Every finding on record at Premier Golden Heart Health Care Services, LLC

An entrance conference was conducted with the Administrator on 03/16/21 at approximately 9:45 am. The Administrator was informed that the purpose of the survey was to conduct an recertification survey. What To Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey" was provided. Agency census: Licensed and Certified: 28 An exit conference was conducted with the Administrator and Alternate Supervising Nurse on 03/22/21 at approximately 2:30 pm . The preliminary findings of the survey were discussed and a written copy provided. The agency was provided with a list of records duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violations. The agency was informed that violations would be cited. Centers for Medicare And Medicaid (CMS) Notice of Medicare Non-Coverage (NOMNC) Quality Improvement Organization (QIO) Plan of Care (POC) (485) Start of Care (SOC) Skilled Nursing Services (SN)

An entrance conference was conducted with the Administrator on 03/16/21 at approximately 9:45 am. The Administrator was informed that the purpose of the survey was to conduct an recertification survey. What To Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey" was provided. Agency census: Licensed and Certified: 28 An exit conference was conducted with the Administrator and Alternate Supervising Nurse on 03/22/21 at approximately 2:30 pm . The preliminary findings of the survey were discussed and a written copy provided. The agency was provided with a list of records duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violations. The agency was informed that violations would be cited. Centers for Medicare And Medicaid (CMS) Notice of Medicare Non-Coverage (NOMNC) Quality Improvement Organization (QIO) Plan of Care (POC) (485) Start of Care (SOC) Skilled Nursing Services (SN)

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review of agency documents and interviews, the agency failed to provide the correct name of the current QIO, in accordance with the Centers for Medicare and Medicaid in 3 (Patients 10, 11, and 12) of 3 discharged patients whose records were reviewed, in that: the agency failed to include the name, address, or telephone number of the QIO on the NOMNC form. The failure could place the agency patients at risk of harm if the NOMNC form is not provided with accurate information for the current QIO, in the event such information was needed by the Patients at discharge. Findings included: Patient #10: Review of the discharged clinical record was completed on 02/02/21 . Patient #10 was discharged on 05/20/21. The NOMNC discharge document, contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO} to appeal." As a result, the patient had no access to the current QIO because the agency failed to list the current QIO information: (IE) (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #11: Review of the discharged clinical record was completed on 02/02/21. Patient #11 was discharged on 10/30/20. The NOMNC (discharge document), contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO to appeal." As a result, the patient had no access to the current QIO because the agency failed to list the current QIO information: (IE) (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #12: Review of the discharged clinical record was completed on 02/02/21. Patient #12 was discharged on 06/05/21. The NOMNC discharge document, contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO} to appeal." As a result, the patient had no access to the current QIO because the agency failed to list the current QIO information: (IE) (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. During an interview with Employee A, Administrator 03/22/21 at approximately 12:10 pm, the surveyor discussed the above findings and asked the Administrator if she knew why the information on the agency NOMNC discharge form failed to list the QIO. The Administrator said, "I thought it did." The surveyor explained that the patients would be unable to appeal the discharge if not provided with the QIO information. Agency policy Regulation: July 1, 2005, the new Medicare regulations (Benefits Improvement and Protection Act) BNI gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary's Medicare coverage of services is ending. The phone number for the Quality Improvement Organization (QIO) should be included in this notice (844-430-9504). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end.

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 3 (Patients #1, #8 and #9) of 3 patient home folders reviewed during a home visit, the agency failed to provide a written visit schedule to the patients. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availably of the patients. Findings Include: Patient #1: Patient #1's clinical record contained a Plan of Care dated 1/13/21 to 3/13/21. The Plan of Care indicated that Patient #1 started on the agency's services on 7/23/21 .0 The Plan of Care contained an order for Patient #1 to receive skilled nursing visits once a week for 8 weeks. The surveyor conducted a home visit to Patient #1 on 3/18/21 at 10:30 a.m. The surveyor asked Patient #1 how Patient #1 if anyone with the agency provided a written schedule of when visits would be made. Patient #1 responded, "No, Brent always come on Tuesdays at 2 pm. When Lindsey was coming she would text me on Sunday the day she planned to come." The surveyor reviewed Patient #1's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #1 said, "No." Patient #8: Patient #8's clinical record contained a Plan of Care dated 1/21/21 to 3/21/21. The Plan of Care indicated that Patient #8 started on the agency's services on 1/27/20. The Plan of Care contained an order for Patient #8 to receive skilled nursing visits once a week for 8 weeks. The surveyor conducted a home visit to Patient #8 on 3/17/21 at 9:00 a.m. The surveyor asked Patient #8 how Patient #8 knew when the nurse was going to make visits. Patient #8 responded, "I don't, they usually call." The surveyor asked Patient #8 whether Patient #8 received a written schedule of when the visits would be made. Patient #8 stated, "No." The surveyor reviewed Patient #8's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #8 said, "No." Patient #9: Patient #9's clinical record contained a Plan of Care dated 1/16/21 to 3/16/21. The Plan of Care indicated that the Patient #9 was admitted to the agency's services on 9/24/19. The Plan of Care contained orders for Patient #9 to received skilled nursing visits once a week for 9 weeks., home The surveyor conducted a home visit to Patient #9 on 3/17/21 at 11:10 a.m. The surveyor asked Patient #8 did Patient #8 get anything in writing of when the nurse would be coming for visits. Patient #8 stated, "No, he always comes on Tuesdays around 3-ish and he calls me to be sure it is ok." The surveyor reviewed Patient #9's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #9 said, "No." During an interview via phone on 3/18/21 at approximately 11:45 am with Employee A, the Administrator/Supervising Nurse Surveyor reviewed the home visit findings related to providing a written schedule to the patients. Surveyor asked why a written schedule was not provided to Patients #1, #8 or #9. The Administrator said, "they [nurses and attendants] call them [the patients] before every visit and they [the patients] know when they are coming." Surveyor explained that per regulations the patients are to be provided with a written schedule. Surveyor asked if the patients were provided with any kind of written schedule. The Administrator said, "No, but they know when the nurse is coming."