care instructions prepared by a registered nurse in one of one record reviewed (Record/Patient #1). This deficient practice has the potential to affect the home health aide services for all of the provider’s patients. Findings included: RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 04/04/2023 with a primary diagnosis of osteoarthritis of the right shoulder with right shoulder surgery. The patient resided in their own home. Review of the clinical record showed the home health aide (HHA) assignment sheet dated 03/20/2023 failed to contain any assigned tasks for the HHA to complete during his/her visits. During an interview on 06/28/2023 at 12:45 PM, the administrator stated that there were no assigned tasks on the form provided to this surveyor, and there was no additional documentation available.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based clinical record review and interview, the home health provider failed to provide the home health aide services that were included in the plan of care in one of one applicable record reviewed (Record/Patient #1). This deficient practice has the potential to affect the home health aide services for all of the provider's patients. Findings included: RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 04/04/2023 with a primary diagnosis of osteoarthritis of the right shoulder with right shoulder surgery. The patient resided in their own home. Review of the home health aide (HHA) assignment sheet dated: - 03/22/2023 had no tasks on the sheet; and - 05/22/2023 showed the tasks of shower with the use of a bath chair. Review of the home health aide (HHA) visit documentation showed that: - On 04/11/2023, 04/18/2023, 04/24/2023, 05/09/2023 and 05/16/2023 the HHA documented providing tasks that were not on the HHA assignment sheet (the assignment sheet contained no assigned tasks); and - On 05/24/2023 and 06/14/2023 the HHA documented providing the patient a partial/complete bath when a shower with a chair was assigned. During an interview on 06/28/2023 at 12:45 PM, the administrator stated they had no additional documentation or clarification to provide prior to survey exit regarding the HHA documentation of care that was not provided according to the HHA assignment sheet.

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 observation and interview, the home health provider failed to organize, manage, and administer its resources in a manner that met the requirements for the Condition of Participation: Organization and Administration of Services. The home health provider failed to ensure: -Administrator was responsible for day to day operations (G948); -Oversight to assure the development, implementation, and updated of the individualized plan of care (G968); and -All home health services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice (G984). The cumulative effect of these systemic deficient practices has the potential to result in the inability of the agency to provide effective ongoing management of all clinical services and to ensure the patient's care needs would be met. .

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 current survey findings, observation, and interview, the home health provider failed to ensure the administrator was responsible for all day to day operations of the provider. This deficient practice has the potential to affect all patients served by the provider. Findings included: This deficient practice led to the failure of the agency to comply with four Conditions of Participation: - §484.50 Condition of Participation: Patient Rights; - §484.55 Condition of Participation: Comprehensive Assessment of Patients; - §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality Care; and - §484.105 Condition of Participation: Organization and Administration of Services. Upon surveyor arrival to the provider on 06/26/2023 at 2:30 PM, the provider's door was locked and no employees were present. The survey team called the telephone number posted on the provider's door. The number called was answered by an unidentified provider staff member in the Arkansas office. Staff member stated that he/she would send staff members back to the Missouri office and that it was closed for the day. At 3:30 PM, the office secretary arrived and let the survey team into the provider's office. During an interview on 06/26/2023 at 4:00 PM, the office secretary stated that the administrator does not come to the office and he/she stays at the Arkansas offices. He/she then stated that he/she was the only personnel that came to the Missouri office on Mondays, Wednesdays, and Fridays from 8:30 AM to 12:00 PM (these hours were not posted on the provider's office door or website).

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to assure the implementation and updates to the individualized plan of care in four of seven full records reviewed (Records/Patients #2, #3, #4, and #7). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's undated policy titled, "Transfer and Discharge Policy," showed: -All transfers and discharges will be documented in the medical record; and -When a discharge occurs, an assessment may be completed. RECORD/PATIENT #4: Review of the clinical record showed: -Patient admitted to home health services on 04/07/2023 with a diagnosis of osteoarthritis of the right hip; -Patient was receiving physical therapy (PT) services two times a week for one week then one time a week for eight weeks; -A physical therapy discharge summary dated 05/30/2023 signed by the PT showing patient fully achieved his/her goals; -The patient had no visits after 05/30/2023; and -The provider failed to perform a discharge on the patient. During an interview on 06/28/2023 at 11:30 AM, the administrator stated that there were no visits after 05/30/2023 and the patient should have been discharged but remained in the electronic medical record (EMR). The administrator also stated that he/she would expect the patient to be discharged from home health services properly when the patient met his/her goals. Based on policy review, clinical record review, home visit observation and interview, the home health provider failed to develop a plan of care (POC) that included: - The types of services, supplies, and equipment required; - The frequency and duration of visits to be made; - All necessary interventions to address the underlying risk factors; - Patient and caregiver education and training to facilitate timely discharge; and - Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; in three of seven records reviewed (Records/Patients #2, #3, and #7).

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on nationally recognized standards, employee file review, and interview, the home health provider failed to ensure all services were provided in accordance with current clinical practice guidance and accepted professional standards of practice in five of five employee records reviewed (Employees #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of Section 192.2495.3, RSMo stated: "Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: (1) Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose conducting an employee criminal records background check shall be deemed to fulfill the provider’s duty to conduct employee criminal background checks pursuant to this section…"; Review of Section 192.2495.6, RSMo: A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, RSMo (Offenses Against Persons), chapter 566, RSMo (Sexual Offenses), or chapter 569 (Robbery, Arson, Burglary and Related Offenses), or any violation of subsection 3 of section 198.070, RSMo (required reporter that knowingly fails to report abuse or neglect of a resident of a residential care, intermediate care or skilled nursing facility), or section 568.020, RSMo (Incest); and Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." EMPLOYEE #1: -Date of hire: 03/16/2020; -Date of employee disqualification list (EDL) check: 05/09/2020; and -The provider failed to obtain a Missouri state Family Care and Safety Registry (FSCR). EMPLOYEE #2: -Date of hire: 04/04/2022; -Date of EDL check: 04/07/2022; and -The provider failed to obtain a Missouri state FCSR. EMPLOYEE #3: -Date of hire: 03/13/2023; -Date of EDL check: 03/17/2023; and -The provider failed to obtain a Missouri state FCSR. EMPLOYEE #4: -Date of hire: 03/24/2008; -Date of EDL check: 01/17/2022; and -The provider failed to obtain a Missouri state FCSR. EMPLOYEE #5: -Date of hire: 07/22/2019; -Date of EDL check: 07/25/2019; and -The provider failed to obtain a Missouri state FCSR. During an interview on 06/28/2023 at 1:00 PM, the administrator stated the he/she expected the EDL check to be run prior to hire of an employee and was not aware that a Missouri FCSR had to be run on each employee prior to first patient contact.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider (HHA) failed to send a completed discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA within 5 business days of the patient's discharge in three of seven full records reviewed (Employees #4, #5, and #6). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's undated policy titled, "Transfer and Discharge Policy," showed the patient will receive an updated list of your current medications along with any instructions needed for ongoing care or treatment. RECORD/PATIENT #4: Review of the clinical record showed: -Patient was admitted to home health services on 04/07/2023 with a diagnosis of osteoarthritis of the right hip; -Patient was discharged from home health services on 05/30/2023; -The provider failed to complete a discharge summary and send a completed discharge summary to the physician. RECORD/PATIENT #5: Review of the clinical record showed: -Patient was admitted to home health services on 07/09/2022 with a diagnosis of diverticulitis of the large intestine (small bulges or pockets [diverticula] develop in the lining of the intestine and become inflamed or infected); -Patient was discharged from home health services on 12/29/2022; and -The provider could not provide proof of the discharge summary being sent to the physician. RECORD/PATIENT #6: Review of the clinical record showed: -Patient was admitted to home health services on 05/31/2022 with a diagnosis of urinary tract infection; -Patient was discharged from home health services on 07/26/2022; and -The provider could not provide proof of the discharge summary being sent to the physician. During an interview on 06/28/2023 at 2:30 PM, the administrator stated that he/she would expect the patient to be discharged properly from services and discharge summaries to be sent to the physician.