Every finding on record at Rrb Home Healthcare, LLC

Based on the findings of an unannounced onsite Medicare recertification survey conducted May 13, 2025, through May 16, 2025, RRB Home Healthcare, LLC was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare recertification survey conducted May 13, 2025, through May 16, 2025, RRB Home Healthcare, LLC was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. As a result of the survey one (1) condition level citation at: 484.105 Organization and Administration Services has been issued. No immediate Jeopardy situation was identified.

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 reviews of policies/procedures, meeting minutes, personnel files (PF) and interview with staff the agency failed to ensure the governing body assumed responsibility for the maintenance of the agency, appointed a qualified Administrator to conduct the day-to-day operations and an alternate to act in their absence and hire a qualified Clinical Manager to provide quality patient care. Findings include: Cross reference: 484.105(a) Governing Body Tag G 0942- the agency governing body failed to appoint a qualified administrator and alternate administrator for one (1) of five (5) PFs reviewed. (PF#1) 484.105(b)(1)(ii) Be responsible for all day-to-day operations of the HHA G 0948- the agency failed to ensure that the administrator is actively involved in the day-to day operations for one (1) of one (1) observation made OBS #1 484.105(b)(2) A Qualified pre-designated person authorized in writing to act in absence of Administrator G 0954 - the agency failed to ensure the appointment of a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator when the administrator is not available for one (1) of one (1) observation. 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours G 0956 - the agency failed to ensure the administrator, or an alternate administrator is available during all operating hours for one (1) of one (1) observation made OBS #1. The cummulative effect of the systemic failures led to the agency's inability to maintain organization and provide quality administrative services to staff and patients. 484.105(c) Clinical Manager G 0958- the agency failed to ensure Clinical Supervisor met the requirements of the job description for one (1) of five (5) files reviewed. PF #4.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on a review of policy and procedure, personnel files (PF), and an interview with the agency staff, the agency governing body failed to appoint a qualified administrator and alternate administrator for one (1) of five (5) PFs reviewed. (PF#1) Findings include: Review of agency policy #1002 titled, "Governing Body" on May 16, 2025, at approximately 3:15 pm states, "The Governing Body (Board of Directors) manages the operation of RRB Home Healthcare, LLC. Procedure:3. The Governing Body appoints an Administrator and a Supervising Nurse..." Review of policy #1020 titled, "The Administrator" on May 16, 2025, at approximately 3:15 pm states, "Policy: The governing body of RRB Home Healthcare, LLC shall appoint an administrator who supervises the provision of all services. A qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, will also be appointed to act in the absence of the administrator. Qualifications: The administrator: May be a physician, or registered nurse OR have a baccalaureate or postgraduate degree in administration in a health or human services field and at least one full year of full-time administrative experience as the administrator of an agency or licensed health care facility; OR have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in home health care, hospice, or related field... Will be available during the agency's usual working hours along with the alternate administrator..." Review of policy #1021 titled, "The Alternate Administrator" on May 16, 2025, at approximately 3:15 pm states, "1. Purpose 1.1. The guidelines provided are designed to establish a clear framework for the management and operation of RRB Home Healthcare, LLC. Their primary purpose is to ensure that the organization runs efficiently and effectively, with a focus on maintaining high standards of care and service delivery. The guidelines outline the responsibilities and qualifications required for key leadership roles, particularly the administrator and alternate administrator, to ensure that the agency is led by competent and qualified individuals..." Review of the agency's organizational chart on May 13, 2025, at approximately 1:40 pm revealed no specific persons identified as the Alternate Administrator. A review of personnel files conducted on May 13, 2025, at approximately 2:15 pm revealed the following: PF#1 Date of hire (DOH) 4/26/2024: There was no evidence of a signed job description. Did not contain any documentation showing evidence of being a physician or registered nurse or having a baccalaureate or postgraduate degree in administration in a health or human services field and at least one full year of full-time administrative experience as the administrator of an agency or licensed health care facility; OR have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in home health care, hospice, or related field. An interview with the administrative assistant and Director of Nursing conducted on Tuesday, 5/13/25, at 5 pm, and again on May 16, 2025, via telephone with the administrative assistant at approximately 4:30 pm confirmed the above findings. During an interview with the Director of Nursing on May 13, 2025, at approximately 1:35 pm it was also confirmed the Administrator on file was no longer at the agency. The newly hired Administrator was unavailable in person or over the phone. She reported he was "on a flight to Africa to see his mother." The Director of Nursing also reported that the agency did not have an alternate administrator involved in the day-to-day operations.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observations (OBS) and interview with agency staff, the agency failed to ensure that the administrator is actively involved in the day-to day operations for one (1) of one (1) observation made OBS #1 Findings include: OBS #1 completed 5/13/25, at the agency location: 501 Cambria Ave, SUITE 111, BENSALEM, PA 19020, at 12:30 pm revealed no Administrator or alternate available in person or over the phone. An interview with the Director of Nursing was conducted on May 13, 2025, at approximately 1:35 pm, confirmed that the Administrator on file with the DOH was no longer at the agency. The new Administrator was unavailable in person and over the phone. She reported he was "on a flight to Africa to see his mother." The Director of Nursing also reported that the agency did not have an alternate administrator involved in the day-to-day operations. An interview with the administrative assistant and Director of Nursing conducted on Tuesday, 5/13/25, at 5 pm, and again on May 16, 2025, via telephone with the administrative assistant at approximately 4:30 pm confirmed the above findings.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on observation (OBS), a review of the agency policy and procedures, agency documents and an interview with staff, the agency failed to ensure the appointment of a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator when the administrator is not available for one (1) of one (1) observation. Findings include: OBS #1 completed 5/13/25 at 12:30 pm revealed no Administrator or alternate available in person or over the phone. Review of policy #1021 titled, "The Alternate Administrator" on May 16, 2025, at approximately 3:15 pm states, "1. Purpose 1.1. The guidelines provided are designed to establish a clear framework for the management and operation of RRB Home Healthcare, LLC. Their primary purpose is to ensure that the organization runs efficiently and effectively, with a focus on maintaining high standards of care and service delivery. The guidelines outline the responsibilities and qualifications required for key leadership roles, particularly the administrator and alternate administrator, to ensure that the agency is led by competent and qualified individuals..." Review of the agency's organizational chart on May 13, 2025, at approximately 1:40 pm revealed no specific persons identified as the Alternate Administrator. An interview with the Director of Nursing was conducted on May 13, 2025, at approximately 1:35 pm confirmed the Administrator on file with the DOH was no longer at the agency. The new Administrator was unavailable in person and over the phone. She reported he was "on a flight to Africa to see his mother." The Director of Nursing also reported that the agency did not have an alternate administrator involved in the day-to-day operations. An interview with the administrative assistant and Director of Nursing conducted on Tuesday, 5/13/25, at 5 pm, and again on May 16, 2025, via telephone with the administrative assistant at approximately 4:30 pm confirmed the above findings.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on review of polices/procedures, observations (OBS) and interview with agency staff, the agency failed to ensure the administrator, or an alternate administrator is available during all operating hours for one (1) of one (1) observation made OBS #1. Findings include: A review of the following agency policies and position descriptions conducted on May 16, 2025, starting at approximately 3:15 PM, revealed the following: Policy #1020 states, "The governing body of RRB Home Healthcare, LLC shall appoint an administrator who supervises the provision of all services... Will be available during the agency's usual working hours along with the alternate administrator." OBS # 1, conducted at agency location: 501 Cambria Ave, SUITE 111, BENSALEM, PA 19020, on Tuesday, 5/13/25, at 12:30 pm, revealed no Administrator or alternate Administrator available during all operating hours. An interview with the Director of Nursing was conducted on May 13, 2025, at approximately 1:35 pm, confirmed the Administrator on file with the Department of Health was no longer at the agency. The new Administrator was unavailable in person and over the phone. She reported he was "on a flight to Africa to see his mother." The Director of Nursing also reported that the agency did not have an alternate administrator involved in the day-to-day operations. An interview with the administrative assistant and Director of Nursing conducted on Tuesday, 5/13/25, at 5 pm, and again on May 16, 2025, via telephone with the administrative assistant at approximately 4:30 pm confirmed the above findings.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on a review of personnel files (PF), and an interview with the agency staff, agency failed to ensure Clinical Supervisor met the requirements of the job description for one (1) of five (5) files reviewed. PF #4. Findings include: A review of job descriptions conducted on May 13, 2025, at approximately 2:15 PM, revealed the following: Job description titled "Director of Nursing-Orientation" states, "Regulatory Requirements: "Public Health nursing experience desirable with minimum of two (2) years in a community health setting." A review of personnel files (PF) was conducted on May 13, 2025, at approximately 2:15 PM, revealed the following: PF#4, Date of Hire (DOH) 5/1/24: Did not contain any documentation of two (2) years of experience in a community setting. An interview with the administrative assistant and the Director of Nursing conducted on May 13, 2025, at approximately 5:00 pm confirmed the above findings.

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on a review of policies/procedures, personnel files (PF), and interview with Agencey staff the agency failed to ensure the appointed Administrator was qualified to assume day to day operations for one (1) of five (5) files reviewed. PF #1. Findings include: A review of the following agency policies conducted on May 16, 2025, starting at approximately 3:15 PM, revealed the following: Policy #1020 states, "The governing body of RRB Home Healthcare, LLC shall appoint an administrator who supervises the provision of all services...The administrator will be responsible for the hiring of qualified personnel, as well as the development of personnel qualifications and policies...The administrator: May be a physician, or registered nurse OR have a baccalaureate or postgraduate degree in administration in a health or human services field and at least one full year of full-time administrative experience as the administrator of an agency or licensed health care facility; OR have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in home health care, hospice, or related field... A review of personnel files (PF) was conducted on May 13, 2025, at approximately 2:15 PM, revealed the following: PF #1 Date of Hire (DOH) 4/26/2024: There was no evidence of a signed job description. Did not contain any documentation showing evidence of being a physician or registered nurse or having a baccalaureate or postgraduate degree in administration in a health or human services field and at least one full year of full-time administrative experience as the administrator of an agency or licensed health care facility; OR have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in home health care, hospice, or related field. An interview with the administrative assistant conducted on May 16, 2025, via telephone at approximately 4:30 pm confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey conducted May 9, 2022 through May 11, 2022, RRB Home Healthcare, LLC was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a review of personnel files (PF), agency policies, and an interview with the administrator, the agency failed to document emergency preparedness training upon hire and/or at least every two (2) years for six (6) of six (6) personnel files reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, and PF#6. Findings include: A review of the following agency policies took place on May 9, 2022 starting at approximately 3:00 PM: Policy #4011 Employee Health states (page 5), “All RRB Home Healthcare personnel are required to attend an annual update inservice which consists of the following:…….Emergency Management; ” Policy #7019 Emergency Management Plan states (page 13), “Initial training in emergency preparedness policies and procedures will be provided for all staff members at time of hire,” and (page 14), “Training will be provided for all staff during one of the mandatory in-service training administered quarterly on an annual basis;” and Policy #8054 Employee Education Program states, “All staff members are required to attend, or provide proof of having participated in, mandatory inservice programs. These mandatory inservice training program include:…..Emergency Management.” A review of personnel files was conducted on May 9, 2022 starting at approximately 2:15 PM. The date of hire is indicated below: PF#1 DOH 06/22/2017 did not contain evidence of emergency preparedness training since 2019. PF#2 DOH 04/29/2019 did not contain evidence of emergency preparedness training at time of hire. PF#3 DOH 03/26/2019 did not contain evidence of emergency preparedness training at time of hire or at least every two (2) years. PF#4 DOH 01/24/2022 did not contain evidence of emergency preparedness training at time of hire. PF#5 DOH 10/03/2019 did not contain evidence of emergency preparedness training at time of hire. PF#6 DOH 04/10/2021 did not contain evidence of emergency preparedness training at time of hire. An interview with the administrator, office manager and office associate conducted on May 11, 2022 starting at 3:00 PM confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey conducted May 9, 2022 through May 11, 2022, RRB Home Healthcare, LLC was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on a review of clinical records (CR), agencies policies and documents, and an interview with the administrator, the agency failed to provide written notice of all of the patient rights as outlined in the Code of Federal Regulations (CFR) 484.50 (c) for seven (7) of seven (7) clinical records reviewed: CR#1, CR#2, CR#4, CR#4, CR#5, CR#6, and CR#7. A review of the following agency policy and documents took place on May 10, 2022 at approximately 2:00 PM. Policy #1002 Page 1 states, “purpose is to provide information to patients/families/caregivers regarding the patient’s rights and responsibilities with care and/or services provided, in accordance with applicable laws, regulations and standards.” Policy #1001 Page 1 states, “at the time of initial evaluation, the patient will receive information regarding….Patient Rights and Responsibilities.” The agency’s “Home Health Care Company Patient Information Packet” (booklet), that is contained in an admission folder and provided to patients prior to the start of care contains a section on and lists (page 16) eleven civil and personal patient rights. The list of rights contained in the booklet did not include all of the rights that are to be provided to the patient per the Code of Federal Regulations (CFR 484.50 (c). The agency’s RRB Home Healthcare, LLC Authorization/Agreement for Services has several sections whereby the patient acknowledges, in writing, the receipt of rights and responsibilities. In an interview with the home health administrator on May 11, 2022 at approximately 2:45 pm, the administrator acknowledged that the RRB Home Healthcare, LLC Authorization/Agreement for Services (service agreement) is the document that serves as evidence of the patient receiving a copy of the Patient Rights as contained in the RRB Home Health Care Company Patient Information Packet” (booklet). A review of clinical records was conducted on May 10, 2022 starting at approximately 1:00 PM, and again on May 11, 2022 starting at approximately 9:10 AM. The start of care (SOC) and Centers for Medical and Medicaid Services (CMS) Home Health Certification and Plan of Care Period (CP) are indicated below. CR#1 SOC 10/11/2021, CP 10/11/2021 to 12/09/2021 contained evidence that the patient received a copy of the patient rights as acknowledged/signed by the patient on the service agreement. The list of patient rights contained in the Patient Information Packet (booklet) was not inclusive of the following items nor was there evidence that the information was verbally reviewed with the patient: the transfer and discharge policies of the agency, the right to be free from abuse, injury and misappropriation of property, the extent to which payment for agency services may be expected or denied, the names/addresses/telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization, the right to refuse service or be transferred or discharged. CR#2 SOC 10/2/2021, CP 10/2/2021 to 11/30/2021 contained evidence that the patient received a copy of the patient rights as acknowledged/signed by the patient on the service agreement. The list of patient rights contained in the Patient Information Packet (booklet) was not inclusive of the following items nor was there evidence that the information was verbally reviewed with the patient: the transfer and discharge policies of the agency, the right to be free from abuse, injury and misappropriation of property, the extent to which payment for agency services may be expected or denied, the names/addresses/telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization, the right to refuse service or be transferred or discharged. CR#3 SOC 06/09/2021, CP 12/06/2021 to 02/03/2022 contained evidence that the patient received a copy of the patient rights as acknowledged/signed by the patient on the service agreement. The list of patient rights contained in the Patient Information Packet (booklet) was not inclusive of the following items nor was there evidence that the information was verbally reviewed with the patient: the transfer and discharge policies of the agency, the right to be free from abuse, injury and misappropriation of property, the extent to which payment for agency services may be expected or denied, the names/addresses/telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization, the right to refuse service or be transferred or discharged. CR#4 SOC 10/04/2021, CP 12/03/2021 to 01/31/2022 contained evidence that the patient received a copy of the patient rights as acknowledged/signed by the patient on the service agreement. The list of patient rights contained in the Patient Information Packet (booklet) was not inclusive of the following items nor was there evidence that the information was verbally reviewed with the patient: the transfer and discharge policies of the agency, the right to be free from abuse, injury and misappropriation of property, the extent to which payment for agency services may be expected or denied, the names/addresses/telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization, the right to refuse service or be transferred or discharged. CR#5 SOC 02/04/2021, CP 10/02/2021 to 11/30/2021 contained evidence that the patient received a copy of the patient rights as acknowledged/signed by the patient on the service agreement. The list of patient rights contained in the Patient Information Packet (booklet) was not inclusive of the following items nor was there evidence that the information was verbally reviewed with the patient: the transfer and discharge policies of the agency, the right to be free from abuse, injury and misappropriation of property, the extent to which payment for agency services may be expected or denied, the names/addresses/telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization, the right to refuse service or be transferred or discharged. CR#6 SOC 12/15/2021, CP 12/15/2021 to 02/12/2022 contained evidence that the patient received a copy of the patient rights as acknowledged/signed by the patient on the service agreement. The list of patient rights contained in the Patient Information Packet (booklet) was not inclusive of the following items nor was there evidence that the information was verbally reviewed with the patient: the transfer and discharge policies of the agency, the right to be free from abuse, injury and misappropriation of property, the extent to which payment for agency services may be expected or denied, the names/addresses/telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization, the right to refuse service or be transferred or discharged. CR#7 SOC 10/25/2021, CP 10/25/2021 to 12/23/2021 contained evidence that the patient received a copy of the patient rights as acknowledged/signed by the patient on the service agreement. The list of patient rights contained in the Patient Information Packet (booklet) was not inclusive of the following items nor was there evidence that the information was verbally reviewed with the patient: the transfer and discharge policies of the agency, the right to be free from abuse, injury and misappropriation of property, the extent to which payment for agency services may be expected or denied, the names/addresses/telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization, the right to refuse service or be transferred or discharged. An interview with the administrator, office manager and office associate conducted on May 11, 2022 starting at 3:00 PM confirmed the above findings.

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 a review of clinical records (CR), an interview with the administrator, and a review of agency policies, the agency failed to ensure that services were provided in accordance with physician orders for four (4) of seven (7) clinical records: CR#1, CR#4, CR#5, and CR#6. Findings include: A review of the following agency policies took place on May 10, 2022 starting at approximately 10:00 AM: Policy #2017 states: page 1 – “Each individual providing care and/or services to the patient should contact the Clinical Supervisor at least weekly to confirm that visits have been conducted as scheduled….The physician is contacted whenever changes to the type and/or frequency of patient visits are required based on patient needs.” Policy #2027 states: page 2 – “Physician verbal/telephone orders are accepted by qualified staff and submitted to the physician for his/her signature within 7 days. Verbal/Telephone orders are signed by the physician within 7 days of receipt of the orders by RRB Home Healthcare personnel.” In an interview with the Director of Nursing (DON) on May 10, 2022 at approximately 1:00 PM, the DON stated that the Physical Therapy Evaluation Document is intended to serve as documentation of the physical therapist initial assessment and subsequent reassessment(s) every thirty (30) days, and contains a section noting frequency and duration of treatment which serves as the physician order for visit frequency and duration, and is to be signed by a physician. In an interview with the Director of Nursing (DON) on May 11, 2022 at 2:45 PM, the DON stated that when a missed visit occurs, a missed visit note is to be noted in the record, but the physician does not need to be notified of each missed visit. Code of Federal Regulations (CFR) Title 42 Public Health, Chapter IV – Centers for Medicare and Medicaid, Department of Health and Human Services, Subchapter B – Medicare Program, Subpart E – Home Health Services, Section 409.44 Skilled Services Requirements states: (c) Physical therapy, speech-language pathology services, and occupational therapy (2) Physical and occupational therapy and speech-language pathology services must be reasonable and necessary. To be considered reasonable and necessary, the following conditions must be met: (i) The services must be considered under accepted standards of professional clinical practice, to be a specific, safe, and effective treatment for the beneficiary's condition. Each of the following requirements must also be met….: (B) At least every 30 calendar days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient.... A review of clinical records was conducted on May 10, 2022 starting at approximately 1:00 PM, and again on May 11, 2022 starting at approximately 9:10 AM. The start of care (SOC) and certification period (CP) per the Centers for Medicare and Medicaid Services (CMS) Home Health Certification and Plan of Care (CMS 485) are indicated below. CR#1 SOC 10/11/2021, CP 10/11/2021 to 12/09/2021. Per the CMS 485, the patient had orders for Skilled Nursing (SN) visits two (2) times per week for nine (9) weeks. There was one (1) missed skilled nursing visit the week of 10/17. There was no missed visit note in the clinical record nor was there any documentation of the Clinical Supervisor being contacted. CR#4 SOC 10/04/2021, CP 12/03/2021 to 01/31/2022. Per the CMS 485 for the certification period, the patient had orders for Skilled Nursing one (1) time per week for nine (9) weeks, and for physical therapy to evaluate and treat. There was no documentation of a thirty (30) day reassessment of the patient by the physical therapist after 11/08/2021 until 01/10/2022 at which time physical therapy orders were obtained for the frequency of visits via the Physical Therapy Evaluation Document. Seven (7) physical therapy visits were provided on 12/03/2021 (documentation was related to a treatment, not a reassessment), 12/10/2021, 12/13/2021, 12/17/2021, 12/22/2021, 12/27/2021 and 01/03/2022 without a documented physician’s order. In addition, the clinical record contained documentation of a physical therapy reassessment conducted on 11/08/2021, thirty-three (33) days after the initial evaluation (10/06/2021), and then again on 01/10/2022 both of which are beyond the required thirty (30) day reassessment period. CR#5 SOC 02/04/2021, CP 10/02/2021 to 11/30/2021. Per the CMS 485 for the certification period, the patient had orders for Skilled Nursing visits one (1) time per week for nine (9) weeks, home health aide visits two (2) to three (3) times per week for nine (9) weeks, and for physical therapy to evaluate and treat. There was a missed skilled nursing visit the week of 10/17. There was no missed visit note in the clinical record nor was there any documentation of the Clinical Supervisor being contacted. The patient received physical therapy visits on 10/07/2021, 10/11/2021, 10/14/2021, 10/18/2021, 10/21/2021, 10/25/2021, 10/28/2021, 11/01/2021, 11/04/2021, 11/08/2021. There was no evidence in the clinical record of physician orders or a physical therapy reassessment prior to 11/12/2021 to support the noted visits for the above certification period. CR#6 SOC 12/15/2021, CP 12/15/2021 to 02/12/2022. Per the CMS 485 for the certification period, the patient had orders for skilled nursing visits two (2) times per week for nine (9) weeks, and for physical therapy to evaluate and treat. Per a physician order received by RRB Home Healthcare Agency on 10/15/2021, the orders for skilled nursing visits were one (1) time per week for nine (9) weeks. Per the Outcome and Assessment Information Set (OASIS) initial assessment completed at the SOC on 12/15/2021, under Other Interventions, skilled nursing visits were documented as one (1) time per week for nine (9) weeks). The patient received skilled nursing visits two (2) times per week for nine (9) weeks until discharge on 01/21/2022. There was no documentation of a physician’s order clarifying the discrepancy regarding frequency and duration of visits. The CMS 485 contained an order for a referral to Speech Therapy related to a diagnosis of aphasia. There was no evidence of completion of a speech therapy referral in the CR. The CMS 485 contained an order for skilled nursing to instruct the patient/caregiver on proper use of a glucometer (portable device to check blood sugar) and logging daily blood sugar values, and that skilled nursing was to document patient/caregiver competency with glucometer and daily log. The patient received skilled nursing visits on 12/15/2021 and then two (2) times per week until 01/21/2022 at which time the patient was discharged. There was no documentation in any of the skilled nursing visit notes or the skilled nursing discharge note of the patient having received instruction or demonstrating competency on the use of the glucometer and logging of blood sugar values. An initial physical therapy evaluation was completed on 12/21/2021 whereby frequency and documentation orders for visits two (2) times per week for eight (8) weeks were obtained via the Physical Therapy Evaluation Note. The orders were not countersigned by the physician until 05/09/2022. A physical therapy discharge summary was completed on 12/30/2021 and signed by the physical therapist. The section for documenting a physician signature is still blank/has not been obtained. An interview with the administrator, office manager and office associate conducted on May 11, 2022 starting at 3:00 PM confirmed the above findings.

Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This STANDARD is not met as evidenced by: Based on a review of clinical records (CR), agency policies, and an interview with the Home Health Director of Nursing, the agency failed to document the supervision of a home health aide every fourteen (14) days for one (1) of one (1) clinical record: CR#5 Findings include: A review of the following agency policies took place on May 10, 2022 starting at approximately 10:00 AM: Policy #8047 states: “All patients receiving skilled services with Certified Home Health Aide (CHHA) services will be scheduled once every two (2) weeks for a direct supervisory visit by the Registered Nurse/Licensed Practical/Vocational Nurse.” In an interview with the Director of Nursing (DON) on May 11, 2022 at approximately 2:45 PM, the DON stated that the registered nurses are aware of the need to conduct and document home health aide supervisory visits every two (2) weeks, and that this was a documentation issue as opposed to a practice issue. A review of clinical records was conducted on May 10, 2022 starting at approximately 1:00 PM, and again on May 11, 2022 starting at approximately 9:10 AM. The start of care (SOC) and certification period (CP) per the Centers for Medicare and Medicaid Services (CMS) Home Health Certification and Plan of Care (CMS 485) are indicated below. CR#5 SOC 02/04/2021, CP 10/02/2021 to 11/30/2021 contained a CMS 485 with orders for Home Health Aide (HHA) Visits two (2) to three (3) times per week for nine (9) weeks. HHA visits occurred on 10/4, 10/6, 10/8, 10/11, 10/13, 10/15, 10/18, 10/20, 10/22, 10/25, 10/27, 10/29, 11/01, 11/03, 11/05, 11/08, 11/10, 11/12, 11/15, 11/17, 11/19, 11/22, 11/24, 11/16 and 11/29. There was no documentation in the clinical record of supervisory visits conducted for any of the visits over the certification period. An interview with the administrator, office manager and office associate conducted on May 11, 2022 starting at 3:00 PM confirmed the above findings.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on a review of agency policies, Governing Board documents, and an interview with the administrator, the agency failed to document that the governing board approved the annual budget and demonstrated oversight of the quality assessment and performance improvement program. Findings include: In an interview conducted with the office manager and administrator on May 10, 2022 at approximately 10:00 AM and again on May 11, 2022 at approximately 2:45 PM, the office manager and administrator noted that the Governing Body does review and discuss performance improvement activities and approves the annual budget, but that the discussion was not reflected in the Governing Body meeting minutes. A review of the following agency policies took place on May 9, 2022 starting at approximately at 12:00 PM: Policy #6012 Annual Operating Budget states: Page 1- "the board of directors approves the agency's annual operating budget." Policy #6002 Governance Board of Directors/Management Company states: Page 1 - "the Board of Directors is the governing body for RRB Home Healthcare and as such possesses ultimate responsibility and legal authority for managing the organization, for the safety or RRB Home Healthcare personnel and patients, and for the quality of care, treatment and services provided." Policy #6005 states: Page 1 - "The Board of Directors is responsible for ....approving the organization's long range, strategic and operational plans, providing budget oversight, monitoring and evaluating the effectiveness of the agency's performance on an annual basis to ensure that the organization's mission is consistently sustained over time." A review of the Governing Body minutes took place on May 9, 2022 at approximately 11:00 AM. The Governing Body minutes dated 12/20/2020 did not contain documentation of budget approval nor documented discussion regarding performance improvement activities. The agency provided an operating budget for the period January 1, 2022 to December 2022. The Governing Body minutes dated 12/17/2021 did not contain documentation of Governing Body budget approval for the 2022 budget, nor was there documented discussion regarding the agency's performance improvement activities. An interview with the administrator, office manager and office associate conducted on May 11, 2022 starting at 3:00 PM confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of personnel files (PF), agency policies and an interview with the Home Health Administrator, the agency failed to demonstrate the presence of the following: initial and/or annual competency evaluation/skills assessment, annual performance evaluation, current cardiopulmonary resuscitation certification, criminal background check, and/or tuberculosis screening for six (6) of six (6) personnel files: PF#1, PF#2, PF#3, PF#4, PF#5, and PF#6. Findings include: A review of the following agency policies and position descriptions took place on May 9, 2022 starting at approximately 3:15 PM: Policy #8011 states: Page 1- “It is the policy of RRB Home Healthcare to periodically and routinely evaluate the job performance and competency of each employee. This evaluation will be carried out according to the timetables described…..one year from each employee’s initial date of employment, annually thereafter on each employee’s anniversary date,” Page 2 -“Staff competence is assessed during orientation,….and annual… Proper documentation of each employee’s job performance will be maintained and recorded on the appropriate form by the evaluator. This document will become a permanent portion of each employee’s personnel file,” Page 3 – “This document is completed on the employee’s anniversary date for all employees who have successfully completed their first year of employment.” Policy #8002 Criminal Background Check states: Page 1: “RRB Home Healthcare performs background screening on all final candidates for employment….” Policy #4005 Tuberculosis Screening Program states: Page 1 – “It is the policy of RRB Home Healthcare to screen all employee for the presence of inactive or active tuberculosis at the time of employment…” Position Descriptions for Physical Therapist, Occupational Therapist, and Home Health Aide list the following items as “regulatory requirements”……”Current TB testing, current BCLS certification.” In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) baseline tuberculosis screening upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17) (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf). *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19). A review of personnel files was conducted on May 9, 2022 starting at approximately 2:15 PM. The date of hire is indicated below: PF#1 DOH 06/22/2017 did not contain evidence of an annual performance evaluation/competency assessment. The last performance evaluation contained in the PF was conducted in 2019. PF#2 DOH 04/29/2019 did not contain evidence of a competency assessment or performance evaluation in 2021. The last evaluation contained in the PF was conducted in 2020. The cardiopulmonary resuscitation card contained in the PF had an expiration date of 7/23/2021. There was one tuberculin skin test result contained in the PF, dated 11/16/2020. PF#3 DOH 03/26/2019 did not contain evidence of an annual performance evaluation/competency assessment. There was one competency evaluation in the PF, but it did not contain a completion date. The cardiopulmonary resuscitation card contained in the PF had an expiration date of 08/2021. PF#4 DOH 01/24/2022 did not contain evidence of cardiopulmonary resuscitation (CPR) certification. A position description in the PF was signed by the employee at time of hire (01/24/2022) acknowledging that CPR was a requirement of the position. There was no confirmation of tuberculosis screening upon hire. A health document contained in the PF, dated 11/30/2021 from another agency, had a handwritten notation that a “Quantiferon TB test” was negative along with unknown initials next to the notation. There was no Quantiferon-TB Gold test result in the file. A tuberculosis symptom screen or risk assessment was not completed upon hire. PF#5 DOH 10/03/2019 did not contain evidence of competency assessment upon hire. A competency assessment contained in the PF was completed on 10/3/2020. There was no evidence of a competency assessment or performance evaluation in 2021. The cardiopulmonary resuscitation card contained in the PF had an expiration date of 08/17/2021. The Pennsylvania Access to Criminal History (PATCH) was not obtained at time of hire. The date of the PATCH was 11/01/2021, approximately thirty (30) days after the date of hire. PF#6 DOH 04/10/2021 did not contain evidence of cardiopulmonary resuscitation (CPR) certification. The file contained a Federal Bureau of Investigation (FBI) criminal history background check that was obtained on 4/23/2018. There was no evidence of an updated criminal history background check at time of hire. There was no tuberculosis symptom screen or risk assessment completed upon hire. An interview with the administrator, office manager and office associate conducted on May 11, 2022 starting at 3:00 PM confirmed the above findings.