Every finding on record at Kc Home Health, LLC

A complaint investigation (97202) was completed on 05/09/2023 at the home health provider. The provider had three current patients. The complaint is substantiated. One or more of the allegations reported were verified and deficiencies were cited that were related to the allegations being investigated. One condition-level deficiency was identified at an immediate jeopardy (IJ) level as follows: - §484.105 Condition of Participation: Organization and Administration of Services. An immediate jeopardy level for potential for future harm to patients was identified during the survey. The findings were confirmed as immediate jeopardy by the Centers for Medicare and Medicaid Services (CMS). On 05/01/2023 at 04:30 PM , a copy of the IJ Template was placed through the mail slot at the agency physical address, as the administrator and clinical manager did not reach out to the state agency in response to requests for communication. On 05/02/2023 at 10/47 AM, the administrator contacted the state agency acknowledging receipt of the IJ Template. A formal written removal plan was submitted by the home health provider prior to the survey exit. This removal plan was reviewed by CMS and it was determined at the time of the survey exit on 05/09/2023, that a satisfactory removal plan had been initiated related to the immediate jeopardy findings. The condition level deficiencies identified above remain as cited.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation and interview the home health provider failed to ensure: That a clinical manager was available during all operating hours (G0950); and That the administrator or a pre-designated person was available during all operating hours (G0956). This cumulative effect of these deficient practices has the potential to affect all of the agency's patients.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure that a clinical manager was available during all operating hours. Findings included: Direct observation on 05/01/2023 began at 08:50 AM: - This surveyor (I) arrived at the agency's physical location. Business identification on the door showed that the agency’s office hours were 09:00 AM to 05:00 PM; - At 08:55 AM, I called the agency number, there was an answering machine message identifying the agency, and I left a message requesting a call back with information regarding the services that the agency offers; - At 09:25 AM, I called the agency number again, and left a message announcing an on-site complaint survey and requesting that a staff member meet me at the office or call the state agency number (phone number provided in the message); - At 09:33 AM, I called the other number displayed on the agency’s door, (I could hear the phone ringing from the lobby in front of the office). I left a message stating I was trying to reach the administrator regarding a complaint survey; - At 10:45 AM, this surveyor put a document through the agency's mail slot containing the Department of Health and Senior Services (DHSS) header requesting that someone from the agency contact our Bureau (this surveyor could see the document through the agency’s locked door; and - The surveyor or state agency office received no communication from the agency regarding telephone messages or written messages left at the agency’s physical location. During an interview on 05/02/2023 at 10:47, the administrator stated that: - A staff member did report to the agency’s physical address later in the day on 05/01/2023; and - Their patients, since they only have three, generally call the nurse’s cell phone when they need assistance. This surveyor called the agency number on 05/02/2023 at 09:30 PM, the Clinical Manager (CM) answered the phone. The CM stated that he/she: - Had given the patients his/her cell phone number in the past; - Seldom answered the office phone number; - Had been notified by the administrator that he/she was to answer the office phone; and - That he/she must be available during business hours.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure that the administrator or a pre-designated person was available during all operating hours. Findings included: Direct observation on 05/01/2023 began at 08:50 AM: - This surveyor (I) arrived at the agency's physical location. Business identification on the door showed that the agency’s office hours were 09:00 AM to 05:00 PM; - At 08:55 AM, I called the agency number, there was an answering machine message identifying the agency, and I left a message requesting a call back with information regarding the services that the agency offers; - At 09:25 AM, I called the agency number again, and left a message announcing an on-site complaint survey and requesting that a staff member meet me at the office or call the state agency number (phone number provided in the message); - At 09:33 AM, I called the other number displayed on the agency’s door, (I could hear the phone ringing from the lobby in front of the office). I left a message stating I was trying to reach the administrator regarding a complaint survey; - At 10:45 AM, this surveyor put a document through the agency's mail slot containing the Department of Health and Senior Services (DHSS) header requesting that someone from the agency contact our Bureau (this surveyor could see the document through the agency’s locked door; - The surveyor or state agency office received no communication from the agency regarding telephone messages or written messages left at the agency’s physical location; and - At 04:30 PM, the Immediate Jeopardy Template was placed through the mail slot at the agency’s physical location, and the document left by the surveyor earlier in the day was no longer visible on the floor of the agency. During an interview on 05/02/2023 at 10:47, the administrator stated that: - A staff member did report to the agency’s physical address later in the day on 05/01/2023; - He/she had not been aware the state agency had been attempting to contact the administrator/clinical manager: * He/she had found the Immediate Jeopardy Template on his/her desk this morning; and * Had no knowledge of the written document left at the agency the morning of 05/01/2023; and - Their patients, since they only have three, generally call the nurse’s cell phone when they need assistance.