Every finding on record at Horizon Health Services, LLC

Substantial Allegation Survey Substantial Allegation 31937 An entrance conference was conducted on 10/12/21 at 10:00 AM with the Director of Nursing. An exit conference was conducted on 10/14/21 at 3:45 PM with administrative staff. The following deficiencies are based upon substantial allegation 31937 completed on 10/14/21. Horizon Health Services 368088, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 record review and staff interview, the agency failed to ensure the patient had the right to be informed of the frequency of home health aide (HHA) visits and any changed in the care to be furnished for one of three patients reviewed (Patient #2). The census was 503. Findings include: Review of admission packet and the Patient Bill of Rights revealed the patient is to be informed about the care to be furnished and the frequency of visits. The patient is to receive proper written notice of the organization reducing or terminating ongoing care. Review of Patient #2's medical record revealed on 07/19/21 the registered nurse visited the patient to assess the needs, prior to admission, and determined the patient needed the home health aide services seven days per week due to unstable ambulation, unsafe transfers, shortness of breath, hard of hearing, has glaucoma and cataracts (poor vision), major depressive disorder and anxiety disorder. An Admission Service Agreement revealed a representative of the agency had explained the patient care plan, frequency of home health aide (HHA) visits as seven days per week for 30 hours per week. The patient understood the treatment plan may change and if so, these changes would be discussed with the patient. Review of the physician ordered plan of care for the certification period dated 07/19/21 through 09/16/21 revealed orders for home health aide services, five times per week for nine weeks, 30 hours per week. Review of visit sheets revealed the home health aide worked 30 hours per week, Monday through Friday only, for the weeks of 07/19/21, 08/02/21, 08/09/21, 08/16/21, 08/23/21, 08/30/21, 09/06/21 and 09/13/21. The week of 07/26/21 the patient was admitted to the hospital on 07/27/21 and 07/28/21. Review of patient's medical record revealed no documentation the patient was made aware of changes in frequency of the home health aide visits from seven days per week to five days per week. Interview with Staff A on 10/14/21 at 10:58 AM revealed the patient required home health aide services seven days per week, but the agency did not have a home health aide to work the weekends. Staff C confirmed in an interview on 10/14/21 at 3:58 PM there was no documentation in the patient's record that the patient was made aware of the changes in frequency of home health aide visits. Additionally, Staff C stated the agency could not provide home health aide services seven days per week due to lack of staff.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review, policy review, and staff interview, the agency failed to make a patient's medical record available to a patient upon request for one of three patients reviewed (Patient #2). Findings include: Review of the agency's undated policy titled, Privacy Act Statement - Clinical Record, revealed "access to consumer/client information is restricted to designed personnel. Other individuals will have limited access if and only when signed consumer/client consent authorizing release is represented to the agency." Per phone interview on 10/14/21 at 11:34 AM the scheduler for the agency had talked with the patient's son once last month who asked for the hours and days the aides worked for the patient and their names. The scheduler stated they never provided this information because of HIPAA (Health Insurance Portability and Accountability Act). The patient was alert and oriented and capable of signing her own papers. No where in the chart did it mention anything about a family member being a Power of Attorney (POA) for the patient. The scheduler stated if a patient did have a POA then the doctor would write an order regarding this. There was no such order in the patient's record. Phone interview on 10/14/21 at 11:45 AM with Staff J, the authorization manager, revealed she had spoke to the patient's son once who faxed a piece of paper stating it was the POA paperwork. It was unreadable where the patient and notary were to sign. Staff J consulted the patient's case manager with the area agency on aging regarding the son being the POA. The case manager was not aware of this. The home health agency and the case manager did not believe the document was real so the case manager told Staff J not to give out any information about the patient. The agency did not believe it to be real so the document was shredded. Staff J confirmed it was not in the patient's medical record. The patient's son was referred to the area agency on aging's helpline. Per interview on 10/14/21 at 2:50 PM, Staff D confirmed the agency did not feel this was a legitimate legal document. The agency checked the County Fiscal Auditor website and could not locate a Power of Attorney recorded on or after the date the document was purportedly signed. Review of the website https://fiscalofficer.cuyahogacounty.us/en-US/home.aspx revealed a webpage titled, Recorded Documents. From that webpage was a link to a webpage for Living Wills and Durable Power of Attorneys for Healthcare. The webpage revealed the following: "Now you can file your Living Will and Durable Power of Attorney for Health Care at the Cuyahoga County Recorded Documents Office, thanks to County Recorded Documents services After documents are registered as files with the Recorded Documents Office, they are easily searchable on-line at Fiscal Offer's Recorded Documents Services by doctors and hospitals. You pay only a small fee of $40.00 for a service that will give you peace of mind." "You might already have a Living Will and Durable power of Attorney for Health Care. Do your loved ones and the doctor know where to find them? By recording your Living Will and Durable Power of Attorney for Health Care, you guarantee the documents are available when needed if you are unable to tell your family where to look." Review of the eight page page document titled Durable Power of Attorney confirmed it was difficult to read, but stated the patient's son was the patient's Durable Power of Attorney, was signed by the patient and was notarized by an attorney in 2012. This substantiates Substantial Allegation 31937.

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION NUMBER OH00120430 The following deficiencies are based on the Substantial Allegation Survey completed on 03/10/2021. An entrance conference was conducted with the administrator on 03/02/2021at12:00 P.M. and a remote exit conference was conducted on 03/10/2021 at 3:00 P.M. with the Administrator.

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 agency documentation, medical record review, and review of agency policy, the agency failed to provide a list of potential home health agencies to one patient (Patient #1) who received a 30 day discharge notice from the agency. This deficient negatively affected one (Patient #1) of three patients reviewed. The agency census was 432. Findings include: Review of the medical record for Patient #1 revealed the patient had a start of care dare of 02/01/2012. The patient was admitted to the agency with diagnoses which included paraplegia and a functional intestinal disorder. The Medicare certification under review was 12/15/2020 through 02/12/2021. Review of the agency documentation revealed the agency had provided a 30 day Notice to Discharge to Patient #1 dated 12/29/2020. The agency documentation revealed the agency administrative staff had contacted Patient #1 to discuss the issuance of the 30 day notice as well. Review of the agency documentation and communication notes revealed the agency had failed to provide a list of other agencies or providers to the patient as required. Review of the agency's undated policy titled "Discharge, Transfer Planning-30 Day Notices" directed that it was the policy of the agency to provide guidelines and criteria for transferring clients to another organization or level of care within the organization and for terminating clients from home health service. The client will be given the opportunity to participate in their discharge and or transfer to another organization or level of care to the extent they are physically and mentally possible. The transfer or discharge from Horizon services will be completed in a prompt and orderly fashion. The client is informed of any alternatives as appropriate and participates in securing acceptable alternatives. This deficient practice was confirmed in interview with Administrative Staff A on 03/10/2021 at 11:45 A.M. This citation substantiates Complaint Number OH00120430. .

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 on medical record review, staff interview and review of agency job description, the agency failed to ensure home health aides followed the plan of care. This deficient practice negatively affected one (Patient #1) of three medical records reviewed for aide compliance with the plan of care. The agency census was 432. Findings include: Review of the medical record for Patient #1 revealed the patient had a start of care dare of 02/01/2012. The patient was admitted to the agency with diagnoses which included paraplegia and a functional intestinal disorder. The Medicare certification under review was 12/15/2020 through 02/12/2021. The plan of care directed the patient to have home health aide services five days per week for a total of 33 hours of aide services weekly for personal assistance with activities of daily living (ADL) and instrumental ADL's and homemaking activities. Review of the home health aide's plan of care, prepared by the registered nurse (RN) on 12/10/2020, directed the home health aides to perform the following tasks at each patient visit: chair bath, hair care/comb, oral care, skin care, pericare, medication reminders, assist with dressing, assist with bedside commode, incontinence care, record bowel movements daily, and assist with transfers. The RN included special instructions for the home health aide to wrap both the patient's feet in gauze (skin protectant/padded barrier) daily, or as needed, to prevent skin breakdown and/or injury and to stand patient in the stander (therapy standing device) 30 minutes daily. The plan of care further directed the home aide to perform the following tasks weekly: shampoo hair and nail care. The plan of care indicated these tasks were discussed with the home health aide. Review of the home health Weekly Activity Sheets visit notes for the weeks of 12/27/2020, 01/03/2021 and 1/10/2021 failed to document the every visit medication reminder, recording of bowel movements, placing patient in stander, feet padded or protected, oral care, hair combing, and pericare or assistance with the bedside commode were provided as per the plan of care. Additionally the documentation indicated the home health aide had failed to provide weekly hair shampoo and nail care as directed by the plan of care. Review of the agency's undated home health aide job description directed the home health aide will perform all duties within the boundaries of the personal care policies and procedures and the home health aide will perform duties as designated in the care plan. This deficient practice was confirmed in interview with Staff A on 03/010/021 at 11:45 AM. This citation substantiates Complaint Number OH00120430.