Every finding on record at Prime Home Care LLC

Substantial Allegation Survey Substantial Allegation 103328 and 103862 Prime Home Care LLC is in substantial compliance with the requirements of 42 CFR Part 484, Subpart B, C for Home Health Agency in regard to the allegations contained in the substantial allegation 103328 completed on 01/22/24. No deficiencies were issued related to allegations contained in complaint 103862. An entrance conference was conducted on 01/22/24 at 9:10 AM with the Director of Nursing and Branch Manager, an exit conference was conducted on 01/22/24 at 5:10 PM with Director of Nursing and Branch Manager.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, it was determined that the agency failed to follow the physician orders in the plan of care for home health aide visits. This was found in one (Patient #2) of six medical records reviewed. This had a potential to affect all patient receiving home health aide services. The census at the time of survey was 99. The medical record review for Patient #2 revealed care started with the agency on 08/22/23. The medical record review revealed the patient was to receive 20 hours of home health aide services per week. The medical record review revealed the agency provided home health aide aide services until 10/17/23. The patient terminated the aide on 10/18/23. The agency was unable to staff the patient through discharge on 01/03/24. The medical record review revealed the agency did not provider services per the physician orders in the plan of care. Interview with Staff A and Staff B did confirm the findings at the time of discovery.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview it was determined that the agency failed to notify the attending physician of the inability of the agency to staff the home health aide services. This was found in one (Patient #2) of six medical records reviewed. This had a potential to affect all patient receiving home health aide services. The census at the time of survey was 99. The medical record review for Patient #2 revealed care started with the agency on 08/22/23. The medical record review revealed the patient was to receive 20 hours of home health aide services per week. The medical record review revealed the agency provided home health aide aide services until 10/17/23. The patient terminated the aide on 10/18/23. The agency was unable to staff the patient through discharge on 01/03/24. The medical record review revealed the agency did not notify the physician when they were unable to provide home health aides per the plan of care. Interview with Staff A and Staff B did confirm the findings at the time of discovery.

Substantial Allegation Survey Substantial Allegation 100170 Prime Home Care was in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies in regards to substantial allegation 100170 completed on 08/18/23, however the following deficiencies are cited un-related to this allegation.

Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This ELEMENT is not met as evidenced by: Based on a review of personnel files, review of agency training for home health aides (HHA), and staff interview, the agency failed to provide a total of 75 hours training for new HHA's. This affected four (Staff C, D, E, and F) out of five personnel files reviewed and had the potential to affect all patient's cared for by the HHAs at this agency. Review of the personnel file for Staff C revealed a hire date of 05/02/23. Staff C received training by this agency on 05/02/23. A training certificate listed five hours and 20 minutes of pre-service training (on-line module) A competency checklist was completed by Staff C on 05/02/23 which was signed off by a registered nurse (RN). Review of the personnel file for Staff D revealed a hire date of 04/28/23. Staff D received training by the agency on 04/28/23. A training certificate listed five hours and 20 minutes of pre-service training (on-line module) A competency checklist was completed by Staff D on 04/28/23 which was signed off by a RN. Review of the personnel file for Staff E revealed a hire date of 05/02/23. Staff E received training by this agency on 05/02/23. A training certificate listed five hours and 20 minutes of pre-service training (on-line module) A competency checklist was completed by Staff E on 05/02/23 which was signed off by a RN. Review of the personnel file for Staff F revealed a hire date of 11/03/22. Staff R received training by this agency on 11/03/22. A training certificate listed five hours and 20 minutes of pre-service training (on-line module) A competency checklist was completed by Staff F on 11/03/22 which was signed off by a RN. Interview with Staff A on 08/18/23 at 11:00 AM revealed Staff C, D, E and F received classroom and supervised practical training of approximately eight hours. The findings of not completing the required classroom and supervised practical training to equal at least 75 hours was verified with Staff A and B on 8/18/23 at 11:00 AM. .

Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This ELEMENT is not met as evidenced by: Based on a review of personnel files and staff interview, the agency failed to complete the required 16 hours of classroom training followed by 16 hours of supervised practical training as part of the 75 hours of training for home health aides (HHA). This affected four (Staff C, D, E, and F) out of five personnel files reviewed and had the potential to affect all patients cared for by this agency. Review of the personnel file for Staff C revealed a hire date of 05/02/23. Staff C received training by this agency on 05/02/23. A training certificate listed five hours and 20 minutes of pre-service training (on-line module) with no evidence of any supervised practical training. Review of the personnel file for Staff D revealed a hire date of 04/28/23. Staff D received training by the agency on 04/28/23. A training certificate listed five hours and 20 minutes of pre-service training (on-line module) with no evidence of any supervised practical training. Review of the personnel file for Staff E revealed a hire date of 05/02/23. Staff E received training by this agency on 05/02/23. A training certificate listed five hours and 20 minutes of pre-service training (on-line module) with no evidence of any supervised practical training. Review of the personnel file for Staff F revealed a hire date of 11/03/22. Staff R received training by this agency on 11/03/22. A training certificate listed five hours and 20 minutes of pre-service training (on-line module) with no evidence of any supervised practical training. Interview with Staff A on 08/18/23 at 11:00 AM revealed Staff C, D, E and F classroom and supervised practical training of approximately eight hours but have no documentation of supervised training except for a competency checklist. The findings of not completing a minimum of 16 hours of classroom training then minimum of l6 hours of supervised practical training as part of the 75 hours was verified with Staff A on 08/18/23 at 11:00 AM.