Every finding on record at Humble Horizon Home Health LLC

A complaint survey was conducted by Healthcare Licensing and Surveys from 11/21/22 to 11/22/22. The survey was prompted by complaint intake #93977.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on review of the agency's staff list, review of staff assignments, medical record review, staff interview, review of personnel files, and review of Wyoming State Board of Nursing license verification data, the agency failed to ensure home health aide services were provided by individuals who met personnel requirements. Specifically, the agency failed to ensure home health aides assigned to 3 of 5 sample patients (#1, #2, #4) were qualified (G754), and failed to ensure home health aides were assigned to specific patients by an appropriate skilled professional for 3 of 5 sample patients (#1, #2, #4) who received HHA services (G798). These failures resulted in the inability of the agency to meet all necessary requirements of the Condition of Participation: Home Health aide services.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on review of the agency's staff list, review of staff assignments for the week of the survey, review of patient medical records, review of agency personnel files, review of the Wyoming State Board of Nursing licensure verification date, and staff interviews, the agency failed to provide individuals who met the personnel requirements of a certified nurse aide/home health aide for 3 of 5 sample patients (#1, #2, #4). The findings were: 1. Review of the agency staff list showed employees #2, #3 and #5 were described as home health aides (HHAs). 2. Review of the medical record for patient #1 showed the patient had a diagnosis of low back pain and was admitted to the agency on 7/25/22. Further review showed orders for personal care including assistance with a shower, grooming and massage. Review of the staff assignments for the week of 11/20/22 through 11/26/22 showed employee #3 was assigned to provide services to the patient 3 times a week for a total of 11 hours. The following concerns were identified: a. Review of the personnel file for employee #3 showed she was hired on 9/21/22. There were documents signed by the employee and the administrator that indicated the employee was hired as a HHA. Further review showed an agency policy titled "Housekeeping Policy", undated, defined the role of the housekeeper to include "Personal care- Providing assistance...for persons with the inability to perform with one or more of the following activities of daily living, eating, dressing, bathing, toileting, transferring..." The document was signed by the employee and the administrator upon hire. b. Review of the Wyoming State Board of Nursing licensure verification website showed employee #3 was neither a certified nurse aide (CNA) nor a home health aide (HHA). c. Interview with employee #3 on 11/21/22 at 4:52 PM confirmed she had previous experience as a caregiver but was not a CNA/HHA. The employee stated she provided showers and massage to the patient on a regular basis. 3. Review of the medical record for patient #2 showed the patient had a past stroke and was admitted to the agency on 11/11/22. Further review showed orders for personal care including stand-by assist with a shower. Review of the staff assignments for the week of 11/20/22 through 11/26/22 showed employee #2 was assigned to provide services to the patient 4 times a week for a total of 8 hours. The following concerns were identified: a. Review of the personnel file for employee #2 showed a hire date of 4/12/22. Further review showed a document signed by the employee and the administrator that described the job of a HHA. b. Review of the Wyoming State Board of Nursing licensure verification website showed employee #2 was neither a certified nurse aide (CNA) nor a home health aide (HHA). 4. Review of the medical record for patient #4 showed the patient had a diagnosis of dementia and was admitted to the agency on 12/29/21. Further review showed orders for personal care including assistance with peri-care. Review of the staff assignments for the week of 11/20/22 through 11/26/22 showed employee #5 was assigned to provide services to the patient 4 times a week for a total of 21 hours. The following concerns were identified: a. Review of the personnel file for employee #5 showed she was hired on 3/3/22. In addition there were documents signed by the employee and the administrator that indicated she was hired as a HHA. Further review showed an agency policy titled "Housekeeping Policy", undated, defined the role of the housekeeper to include "Personal care- Providing assistance...for persons with the inability to perform with one or more of the following activities of daily living, eating, dressing, bathing, toileting, transferring..." The document was signed by the employee and the administrator upon hire. b. Review of the Wyoming State Board of Nursing licensure verification website showed employee #5 was neither a certified nurse aide (CNA) nor a home health aide (HHA). 5. Interview with the chief executive officer and chief financial officer on 11/21/22 at 9:45 AM verified the agency hired 3 employees (#2, #3, #5) that were not CNA/HHAs to provide HHA services, including personal care, to patients with veterans' benefits for home care.

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 review of the staff assignments, and staff interviews, the agency failed to ensure home health aides (HHA) were assigned to specific patients by an appropriate skilled professional for 4 of 4 home health aides (employee #2, #3, #4, #5) assigned to patients the week of 11/20/22 through 11/26/22. The findings were: 1. Review of the staff assignments for the week of 11/20/22 through 11/26/22 showed 4 HHAs, employee #2, #3, #4 and #5 were assigned to provide patient care. 2. Interview with employee #1 on 11/21/22 at 8:44 AM revealed the previous administrator made all staff assignments. 3. Interview with the chief executive officer on 11/22/22 at 9:35 AM revealed the agency's previous administrator was dismissed from her position the former week, was non-clinical, and did not meet the criteria required to assign HHAs.

A complaint survey was conducted by Healthcare Licensing and Surveys from 7/26/2021 to 7/27/2021. The survey was prompted by complaint intakes WY000003253. In addition, a COVID-19 focused infection control survey was conducted. Based on the findings of the survey team, it was determined that no deficiencies were identified pertaining to the infection control survey.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on observation, review of personnel records, and staff interview, the agency failed to ensure home health aide (HHA) services were provided by individuals who met personnel requirements. Specifically, the agency failed to ensure HHAs completed required training specific to providing care in the home setting for 5 of 6 HHAs (#1, #2, #4, #5, #6) employed at the time of survey (G754). This failure resulted in the inability of the agency to meet all necessary requirements of the Condition of Participation: Home Health aide services.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on observation, review of personnel records and staff interview, the agency failed to ensure home health aids (HHAs) completed training and competency evaluation in the home setting for 5 of 6 HHAs ( #1, #2, #4, #5, #6). The findings were: 1. Observation of a home visit for patient #1 on 7/26/2021 at 11:15 AM showed HHA #1 provided personal care to the patient. The HHA provided personal care independently without direct supervision from the agency. 2. Observation of a home visit for patient # 2 on 7/27/2021 at 10:45 AM showed HHA #2 provided personal care to the patient. The HHA provided personal care to the patient without direct supervision from the agency. 3. Review of the agency schedule showed 6 HHAs (#1, #2, #3, #4, #5, #6) were scheduled to complete home visits the week of survey. 4. Review of personnel files revealed that 5 of 6 employed HHAs (#1, #2, #4, #5, #6), did not have documentation of completed training in the home setting prior to working independently. 5. Interview of Co-owner/CEO on 7/27/2021 at 9:15 AM verified that only HHA #3 had the required training and endorsement by the Wyoming Board of Nursing and the other 5 HHAs did not.

An unannounced on-site survey, authorized by the Centers for Medicare and Medicaid Services (CMS), was conducted by Healthcare Licensing and Surveys from 5/13/21 through 5/14/21. The survey was prompted by complaint intake WY000003225. In addition, a COVID-19 focused infection control survey, which included a review of emergency preparedness requirements, was conducted by Healthcare Licensing and Surveys from 5/13/21 through 5/14/21. Based on the findings of the survey team, it was determined that no deficiencies were identified pertaining to the infection control survey.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on medical record review, staff interview, patient list review, employee list review, and recruitment documentation review,the agency failed to ensure a qualified professional completed home health aide care plans (G798), and further failed to ensure a registered nurse completed home health aide supervision visits (G814) for 14 of 14 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14). This failure resulted in an unacceptable risk of harm for all patients who received home health aide services. The census was 54, with 50 patients who received home health aide services. The findings were: Refer to G798 regarding the agency's failure to ensure a qualified professional completed home health aide care plans, and G814 regarding the agency's failure to provide required supervision of home health aides.

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 medical record review, staff interview, patient list review, employee list review, and recruitment documentation review, the agency failed to ensure a registered nurse was available for supervision of home health aides, which included a qualified professional to complete home health aide care plans for 14 of 14 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14). The census was 54, with 50 patients who received home health aide services. The findings were: 1. Review of the physician orders for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 showed each received home health aide services. Review of the corresponding home health aide care plans showed the plans were completed by the agency administrator. Interview with the administrator on 5/13/21 at 3:35 PM confirmed she completed home health aide care plans. She further confirmed she did not have a nursing or therapy license, and was not qualified to complete those plans. Review of the patient list showed there were 54 active patients. Interview with the administrator on 5/14/21 at 10 AM confirmed the census was 54, and 50 of those patients received home health aide services. 2. Review of the employee list showed RN (registered nurse) #1 had a date of hire of 5/11/21. Medial record review showed the nurse first started to complete home health aide care plans on 5/14/21, having completed the plan for patient #6. The review showed RN #2 had a date of hire date of 5/3/21. However, review of all current patients in the electronic medical record system showed RN #2 had not completed home health aide care plans. Interview with RN #2 on 5/14/21 at 10:53 AM confirmed she had not completed any of the agency home health aide care plans. Further review of the employee list showed 2 RNs who were not actually employees of the agency, but were employees at an agency in a neighboring state, and who were available for skilled nursing visits only. Interview with RN #3 on 5/14/21 at 10: 45 AM confirmed this. The review showed there were no RNs were on the agency staff from 3/12/21 until 5/3/21. Interview with the chief financial officer (CFO) on 5/14/2021 at 11:10 AM also confirmed the two RNs from a home health agency in another state were not available to complete home health aide care plans. 3. Interview with RN #4 on 5/13/21 at 6:20 PM revealed her official last day at the agency was 3/12/21. However, she confirmed she came back for one day to complete a home visit for patient #2. She stated this was in late March of 2021 (she could not remember the date), and she had not worked for the agency for any additional work after 3/12/21. She stated the visit did not include a home health aide supervisory visit, and she had completed no home health aide visits after 3/12/21. 4. Review of the entire electronic medical record system during the survey, which included all 50 patients who received home health aide services, showed no home health aide care plans were completed or updated by a qualified professional from 3/12/21 until 5/14/21 (63 days). 5. Interview with the chief executive officer (CEO) on 5/13/21 at 4:30 PM resulted in the CEO stating, "A nurse is the only one that should make a care plan..." Interview with the CEO and CFO on 5/14/21 at 3 PM showed they had discovered home health aide care plans completed by an RN prior to 3/12/21. However, they confirmed there was no qualified professional, including an RN, available for home health aide care plan development or updates from 3/12/21 until 5/14/21. They were able to provide documentation to show the agency had actively attempted to recruit an RN since 4/19/21 on the electronic "Virtual Recruiter Assistant."

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, patient list review, employee list review, and recruitment documentation review, the agency failed to ensure a registered nurse completed home health aide supervision visits for 14 of 14 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14). The census was 54, with 50 patients who received home health aide services. The findings were: 1. Review of the physician orders for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 showed each received home health aide services. Medical record review showed none of the patients received supervised home health aide visits from 3/12/21 through the survey last date of 5/14/21. Review of the patient list showed there were 54 active patients. Interview with the administrator on 5/14/21 at 10 AM confirmed the census was 54, and 50 of those patients received home health aide services. 2. Review of the employee list showed RN (registered nurse) #1 had a date of hire of 5/11/21. The first active day at the agency was on 5/14/21 (during the survey), and she had made no home visits. The review showed RN #2 had a date of hire date of 5/3/21. However, the review of all current patients in the electronic medical record system showed RN #2 made her first nurse visit on 5/5/2021 to patient #11 and again on 5/12/2021 for skilled nursing services. No supervisory visit was made on either visit. Interview with RN #2 on 5/14/21 at 10:53 AM confirmed she had not completed any home health aide supervisory visits. Further review of th employee list showed 2 RNs who were not actually employees of the agency, but were employees at an agency in a neighboring state, and who were available for skilled nursing visits only. Interview with RN #3 on 5/14/21 at 10: 45 AM confirmed this. The review showed no RNs were on the agency staff from 3/12/21 until 5/3/21. Interview with the chief financial officer (CFO) on 5/14/2021 at 11:10 AM also confirmed the two RNs from another state agency were not available for home health aide supervisory visits. 3. Interview with RN #4 on 5/13/21 at 6:20 PM revealed her official last day at the agency was 3/12/21. However, she confirmed she came back for one day to complete a home visit for patient #2. She stated this was in late March of 2021 (she could not remember the date), and she had not worked for the agency for any additional work after 3/12/21. She stated the visit did not include a home health aide supervisory visit. 4. Interview with the CEO and CFO on 5/14/21 at 3 PM confirmed no RN was available for home health aide supervisory visits from 3/12/21 until 5/14/21. They were able to provide documentation to show the agency had actively attempted to recruit an RN since 4/19/21 on the electronic "Virtual Recruiter Assistant."

An unannounced onsite survey, authorized by the Centers for Medicare and Medicaid Services (CMS) was conducted by Healthcare Licensing and Surveys from 4/14/21 through 4/23/21. The Conditions for Participation reviewed were Care Planning, Coordination, Quality of Care and Patient Rights. The survey was prompted by complaint intakes WY00003211 and WY00003132. In addition, a COVID-19 focused infection control survey, which included a review of emergency preparedness requirements, was conducted by Healthcare Licensing and Surveys from 4/14/21 through 4/23/21.

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 medical record review, patient and staff interview, case manager interview, and policy and procedure review, the agency failed to ensure efforts were made to resolve behavioral issues prior to discharging a patient for 1 of 3 sample patients (#3). The findings were: Review of the medical record showed patient #3 was admitted to the agency on 8/3/20 with a self care deficit and respiratory insufficiency. Review of the care plan from admission to discharge showed the patient was receiving shower assistance and light housekeeping 3-5 times a week. Review of the agency's "Discharge or Transfer Policy" (undated) showed "Prior to discharging you for cause, our agency must:... Make efforts to resolve the problem(s) presented by your behavior...Document in your medical record the problem(s) and efforts made to resolve the problem(s)". The following concerns were identified: 1. Interview with the patient on 4/14/21 at 3:20 PM indicated the agency abruptly discontinued services on 2/8/21. The patient stated the agency "fired" him/her. The patient stated she did not feel unsafe or in danger after the services were discontinued. Interview with the patient's case manager on 4/16/21 at 12:42 PM verified the agency did not give the patient a 30-day notice, stating, "They just dropped her". 2. Review of the patient's medical record showed notes made on 2/8/21 that indicated the patient was "not feeling well today at all. [S/he] is being very difficult. [S/he] doesn't want to do anything for today ..." "... the patient was 'crying and yelling...this was all over time change'" "Patient has become increasingly disrespectful towards staff, and was asked to be more respectful". The agency was unable to produce additional documentation of patient behavior, nor was the agency able to produce evidence of efforts made to resolve the problems. 3. Interview with the agency administrator on 4/14/21 at 2 PM revealed the patient had "been a problem" and the agency had decided to discontinue services. 4. Review of the "Humble Horizon Home Health Discharge Form" (undated) sent to the patient's case manager and signed by the agency administrator showed the agency was giving a 30-day discharge notice and had visits scheduled with the patient on 2/15, 2/17, 2/24 and 3/3/21. The agency's last day of service with the patient was scheduled to be 3/8/21. However, further review of the medical record showed no evidence the scheduled visits were attempted or the scheduled visits refused by the patient after 2/8/21.