Every finding on record at Main Homehealth Services Inc

A Recertification and Follow-up survey entrance conference was conducted on 06/29/2021 with the Administrator and Alternate Administrator/Supervising Nurse at 11:30 a.m. Census: Licensed and Certified - 20 Licensed Home Health - 0 Personal Assistant Services - 62 An exit conference was conducted on 07/06/2021 with the Administrator and Alternate Administrator/Supervising Nurse at 3:30 p.m. The preliminary findings were discussed. VA-Veteran Affairs POC-Plan of Care SOC-Start of Care SN-Skilled Nursing

A Recertification and Follow-up survey entrance conference was conducted on 06/29/2021 with the Administrator and Alternate Administrator/Supervising Nurse at 11:30 a.m. Census: Licensed and Certified - 20 Licensed Home Health - 0 Personal Assistant Services - 62 An exit conference was conducted on 07/06/2021 with the Administrator and Alternate Administrator/Supervising Nurse at 3:30 p.m. The preliminary findings were discussed. The agency was provided the opportunity to provided further evidence, none was provided. The agency was provided with handout how to write an acceptable plan of correction. The agency was in compliance with 42 Code of Federal Regulations Part 484, Conditions of Participation requirements for Home and Community Support Services Agencies. VA-Veteran Affairs POC-Plan of Care SOC-Start of Care SN-Skilled Nursing

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide 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 to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on record reviews, observation and interviews, the agency failed to ensure the patient's right to be provided with written notice of the agency's transfer/discharge policy within 4 business days of the initial evaluation visit in 2 (Patients#6 and #7) of 2 patients who received home visits and whose home folder was available to review. The agency failure could place the agency patients at risk of harm due to inadequate continuity of care related to discharge or transfer. FINDINGS INCLUDE: Patient record #6: The clinical record contained a POC for the certification period 09/18/2018-11/16/2018, with a start of care date 09/18/2018. Review of the record revealed no evidence a written notice of the agency's transfer and discharge policy had been provided to Patient #2. During a home visit with Patient #6 on 07/06/2021 at approximately 11:00 a.m., the surveyor asked to review the agency home folder. Patient #6 retrieved and granted permission for the surveyor to review the documents included in the folder. The surveyor asked if anything had been removed or was missing from the folder. Patient #6 stated, "No." The surveyor found no evidence of a written notice of the agency's transfer and discharge policy had been provided to Patient #6. During an interview with the Alternate Administrator/Supervising Nurse, Employee B on 07/06/2021 at approximately 10:10 a.m. the surveyor asked why the agency transfer and discharge policies were not in the home folders. Employee B asked the surveyor, "Are they supposed to be in there." Employee B did not dispute the survey findings and did provide any additional evidence to explain or correct the findings.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient's individualized plan of care was reviewed by the patient's physician no less than once every 60 days, beginning with the start of care date for 5 (Patient #2, #3, #4, #5, #6, and #8) of 8 for which records were reviewed. This failure has the potential to cause harm to agency patients in that the physician may not be aware of changes in the patient's condition or the need for additional care and services. Findings Included: Review of the clinical record for Patient #2 revealed a start of care date of 09/13/2018. Review of the plan of care for the certification period 09/09/2020 - 11/07/2020 revealed no documentation that the physician reviewed or signed the plan of care. Review of the clinical record for Patient #3 revealed a start of care date of 02/08/2021. Review of the plan of care for the certification period 02/08/2021 - 04/08/2021 revealed no documentation that the physician reviewed or signed the plan of care. Review of the clinical record for Patient #4 revealed a start of care date of 11/05/2018. Review of the plan of care for the certification period 11/05/2018 - 01/03/2018 revealed no documentation that the physician reviewed or signed the plan of care. Review of the clinical record for Patient #5 revealed a start of care date of 07/31/2018. Review of the plan of care for the certification period 09/09/2020 - 11/07/2020 revealed no documentation that the physician reviewed or signed the plan of care. Review of the clinical record for Patient #6 revealed a start of care date of 09/18/2018. Review of the plan of care for the certification period 09/18/2018 - 11/16/2018 revealed no documentation that the physician reviewed or signed the plan of care. Review of the clinical record for Patient #8 revealed a start of care date of 05/27/2019. Review of the plan of care for the certification period 05/27/2019 - 06/25/2019 revealed no documentation that the physician reviewed or signed the plan of care. An Interview was conducted on 07/2/2021 with the Alternate Administrator/Supervising Nurse, Employee B at 2:09 p.m. The Surveyor discussed the above findings of the plan of care not signed by the physician with Employee B. Employee B stated, "Sometimes they sign them and sometimes they don't." Review of the agency's Policy and Procedure Manual revealed a policy entitled "PLAN OF CARE PC.8", which read in part ... "VI. The individualized plan of care must be reviewed and revised by the physician and/or non-physician practitioner who is responsible for the home health plan of care and the Agency as frequently as the patient's/client's condition or needs require, but no less frequently than once every sixty (60) days, beginning with the start of care date..."

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health staff in 2 (Patients #7 and #8) of 2 patients' home folders reviewed during home visits. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. Findings included: Patient #7: Record review contained a homemaker care plan for the period of 03/30/2021 through 08/26/2021 with a start of care of 12/17/2017. The frequency for the homemaker was written as four times a week for twenty-six weeks. During a home visit for Patient #7 on 07/06/2021 at 10:00 a.m., No evidence was found in the agency home folder provided to Patient #7 of written information outlining a visit schedule including frequency of visits to be made by the home health staff. The surveyor asked if anything had been removed from the folder. Patient #7 said no. The surveyor asked if Patient #7 had been provided with a written schedule of visits. Patient #7 said, "No." Patient #8: Record review contained a homemaker care plan for the period of 04/30/2021 through 10/27/2021 with a start of care of 05/27/2019. The frequency for homemaker was written as two times a week for twenty-six weeks. During a home visit for Patient #8 on 07/06/2021 at 11:45 a.m., No evidence was found in the agency home folder provided to Patient #8 of written information outlining a visit schedule including frequency of visits to be made by the home health staff. The surveyor asked if anything had been removed from the folder. Patient #8 said no. The surveyor asked if Patient #8 had been provided with a written schedule of visits. Patient #8 said, "No." An interview was conducted with the Alt. Administrator/Supervising Nurse, Employee B on 7/06/2021 at 2:00 p.m. Surveyor asked Employee B if the agency provides a written schedule of visits to the patients. The Alt. Administrator, Supervising Nurse, Employee B said, "No." The surveyor asked Employee B why. Employee B said, "It's not necessary, it will change." The surveyor reviewed federal COP's effective 1/13/18 that included the patient is to receive a written schedule of visits of when any agency personnel will be making visits to the patient home.