Every finding on record at Home Preferred Home Health, Ltd

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 01/05/23, Attentive Home Services, 368195 is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey The following deficiencies are based on the partial extended recertification survey completed 01/05/23. Attentive Home Health Services 368195, is not in compliance with the requirements found at Home Health Agency 42 CFR Part 484, Subpart B, C.

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 observation, record review and staff interview, the agency failed to notify the physician of missed visits. This affected one (Patient #6) out of eighteen patient records reviewed. The census was 251. Review of the record revealed Patient #6 had a start of care date of 08/05/22. The certification reviewed was from 12/03/22 through 01/31/23. Review of the physician’s orders dated 12/03/22 revealed as of 12/04/22 the home health aide (HHA) was to visit two times a week for eight weeks for personal care. Review of the medical record for Patient #6 revealed no HHA visits had been made the weeks of 12/04/22 and 12/11/22. There was no evidence the physician was notified of these missed visits. Review of the agency’s policy titled “Plan of Care – CMS #485 and Physician’s Orders,” revised 02/2022, revealed the patient’s orders for treatments and services are the foundation of the plan of care. If the Agency misses a visit or a treatment or services as required by the plan of care…then the Agency must notify the physician of such missed services. Interview on 01/05/23 at 10:30 AM Staff B confirmed no HHA visits were made the weeks of 12/04/22 and 12/11/22. Staff B confirmed the physician was not notified of these missed visits.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of personnel record, social work job description, staff interview and Ohio Revised Codes (ORC), the agency failed to ensure the social worker held a state licensure required by Ohio law. This had the potential to affected all patients served by the agency. The agency census 251. Interview on 01/05/23 at 11:18 AM with Staff A revealed the agency's social worker (Staff E) was not licensed as a social worker. Staff A stated she did not think the social worker had to be licensed. Staff A stated Staff E (Social Worker) had worked at the agency for a long time. Review of Staff E's personnel record revealed no social work license was present. Further review of Staff E's personnel record revealed she had been employed as a social worker at the agency since 07/09/18. Review of ORC Section 4757.02 revealed Ohio Law was, "No person shall practice or claim to the public to be practicing social work for a fee, salary, or other consideration unless the person is currently licensed under this chapter as an independent social worker or a social worker" and the same law revealed in Ohio, "no person shall use the title "social worker," "independent social worker," "social work assistant," or any other title or description incorporating the words "social worker" or any initials used to identify persons acting in those capacities unless the person is currently authorized by licensure or registration under this chapter to act in the capacity indicated by the title or initials." Review of the agency's job description for Medical Social Worker (MSW), revised March 2018, revealed no requirements for social work licensure. Interview on 01/05/23 at 11:59 AM Staff B confirmed the social worker was not licensed as such and the policy did not require a licensure.