Every finding on record at Metrostar Healthcare Services LLC

An Emergency Preparedness survey was initiated on 11/12/2024 at 12:30 PM. Census: Licensed and Certified- 1 Licensed Home Health- 0 Personal Assistance Services- 37 No deficiencies were cited.

A Recertification survey was initiated on 11/12/2024 at 12:30 PM. Census: Licensed and Certified- 1 Licensed Home Health- 0 Personal Assistance Services- 37 Acronyms: POC- Plan of Care SOC- Start of Care DON- Director of Nurses

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 observation, record review and interviews, the agency failed to provide written notice of the agency's transfer and discharge policy for 1 (Patient #1) of 1 patient who received a home visit from the surveyor. This failure did not conform to the patients’ right to be provided information regarding the criteria used to determine if the patient could be discharged or transferred from agency services. The failure potentially placed the patients at risk of inadequate plans of continued healthcare and services after discharge from the agency. FINDINGS INCLUDE: Patient #1: Record review revealed a POC dated 09/03/2024 - 11/01/2024 with a SOC date 09/03/2024. During a home visit and interview on 11/01/2024 at 10:00 AM, the surveyor reviewed the patients’ home folder (white binder) provided by the agency. The surveyor asked the patient if anything was missing from the binder or had been removed. Patient #1 stated she did not know and said her family member, Identifier C took care of it. The surveyor asked Identifier C if anything was missing from the binder or had been removed. Identifier C stated, “I don’t think so, but let me check.” Identifier C brought a purple, paper folder for the surveyor to review along with the white binder from the agency. The purple folder contained various medical documents and discharge instructions from a facility, but no agency discharge policy. The surveyor asked if there were any other documents provided to the patient from the agency. Identifier C stated there were no other papers or documents. Identifier C asked what the surveyor was looking for. The surveyor showed Identifier C the policy section of the home folder from the agency and stated she was looking for notice of the agency’s transfer/discharge policy. Identifier C and the surveyor reviewed the white binder again and no transfer or discharge policy was found. Review of the patient’s home folder and additional documents provided by Identifier C showed no evidence a written notice of the agency's transfer and discharge policy had been provided by the agency. During an interview with the Administrator/DON on 11/14/2024 at 2:45 PM, the surveyor reviewed the findings and asked why the agency did not provide written notice of the agency’s transfer and discharge policy. The Administrator/DON reviewed the agency’s sample home folder with the surveyor and stated, “the policy is in here.” The surveyor stated the policy was not found in the patient’s home folder or additional documents provided for review by Identifier C. The Administrator/DON stated, “I’m aware they (policies) are supposed to be in there, I just gave the patient a new home folder when we readmitted her. I thought it was there.”