Every finding on record at Peninsula Home Care, LLC

A recertification survey of Peninsula Home Health agency was conducted September 18-19, 2023. After the review of the agency's emergency preparedness program and plan, the agency was found to be in compliance with all Conditions of Participation and related standards found at 42 CFR (Code of Federal Regulations) Part 484.102.

A standard home health agency re-certification survey was conducted at Peninsula Home Health agency on September 18-19, 2023. The survey included the following: a review of clinical records; a review of the complaint/incident reports; a review of on-call documentation; a review of admission documentation including patient bill of rights; a review of personnel files including professional licenses and expiration dates; a review of Quality Assurance Project Plan and Reports (QAPI) & Potentially Avoidable Event Report; a review of the organizational chart; a review of the CLIA waiver, and interviews with the agency's administrative. The agency's emergency preparedness program and plan were reviewed. Two home visit observations were conducted during the survey. One initial start of care and one skilled nursing A total of fifteen randomly selected patient records were reviewed during the survey. The scope of services included the following: Skilled Nursing Services - Ten Physical Therapy Services - Ten Occupational Therapy Services - Six Medical Social Worker - One Home Health Aide Services - One Speech-Language Services - One Findings in this report were based on data present in the clinical record at the time of the reviews. The agency's administrative and clinical staff were kept informed of the survey findings as the survey progressed. The agency's staff were given the opportunity to present information relative to the findings during the course of the survey. The exit conference was conducted with agency personnel on September 19, 2023. The findings of the Medicare re-certification survey were reviewed; a copy of the patient identification key-code and a signed plan of correction verification form were provided to the agency's administrator.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on the review of the information provided to patients in the agency's admission packet, including the agency's patient rights statement and observations during home visits, the agency failed to provide patients with clear, complete information regarding access to the Office of Health Care Quality Home Health department physical address and hotline phone number. The findings include: The agency's admission folder contained a Patient Information Handbook, which was provided to the patients. The information identified as the state hotline phone number in the handbook was incorrect. On interview, 9/19/2023, the agency's administrator was unaware of the incorrect information and was provided with the correct contact information for the Office of Health Care Quality Home Health department, which included the address and hotline phone number.