Every finding on record at Pure Health Services, LLC

The #100038 complaint investigation, conducted by the Department of Inspections and Appeals from 8/21/23 through 8/28/23, resulted in substantiation of the complaint allegations and found the agency operating out of compliance with related condition level deficiencies under the Condition of Participation 42 CFR 484.50 Patient Rights ( G406 and G430). The agency identified a census of 20 current patients.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on agency policy review, clinical record review, review of additional applicable documents, agency staff interview and patient/caregiver interview, the agency failed to do the following: 1) ensure patients had the right to remain free from abuse. (G430); The systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's 20 patients. The administrator failed to follow the agency’s policy titled Abuse, Neglect, Exploitation, Fraud, dated 1/13/2018, specifically that the agency will follow an established process for investigating allegations of abuse against employees and the employee named in the allegation will be immediately removed from direct patient care pending investigation. As evidenced by: Staff B, Home Care Aide, continued to provide services for Patients #1, #2 and #3 (in addition to 2 patients under a Waiver Program) after the first allegation of misappropriation of property was received on 7/7/23. Staff B was removed from direct patient care 7/17/2023 and terminated on 8/17/2023. Findings include: The systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's 20 patients.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff and patient interview, the agency failed to ensure the patients remained free from misappropriation of property for 3 of 6 sampled patients reviewed (Patient #1, #2 and #3). Failure to ensure patients are free form verbal, mental, sexual and physical abuse, including injuries of unknown source, neglect and misappropriation of property placed agency patients at risk for undue harm, suffering and failure to have their rights respected. Findings include: According to the undated agency policy titled Rights & Responsibilities of Patients Policy, as a patient of our agency, you have the right to be free from neglect or verbal, mental sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the agency. According to the agency policy titled Abuse, Neglect, Exploitation, Fraud, dated 1/13/2018, the agency will follow an established process for investigating allegations of abuse against employees/contracted staff. The employee who is named in allegations will be immediately removed from direct patient care pending investigation. During an interview on 8/22/23 at 1:50 PM, the Administrator stated along with the 3 patients who had money missing there also was 2 patient's who received services, under a waiver program, with money missing. The Administrator stated she suspended Staff B on 7/17/23 and terminated Staff B's employment on 8/17/23. Review of Staff B's personal file confirmed the suspension and termination. 1. Patient #1 had a start of care date of 6/15/23. The Plan of Care (POC), dated 6/15/23 to 8/13/23 and 8/14/23 to 10/12/23, included diagnoses of chronic kidney disease and post COVID 19 and included orders for skilled nursing and home care aide services. The aide care plan, dated 6/15/23, included the assigned tasks of assist with chair bath, lotion, comb hair and shampoo hair every visit and tidy patient area every visit and vacuum weekly. The aide visit note, dated 7/3/23, included documentation Staff B, HCA provided bathing tasks, tidying and vacuum in the patient's home. During an interview on 8/23/23 at 11:02 AM, the patient stated he/she had put approximately $60.00 in his/her billford which had been in a purse, on a chair in the living room on the morning of 7/3/23. Staff B, HCA assisted him/her to the shower and left the area to complete the task of vacuuming. On the morning of 7/7/23 he/she went to retrieved money from the billfold and found the money missing. The patient stated Staff B had been the only person who had the opportunity to access the money without his/her knowledge. He/she reported the missing money to the Administrator on 7/7/23. During an interview on 8/22/23 at 1:50 PM, the Administrator stated on 7/7/23, Patient #1 reported missing $60.00 and identified Staff B, Home Care Aide (HCA) the only person to have access to the money. She removed Staff B from the home and changed the schedule to ensure other persons in patient's home beside the patient when Staff B providing care for more supervision. The administrator failed to follow the agency’s policy titled Abuse, Neglect, Exploitation, Fraud, dated 1/13/2018, specifically that the agency will follow an established process for investigating allegations of abuse against employees and the employee named in the allegation will be immediately removed from direct patient care pending investigation. 2. Patient #2 had a start of care date of 4/17/23. The POC, dated 5/19/23 to 7/17/23 and 7/18/23 to 9/15/23, included diagnoses of diabetes mellitus with circulatory complications and included orders for skilled nursing and home care aide services. The aide care plan, dated 5/19/23 and 7/18/23, included the assigned task of sponge bath, shave, skin care, apply barrier cream and assist with dressing and included household tasks of cleaning living room, bathroom, bedroom and kitchen. The aide visit notes, dated 5/19/23 and 7/18/23, included documentation Staff B, HCA provided bathing services and the household tasks in the patient's home. During an interview on 8/23/23 at 1:20 PM, the patient's spouse stated he/she had placed $20.00 on the kitchen counter on the morning of 5/30/23. He/she returned home and found the money was gone. Staff B, HCA was in Patient #2's home that day and provided services with the patient. No other person was in the home and the patient remained in another room of the home while Staff B was present. The patient's spouse stated the patient mentioned something to a staff member about the missing money and the Administrator called to inquire about the missing money and she spoke to the Administrator spoke about it on 7/15/23. During an interview on 8/22/23 at 1:50 PM, the Administrator stated Staff C, HCA also identified Patient #2 may have had missing money. The Administrator stated she spoke to Patient #2's spouse on 7/15/23 and he/she reported $20.00 missing from the home and identified Staff B the only person to have access to the money. The administrator failed to follow the agency’s policy titled Abuse, Neglect, Exploitation, Fraud, dated 1/13/2018, specifically that the agency will follow an established process for investigating allegations of abuse against employees and the employee named in the allegation will be immediately removed from direct patient care pending investigation. investigation. As evidenced by: Staff B continued to provide services for Patient 2 on 7/18/23 after the Administrator received the allegation on 7/15/23. 3. Patient #3 had a start of care date of 3/30/23. The POC, dated 5/29/23 to 7/27/23 and 7/28/23 to 9/25/23, included diagnoses of chronic obstructive pulmonary disease and included orders for skilled nursing and home care aide services. The aide care plan, dated 5/19/23 and 7/18/23, included the assigned task of sponge bath, shave, skin care, apply barrier cream and assist with dressing and included household tasks of cleaning living room, bathroom, bedroom and kitchen. The aide visit note, dated 7/11/23, included documentation Staff B, HCA provided bathing and household tasks in the patient's home. During an interview on 8/23/23 at 9:15 AM, Patient #3 stated he/she had placed $300.00 in his/her billfold that remained in the pants pocket. On 7/11/23, Staff B, HCA, assisted him/her with a shower. Staff B took the pants from the bathroom and exchanged with the clean pants, along with the billfold, and returned the clean pants to the patient. Later in the day on 7/11/23, he/she noticed $300.00 missing from the billfold. He/she reported no other person had access to the billfold and reported the missing money to Staff C, HCA. During an interview on 8/22/23 at 1:50 PM, the Administrator stated, On 7/14/23 Staff C, HCA reported Patient #3 had reported missing $300.00. When speaking to Patient #3 he/she identified Staff B, HCA the only person to have access to the money. The administrator failed to follow the agency’s policy titled Abuse, Neglect, Exploitation, Fraud, dated 1/13/2018, specifically that the agency will follow an established process for investigating allegations of abuse against employees and the employee named in the allegation will be immediately removed from direct patient care pending investigation. investigation. As evidenced by: Staff B continued to provide services for Patient 3 on 7/11/23 after the administrator received the first allegation for Staff B on 7/7/23. The Administrator received the above information. No further information provided prior to the end of the survey.