Every finding on record at Prime Home Care, LLC

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION 104475 The following deficiency is based on substantial allegation 104475 completed on 03/20/24. Prime Home Care 368335 is in substantial compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interview, record review, and policy review, the facility failed to document both the existence of the complaint and the resolution of a complaint for one of three patients reviewed (Patient #510). This had the potential to affect all patients receiving services from the agency. The census was 509. Review of Patient #510's medical record revealed a 08/01/23 admission with diagnoses including post operative circular system surgery peripheral vascular angioplasty with implants and graphs, chronic venous hypertension, chronic ulcer of left heel and mid foot with necrotic muscle, hemiplegia, type 2 diabetes, cardiomyopathy, and hyperlipidemia. The plan of care for the 08/01/23 to 09/29/23 certification included 13 home health aide hours weekly, a skilled nurse visit weekly, occupational therapy two times a week for one week, three times a week for three weeks, one time a week for one week, physical therapy three times a week for four weeks, and one time a week for one week. An 09/11/23 email sent to Staff B and former Staff S, not part of the medical record, was provided. The email written by Occupational Therapy Assistant Staff R included Patient #510's husband called and told him he "wanted a different nurse because he didn't feel like his wife was a priority." Husband reported that nursing has been "four to five hours late" and has canceled before. He also said he would like a different nurse due to not feeling like her wounds were addressed properly. Review revealed no communication notes related to a complaint. The medical record did not provide any information related to the complaint. Review of the facility's undated COMPLAINT/GRIEVANCE PROCEDURE included the facility takes all concerns very serious. The facility will address all concerns in the proper manner by following Compliant/Grievance Procedure. The facility will have a written grievance for resolving patient complaints. The purpose was to address patient concerns and grievances in the proper manner. Improving patient care and maintaining an atmosphere in which the patient/family members feel free to express their concerns/complaints is our highest priority. The procedure included the facility recognizes that patient's and/or family members may have concerns and/or complaints regarding care. The facility will inform patients of their right to file a grievance, and shall give patients the name and phone number of the provider's contact person responsible for addressing grievances. A grievance concerning an employee may be verbal and/or in writing and must contain the name and address of the person filing the grievance and a description of the action that is being grieved. Verbal grievances should be made by calling the office or written grievances should be mailed to the office using the Patient Concern Form, which is in the patient folder. Interview 03/18/24 at 1:22 P.M. with the Clinical Manager Staff B revealed there was one nurse terminated for cause 01/12/24. Staff B indicated there were complaints of the nurse not showing up to homes although there was documentation of nurse visits. Staff B was unable to remember which patients complained. The complaints were not logged. Staff B did recalled one email of a complaint that came indirectly to her from a therapist related to former Patient #510. Staff B had no written resolution to the complaint and said Former Staff S was to report findings to human resource. Interview 03/20/24 at 12:40 P.M. with Staff M revealed Staff L was placed on leave 12/16/23 after additional concerns were brought to higher management. During the investigation they had no written evidence of an investigation being conducted related the 09/11/23 complaint. Staff M confirmed each branch did not maintain a log of concerns. The policy was not followed.

Extended Substantial Allegation Survey Substantial Allegation 31952 An entrance conference was conducted with administrative staff on 10/12/21, and an exit conference was conducted with administrative staff on 10/14/21. No deficiencies were cited related to allegation(s) contained in substantial allegation 31956 completed on 10/14/21; however, the facility was found not to be in compliance with all requirements for Home Health Agency participation and the following deficiencies are cited. Prime Home Care, LLC 368335, is not in compliance with the requirements found at 42 CFR, Part 484 Subpart B,C for Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure each patient received home health services that are written in an individualized plan of care for one of three patients reviewed (Patient #1). This could affect all patients receiving services from the agency. The agency census was 612. Findings include: Review of the undatedfacility policy titled, Plan of Care-CMS #485 and Physician/Practitioners Orders revealed care and services will provided will be provided according to physician/practitioner orders. Review of the medical record for Patient #1 for certification period 07/07/21 through 09/04/21 revealed physician orders for skilled nursing services once weekly. The primary diagnosis was heart failure with physician notification for a weight gain of 3 pounds in one day and/or 5 pounds in one week. Staff H confirmed in an interview on 10/13/21 at 11:07 AM that no weights were documented per the plan of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy review, the agency failed to ensure treatments were administered only as ordered by a physician or allowed practitioner for one of three medical records reviewed (Patient #1). This could affect all patients receiving services from the agency. The census was 612. Findings include: Review of the undated policy titled, Plan of Care-CMS #485 and Physician/Practitioners Orders revealed drug, services and treatments are administered by staff only as ordered by physician/practitioner. Review of the medical record for Patient #1 for certification period 07/07/21 through 09/04/21 revealed physician orders for skilled nursing services once weekly with a primary diagnosis of heart failure. Review of the nursing documentation dated 08/14/21 revealed the patient had dependent edema with right and left venous ulcers. The nurse cleansed the ulcers with soap and water, applied remedy cream, covered with ABD pads, and secured with an ace wrap. Staff H confirmed in an interview on 10/13/21 at 11:07 AM there was no physician order for wound care.

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 record review, staff interview and observations. the agency failed to report all branch locations to the state survey agency at each survey and at the time the parent proposes to add a branch. (G972). The cumulative effect of this systemic practice resulted in the agency's inability to ensure patients' needs would be met.

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on record review, staff interview and observations. the agency failed to report all branch locations to the state survey agency at each survey and at the time the parent proposes to add a branch. The agency census was 612. Findings include: An interview was conducted with Staff A on 10/12/21 at 11:30 AM who reported the agency had a purchase agreement with another agency effective 07/13/21 with all patients either transitioned and/or provided a thirty day discharge option. The agency reported submitting an application on 09/07/21 to add branch locations at 744 N. Court St. Circleville, Ohio 43113 and 308 Highland Ave., Suite B, Washington Court House, Ohio 43160. Both were pending approval. Review of the active patient census identified patients listed under agency names that included Prime Home West and Prime Dayton. Staff A reported on 10/12/21 these locations operated under a separate entity. An internet search for primehomecare.com revealed a Columbus West location at 132 North Wilson Rd. Columbus, Ohio 43204, and a Columbus Grove City location at 3111 Columbus St., Suite A, Grove City, Ohio 43213, and Prime Dayton at 7229 Taylorsville Rd. Suite 120 Huber Heights, Ohio 45424. A request was made for the Medicare Enrollment Application (CMS- 855 A) form to ensure the branch locations were approved. The administrative staff was not aware of branch identification numbers upon request. A request was made for a CMS approval letter for the locations which was not provided during the survey. Staff A reported the locations were not staffed daily and no patients and/or staff were scheduled from the locations. An interview was conducted with Staff H on 10/13/21 at 11:07 AM who reported they conducted chart audits for all locations. An interview was conducted with Staff I on 10/13/21 at 3:42 PM who reported providing care for patients out of the Columbus and Grove City locations. In addition, he/she stated the Grove City location was growing and accepting new patients. Staff and patients were assigned to each location. An interview was conducted with Staff J on 10/13/21 at 4:18 PM who reported providing patient care out of the Grove City and Dayton areas. Staff and patients were assigned to each location. An unannounced visit was made to the Prime Dayton location at 7229 Taylorsville Rd., Suite 120 Huber Heights, Ohio 45424 on 10/14/21 at 11:00 AM. Signage identifying the agency was observed on the exterior of the building and the interior door advertised the business as open. Upon entrance there was one office staff who reported being the HR/Scheduler for the location. The staff member stated the agency did not operate under a separate entity and all patient referrals came from the main office. The Prime Dayton location had approximately sixty patients, two registered nurses, two licensed practical nurses, and approximately fifty home health aides. In addition, the business was open to the public Monday-Friday 9:00 AM to 5:00 PM. The office had its own patients and staff received training from the Prime Home Care corporate office. A copy of the marketing brochure was obtained and listed Dayton as an agency location. An unannounced visit was made to Columbus West located at 132 North Wilson Rd. Columbus, Ohio 43204 on 10/14/21 at 12:15 PM. Signage on the exterior of the building advertised the location as Sunrise. Upon entrance there was one office staff who reported being the Intake Coordinator for the location. The staff member stated the agency did not operate under a separate entity and Prime Home Care purchased the agency from another owner and transitioned all the patients. It was unknown how many patients were currently active as the referrals were received by an alternate location. The location shared staff with the Columbus Grove City location. The business was open for normal business hours. An unannounced visit was made to the Columbus Grove City location at 3111 Columbus St., Suite A, Grove City, Ohio 43213 on 10/14/21 at 12:45 PM. Signage identifying the agency was observed on the exterior of the building and the interior door advertised the business as open. Upon entrance there was one office staff who reported being the intake coordinator. The staff member stated the agency did not operate under a separate entity and Prime Home Care purchased the agency from another owner and transitioned all the patients. It was unknown how many patients were currently active at this location as the referrals were received by an alternate location. The agency had admission packets identified as Prime Home Care readily available.