Every finding on record at Home Town Health Care, LLC

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site revisit survey, ZVRY-H2, conducted at the above-named Home Health Agency (HHA) 10/26/21 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site revisit survey, ZVRY-H2, conducted at the above-named Home Health Agency (HHA) 10/26/21 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C

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:

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:

Death of patient CFR(s): 484.50(d)(6) The patient dies; or This ELEMENT is not met as evidenced by:

HHA ceases to operate CFR(s): 484.50(d)(7) The HHA ceases to operate. This ELEMENT is not met as evidenced by:

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by:

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by:

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by:

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (ASPEN #ZVRY11) at the above-named Home Health Agency from 02/23/21 to 02/24/21 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (ASPEN #ZVRY11) at the above-named Home Health Agency from 02/23/21 to 02/24/21 resulted in noncompliance with one Condition of Participation (CoP), G406, 42 CFR 484.50, requirements for Patient Rights respective to applicable CoPs 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 and staff interview, the Home Health Agency (HHA) failed to ensure the patient or their representative were informed of all the patient's rights. Failure to inform patients or their representatives of all patient's rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: 1. The Home Health Agency (HHA) failed to ensure patients and their representative (if any) received a written notice of the Home Health Agency's transfer and discharge policies as set forth in paragraph (d) of this section, during the initial evaluation visit, in advance of furnishing care to patients. (Refer to G412) 2. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to have his or her person treated with respect. (Refer to G428) 3. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to be free from mental and sexual abuse, including injuries of unknown source, neglect and misappropriation of property. (Refer to G430) 4. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to make complaints to the HHA regarding the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA. (Refer to G432) 5. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to participate in, be informed about, and consent or refuse care during treatment, where appropriate, with respect to; Completion of all assessments; The care to be furnished, based on the comprehensive assessment; Establishing and revising the plan of care; Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits and Any factors that could impact treatment effectiveness. (Refer to G434) 6. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to receive all services outlined in the plan of care. (Refer to G436) 7. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to a confidential clinical record that included access to or release of patient information and clinical records permitted in accordance with 45 CFR parts 160 and 164. (Refer to G438) 8. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to be advised of 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. (Refer to G440) 9. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. (Refer to G442) 10. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to 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 that included: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization. (Refer to G446) 11. The Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to 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. (Refer to G450) 12. The Home Health Agency (HHA) failed to ensure the patient and representative (if any) were informed of the agency's policies for transfer and discharge. The home health agency failed to ensure the agency's written policy for discharge and transfer included the required circumstances under which the HHA may transfer or discharge the patient from the HHA. (Refer to G452) 13. The Home Health Agency (HHA) failed to ensure the agency only may transfer or discharge the patient from the agency if is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA failed to ensure safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities .(Refer to G454) 14. The Home Health Agency (HHA) failed to ensure agency only may transfer or discharge the patient from the agency if the patient or payer will no longer pay for the services provided by the HHA. (Refer to G456) 15. The Home Health Agency (HHA) failed to ensure agency only may transfer or discharge the patient from the agency if the transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services. (Refer to G458) 16. The Home Health Agency (HHA) failed to ensure agency only may transfer or discharge the patient from the agency if the patient refuses services, or elects to be transferred or discharged. (Refer to G460) 17. The Home Health Agency (HHA) failed to ensure agency only may transfer or discharge the patient from the agency if the HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. (Refer to G462) 18. The Home Health Agency (HHA) failed to ensure the agency advised the patient, representative (if any), the physician(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, prior to discharge of patients for cause. (Refer to G464) 19. The Home Health Agency (HHA) failed to ensure the agency made efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation, prior to discharging patients for cause. (Refer to G466) 468 20. The Home Health Agency (HHA) failed to ensure the HHA provided the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care, prior to discharging patients for cause. (Refer to G468) 21. The Home Health Agency (HHA) failed to ensure the agency documented the problem(s) and efforts made to resolve the problem(s),and entered this documentation into its clinical records prior to discharging patients for cause. (Refer to G470) 22. The Home Health Agency (HHA) failed to ensure the HHA may only transfer or discharge the patient from the HHA if the patient died. (Refer to G472) 23. The Home Health Agency (HHA) failed to ensure the HHA may only transfer or discharge the patient from the HHA if the agency ceased to operate.(Refer to G474)

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 document review, policy review and interview, the Home Health Agency (HHA) failed to ensure a written notice of the Home Health Agency's transfer and discharge policies as set forth in paragraph (d) of this section was provided to the patient and patient's legal representative (if any), during the initial evaluation visit, in advance of furnishing care to patients. The home health agency's failure to ensure patients received written transfer and discharge policies in advance of furnishing care has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of U.S. Code of Federal Regulations at 42 CFR 484.50(d) required: Standard: Transfer and discharge: The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: The transfer or discharge is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; The patient or payer will no longer pay for the services provided by the HHA; The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; The patient refuses services, or elects to be transferred or discharged; The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: (i) Advise the patient, representative (if any), the physician(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; (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; (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and (iv) Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records; The patient dies; or The HHA ceases to operate. Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d). Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to have his or her person treated with respect. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. by statute . Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed each patient shall have the right to have his/her property treated with respect. The Bill of Rights did not include the right to have his or her person treated with respect. During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities did not contain all required rights.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to be free from mental and sexual abuse, including injuries of unknown source, neglect and misappropriation of property. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed each patient shall have the right to be free from verbal, physical and psychological abuse. The Bill of Rights did not include 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 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to make complaints to the HHA regarding the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required by statute. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed the written notice of Rights did not include the right to make complaints to the HHA regarding the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA. During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to participate in, be informed about, and consent or refuse care during treatment, where appropriate, with respect to; Completion of all assessments; The care to be furnished, based on the comprehensive assessment; Establishing and revising the plan of care; Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits and Any factors that could impact treatment effectiveness. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed the written notice of Rights did not include the right to participate in, be informed about, and consent or refuse care during treatment, where appropriate, with respect to; Completion of all assessments; The care to be furnished, based on the comprehensive assessment; Establishing and revising the plan of care; Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits and Any factors that could impact treatment effectiveness. During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to receive all services outlined in the plan of care. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed the written notice of Rights did not include the right to receive all services outlined in the plan of care. During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to a confidential clinical record that included access to or release of patient information and clinical records permitted in accordance with 45 CFR parts 160 and 164. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed the written notice of Rights did not include the right to a confidential clinical record that included access to or release of patient information and clinical records permitted in accordance with 45 CFR parts 160 and 164. During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to be advised of 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 home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed the written notice of Rights did not include the right to be advised of 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). During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed the written notice of Rights did not include the right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to 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 that included: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed the written notice of Rights did not include the right to 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 that included: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization. During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to 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. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Bill of Rights Policy, dated 01/07," showed the Bill of Rights policy was to ensure that patients' human, civil, constitutional and statutory rights are respected and not violated. Review of the home health agency's patient admission packet showed the agency's written notice of Patient Rights provided to the patients was not inclusive of all patient rights as required. Review of agency document titled "Bill of Rights, Updated 9/23/2019" showed the written notice of Rights did not include the right to 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. During an interview on 02/24/20 at 8:30 AM, Staff A, Chief Administrative Officer, confirmed the agency written notice of patient's rights and responsibilities not contain all required rights.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the patient and representative (if any) were informed of the agency's policies for transfer and discharge. The home health agency failed to ensure the agency's written policy for discharge and transfer included the required circumstances under which the HHA may transfer or discharge the patient from the HHA. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d). Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the agency only may transfer or discharge the patient from the agency if is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA failed to ensure safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency only may transfer or discharge the patient from the agency if is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA failed to ensure safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure agency only may transfer or discharge the patient from the agency if the patient or payer will no longer pay for the services provided by the HHA. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency only may transfer or discharge the patient from the agency if the patient of payer will no longer pay for the services provided by the HHA. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure agency only may transfer or discharge the patient from the agency if the transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency only may transfer or discharge the patient from the agency if the transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure agency only may transfer or discharge the patient from the agency if the patient refuses services, or elects to be transferred or discharged. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency only may transfer or discharge the patient from the agency if the patient refuses services, or elects to be transferred or discharged. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure agency only may transfer or discharge the patient from the agency if the HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency only may transfer or discharge the patient from the agency if the HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(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 document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the agency advised the patient, representative (if any), the physician(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, prior to discharge of patients for cause. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency advised the patient, representative (if any), the physician(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, prior to discharge of patients for cause. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

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 document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the agency made efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation, prior to discharging patients for cause. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency made efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home G, or situation, prior to discharging patients for cause. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

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 document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the HHA provided the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care, prior to discharging patients for cause. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the HHA provided the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care, prior to discharging patients for cause. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

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 document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the agency documented the problem(s) and efforts made to resolve the problem(s), and entered this documentation into its clinical records prior to discharging patients for cause. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the agency documented the problem(s) and efforts made to resolve the problem(s), and entered this documentation into its clinical records prior to discharging patients for cause. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

Death of patient CFR(s): 484.50(d)(6) The patient dies; or This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the HHA may only transfer or discharge the patient from the HHA if the patient died. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the HHA may only transfer or discharge the patient from the HHA if the patient died. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

HHA ceases to operate CFR(s): 484.50(d)(7) The HHA ceases to operate. This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the HHA may only transfer or discharge the patient from the HHA if the agency ceased to operate. The home health agency's failure to ensure adopt a comprehensive transfer and discharge policy has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights during transfer and discharge from the agency. Findings Include: Review of a policy titled, "Discharge/Transfer," dated 01/01/07, showed the purpose was to provide current patient discharge/transfer information and comply with state, and federal requirements. The policy did not include required written information on transfer and discharge policies as set forth in 42 CFR 484.50(d) that required the HHA to ensure the HHA may only transfer or discharge the patient from the HHA if the HHA ceased to operate. Review of the home health agency's patient admission packet showed the agency did not include written information on transfer and discharge policies as set forth in 42 CFR 484.50(d), within the packet provided to patients on admission. During an interview on 02/24/20 at 8:45 AM, Staff A, Chief Administrative Officer, confirmed she was unsure if agency staff provided written notice of transfer and discharge policies to patient's on admission. The agency failed to develop transfer and discharge policies for disclosure to patients as required on admission.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure all patient care orders were recorded in the Plan of Care (POC) for one of six records reviewed (Patient 2). Failure to ensure all patient care orders were written in the POC has the potential to place all patients at risk for receiving improper, inconsistent or omitted patient care by agency staff. Findings Include: Review of a policy titled, "Plan of Care (485), Updated: 08/03/15," showed the skilled nurse will complete the 485 within 48 hours of admission, recertification, and significant change. Review of a policy titled, "Confirmation of Physician Orders, January 1, 2007," showed all orders for patient care, treatment and/or services were reviewed/evaluated for appropriateness and accuracy prior to providing care, treatment and/or services. Care, treatment and /or services were provided according to the most recent order/prescription. All orders were renewed or updated to reflect changes in the care, treatment and/or services being provided; the patient's outcome related to care, treatment and /or services; and changes in diagnosis, treatment(including procedures and medications) and equipment. Review of a policy titled, "Wound Care Policy, Updated 04/2019," showed the clinician, in conjunction with the patient and the caregiver, will develop an appropriate plan of care based on the patient's needs and the assessment findings. Each patient will be evaluated and treated using an individualized care plan based on the patient's unique medical condition. Review of Patient 2's medical record showed the patient resided at his home with his son. Patient 2's "Home Health Certification and Plan of Care," POC for the Certification Dates of 12/21/20 through 02/18/21, showed a principal diagnosis of Disruption of external operation (surgical) wound (disrupted surgical wound) and a comorbidity (simultaneous presence of two chronic diseases or conditions) of Pilonidal sinus without abscess (a tunnel in the skin that may fill with fluid or pus). The POC showed, Supplies: Normal Saline (NS), Aquacel (dressing for wound); 4X4 Dressing with risk for emergency department visits/hospital readmissions that included Incision/wound that could exacerbate (worsen) become infected. The POC showed Skilled Nursing (SN) Interventions that included; SN Assess pt. going to wound care appt, treatment is being done there and Goals that included SN: wound will have no S/S infection and wound will decrease in size by ½ LWD (length, width and depth); Target date 02/18/21. The POC Goals and Outcomes comments showed Patient continues on HH (home health) services for wound care three times weekly to coccyx where he had a pilonidal cyst removed a year ago, currently the sinus tract remains infected and has recently been treated with antibiotics ...patient goes to wound care clinic once every two weeks and as needed. RN performed wound care to coccyx per POC. HH to recertify for continuation of services for skilled nursing services to perform wound care three times weekly. Review of the POC showed no orders for agency skilled nurses to follow for treatment to the coccyx. Review of physician orders showed Patient 2's medical record did not contain wound care orders for treatment of Patient 2's wound by agency skilled nurses, integrated into the POC. Review of a faxed document from Patient 2's wound care clinic, titled physician orders, with date seen in clinic: January 4, 2021, showed problem location: wound: lower back, the wound measures 0.4 CM times 0.6 CM times 0.1 CM. Removal dressing, cleanse with NS, cleanse the Peri wound area with wound cleanser. Leave a G rope in tunnel in place for seven days. Apply Prisma (a sterile dressing containing collagen and silver to promote wound healing and fight wound infection) to upper wound as the primary dressing. Cover with 2 x 2 and mepilex foam borders the secondary dressing. This order to be carried out every other day for one week. There was no documentation to show the wound care clinic orders for Patient 2's coccyx wound was recorded in the POC for skilled nurses to follow for dressing changes. Review of a faxed document from patient 2's wound care clinic titled physician orders, with date seen in clinic: January 11, 2021, showed problem location wound: lower back: The wound measures 1 cm x 0.3 cm x 0.2 cm, sinus tracks: 5.0 cm at 6 o'clock. Removal dressing. Cleanse with NS . Cleanse the Perry wound area with wound cleanser. NS. Use Prisma to upper wound. AG roping as the primary dressing. Use 2 x 2's and mepilex foam boarder as a secondary dressing. This order to be carried out every other day for one week. There was no documentation to show the wound care clinic orders for Patient 2's coccyx wound was recorded in the POC for agency skilled nurses to follow for dressing changes. Review of Skilled Nursing Visit Notes for the dates of 12/31/20, 01/06/21, 01/08/21, 01/12/21, 01/15/21, 01/18/21, 01/21/21, 01/22/21, 01/27/21, 01/29/21, 02/01/21, 02/03/21, 02/05/21, 02/08/21, 02/15/21 and 02/19/21, completed by Staff B, RN showed, "RN performed wound care according to POC. RN to continue with POC." The POC for Patient 2 did not contain patient care orders for wound care. During an interview on 02/23/20 at 4:05 PM, Staff A, Chief Administrative Officer, confirmed wound care clinic documents were scanned into clinical documents in the medical record, but were not entered into the computer by nurses as orders for the Plan of Care. Staff A confirmed clinical staff knew to review clinical documents prior to provision of care.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure skilled nurses provided would care management according to the HHA's policies and procedures for one of two patients receiving skilled nursing services (Patient 2). The agency's failure to ensure skilled nurses follow wound care policies places all patients potentially at risk for receiving improper or inconsistent wound care management. Findings Include: Review of a policy titled "Wound Care Policy, Updated; 04/2019," showed the admitting clinician will document each wound to include any or all of the following: measurement of length, width and depth. At least every week, the wound assessment and documentation will include any or all of the following: measurement of length, width, depth. Review of Patient 2's medical record showed the patient resided at his home with his son. Patient 2's "Home Health Certification and Plan of Care (POC)," POC for the Certification Dates of 12/21/20 through 02/18/21, showed a principal diagnosis of Disruption of external operation (surgical) wound (disrupted surgical wound) and a comorbidity (simultaneous presence of two chronic diseases or conditions) of Pilonidal sinus without abscess (a tunnel in the skin that may fill with fluid or pus). The POC showed Skilled Nursing (SN) Interventions that included; SN Assess pt. going to wound care appt, treatment is being done there and Goals that included SN: wound will have no S/S infection and wound will decrease in size by ½ LWD (length, width and depth); Target date 2/18/21. The POC Goals and Outcomes comments showed Patient continues on HH (home health) services for wound care three times weekly to coccyx where he had a pilonidal cyst removed a year ago, currently the sinus tract remains infected and has recently been treated with antibiotics ...patient goes to wound care clinic once every two weeks and as needed. RN performed wound care to coccyx per POC. HH to recertify for continuation of services for skilled nursing services to perform wound care three times weekly. Review of Skilled Nursing Visit Notes for the dates of 12/31/20, 01/06/21, 01/08/21, 01/12/21, 01/15/21, 01/18/21, 01/21/21, 01/22/21, 01/27/21, 01/29/21, 02/1/21, 02/03/21, 02/05/21, 02/08/21, 02/15/21 and 02/19/21, completed by Staff B, RN, showed "Wound care was performed according to the POC." There was no documentation to support Staff B, RN, completed wound assessment that included measurement of the length, width and depth of Patient 2's wound, at least every week. There was no documentation of assessed length, width and depth of the wound, during skilled nursing visit assessments, between the dates of 12/31/20 and 02/19/21 to show the agency met the POC goal to decrease the wound in size by ½ LWD (length, width and depth) by the target date 02/18/21. During an interview on 02/24/20 at 8:50 AM, Staff A, Chief Administrative Officer, confirmed wound care measurements were to be documented every week according to policy.

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on document review and interview, the Home Health Agency (HHA) failed to ensure Laboratory testing followed all applicable requirements of part 493 of this Chapter. This deficient practice has the potential to affect all home health agency patients who may receive laboratory services from the HHA. Findings Include: Review of State Operations Manual (SOM) Appendix C-Survey Procedures and Interpretive Guidelines for Laboratories and Laboratory Services, (Rev. 166, 02-03-17)," showed many Home Health Agencies (HHAs) may be certified with multiple sites under one certificate as long as the sites are under one HHA Medicare provider number, i.e., parent location. Medicare designates these multiple locations using the term parent location for the main location and the additional sites as branches. Hospice is may also be certified with one certificate for multiple sites. Refer to the SOM Chapter 6, §6008 for additional information on HHA's and hospices. Review of agency document titled, "Centers for Medicare and Medicaid Services Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver, Effective 02/21/20; Expiration 02/20/22 ," showed the laboratory name and address listed was different from the name and physical address of the Home Health Agency being surveyed. During an interview on 02/23/21 at 4:49 PM, Staff A, Chief Administrative Officer confirmed the provider number for the identified Home Health Agency at the location and confirmed that no branch locations were designated under the HHA. Staff A confirmed the HHA was not a branch location of a separately licensed and Medicare certified home health agency. Staff A confirmed the home health agency was not a branch office of the location listed on the CLIA certificate. Staff A confirmed the Entity name listed on the CLIA certificate was intended for all HHA locations & provider numbers served. The home health agency failed to ensure the CLIA certificate was issued in the name and physical location of the Medicare certified HHA providing services to patients.