Every finding on record at Salem Home Care, LLC

An unannounced on-site investigation for complaint #71294 was reopened and initiated on 10/19/2022 and completed on 11/02/2022. Complaint #71294, which involved the same underlying allegations as complaint #62323, was originally investigated on 5/16/2022 and completed on 6/2/2022. Complaint #62323 that was unsubstantiated, additional information gathered in the subsequent investigation of complaint #71294 is reflected in this report. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Clinical Director on 10/19/2022 at 10:04 AM. The purpose of the investigation and the investigation needs list were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: AEB - As Evidenced By CFR - Code of Federal Regulations CDRN - Clinical Director Registered Nurse D/T - Due to DR - Doctor Eval - Evaluation HH - Health Health HHA - Home Health Agency LHC - Name of the organization MSW - Masters of Social Work PCP - Primary Care Provider PT - Physical Therapist RN - Registered Nurse VO - Verbal Order

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to provide proper documentation of the agency's attempt to resolve complainant's request prior to discharge and follow the HHA's policy of proper documentation of complaints for one of the records reviewed (Patient #1). Findings: The review of documentation in the medical record revealed that Patient #1 was admitted on 2/9/2022 with the primary diagnosis of dementia and discharged on 2/21/22. Review of the document titled "Client Coordination Care Note" dated 2/18/2022, revealed "RECEIVED MESSAGE FROM [adult child's name]. [The adult child] CALLED INTO THE OFFICE DEMANDING TO HAVE '[Physical therapist's name]/PT ONLY'. THIS CDRN ATTEMPTED 2 CALLS WITH [the patient's adult child]... [The adult child] QUICKLY ESCALTED INTO YELLING AT THIS RN WHILE DEMANDING "YOU MAKE IT HAPPEN" AEB PRESSURED SPEECH WITH LOUD VOLUME. [The adult child's name] HUNG UP ON THIS RN X 2 ATTEMPTS. COLLABORATION WITH KAISER PERMANENTE DR [physician's name], VERY APOLOGETIC FOR [adult child's] BEHAVIOR, WILL FORWARD THIS ONTO PCP FOR FOLLOW-UP AS [physician's name] EXPRESSED CONCERN FOR [patient's] WELLBEING. VO RECEVIED TO CANCEL MSW EVAL THE WEEK OF 2-20-2022 AND DISCHARGE FROM HH SERVICES THE WEEK OF 2-20-22, FROM [patient's doctor], D/T UNSAFE ENVIRONMENT AND VERBALLY ABUSIVE BEHAVIOR. " During an interview with the complainant on 10/27/2022 at 11:24 AM, the complainant stated "We had [name of the home health] come into the home for physical therapy. And it was like for six treatments. The first one they come in to gather information like what kind of medication [the patient] is on, look at the house. It was a 45 minute meeting. So I think there were 5 physical therapy sessions. [The physical therapist] who did the initial assessment, I said are you a physical therapist? [They] said yes and I said can you come out and do the physical therapy? Then [they go] yes, you just have to request for me. So anyway we scheduled the next time when [they were] going to come out next week and [they] did the physical therapy with [the patient], which was fine and [they say] just keep calling and keep asking for me. - [The patient] has vascular dementia, [they are] probably about stage five, so [they] can’t remember things very well and people coming into [their] home so I wanted the same person so I don’t have to start over with a different gal or guy. - I requested [that PT] again. I think [they] came out the second time and there was like three sessions left and so I called in and requested for [them]. Then I got a phone call from the [Executive] Director saying it’s not possible. You are going to get somebody else. And I said well, this [person] says [they] can come out no problem. It does not have to be the same time, the same day of the week. I just would like to have the same person and [the Executive Director] says, ‘it is not gonna happen.’ Well [the PT] told me it could. We have like three sessions left or something like that. I am in a car with [the patient] taking [them] to an appointment so make it happen. Hung up. [The Executive Director] called back a minute or two later and was confrontational and said [they were] not going to come out. Then I said again just make it happen I am in the car I got to go. - So that same day I got a phone call from that physical therapist calling to schedule [the] next time [they] would come out. And I go well this is kind of weird have you talked to the director? [They go] no what is this about? And I say well [the Executive Director] told me that you couldn’t come out the remaining sessions. It will be one of your coworkers. [The PT] says I don’t know anything about that. I will just schedule you this next week and I said okay. - So [they] came out [they were] on time, welcomed [them] at the door sat down with [their] brief case and said this is our last treatment. [The PT] says my Director did not like the way you talked to [them] on the phone so we are canceling the treatment plan. It ticked me off, so I said get out! Leave." Review of a document dated June 7, 2020 and titled "The Importance of Routine and Familiarity to Persons with Dementia" revealed "Persons with dementia thrive on familiarity. Familiarity is important because dementia gradually impairs a person's ability to plan, initiate, and complete an activity. By creating an environment of familiar routines and activities, it allows them to feel comforted and calm." www.alzheimersproject.org. Based on the above article, complainant's request for the same physical therapist for all the therapy visits for the patient with dementia was a reasonable request. During an interview with the Clinical Director on 10/19/2022 beginning at 10:04 AM, they stated “[Patient #1's adult child] was saying only [PT's name] to come and see [Patient #1]… we can’t guarantee that. [The adult child] said you make it happen; you make it happen with large volume. We do try to accommodate. We only had two visits. We had the admit and [physical therapist] saw them and explained [they] can’t come every visit. [Patient #1's adult child] then called and stated, 'you will do it, you will do it.' And after collaboration with Kaiser about the behavior Kaiser told us to discharge so we discharged [Patient #1]. We can’t have people being abusive and swearing at us after two visits; that is not something we can be able to accommodate...I even tried to call [them] back and [they] hung up on me. So that is when we called Kaiser and had that discussion with Kaiser. Apparently, there was some concern that Kaiser had from past behavior I am not sure. So, I collaborated with [name of the physician]. [they were] very apologetic for [the adult child's] behavior. And we received a verbal order to cancel the MSW eval and to discharge from home health services for the week of 2/20/22." During the above interview, the Clinical Director was asked instead of sending the physical therapist to do a discharge was there any attempt by the agency to resolve the family's request. The Clinical Director stated "We had an order from the physician to discharge so we can’t just go out and say we are going to change this to a different visit. We cannot send our clinicians to a verbally abusive environment. We cannot and [the complainant's name] who was not willing to or did not want to discuss what our options were and how we can collaborate. [The adult child] immediately was screaming profanity and swearing at me about making it happen and hung up. There was no ability to collaborate. And I tried to call [them] back to talk to him. [They] hung up on me again. At our LHC group we have a people pillar and part of that people pillar is to protect our staff. We have only seen this person twice and here is somebody calling up and is verbally abusive and aggressive, according to Kaiser Permanente they want to know when anything happens in real time so this was a collaboration with the physician and then the physician wanted to discharge. It wasn’t like I called to get a verbal order to say we are not going to see this patient so I need orders.” During the same interview, the Clinical Director was asked then why send the same physical therapist to do a discharge if you felt it was unsafe. The Clinical Director stated “Because they [the physician] asked us to go out and try to do a discharge. Then [the physical therapist's name] said [they] would try to do the discharge. Typically a discharge visit is to lay eyes and to wrap up visits and give them information and to provide services but they refused to do it. We always offer that but they refused so we were not able to do the discharge. We can’t guarantee the same clinician for every visit.” Based on the above interview with the Clinical Director and record review, the agency failed to provide documentation that indicated the home health agency made a reasonable effort to try to accommodate or resolve the complainant's concern. Review of the "Client Coordination Note Report," dated 2/21/22 revealed, "UPON INFORMAING PATIENT'S [ADULT CHILD] OF THE NEED TO DISCHARGE HOME HEALTH PHYSICAL THERAPY, THE [ADULT CHILD] REQUESTED THAT THIS CLINICIAN LEAVE NOT SCHEDULE ANY FURTHER HOME HEALTH PT VISITS." During an interview with the physical therapist on 10/20/2022 beginning at 3:54 PM, they stated “There is one physical therapist for each region. I was the only physical therapist for that region. I usually see patients for the first visit, revisit, and discharge visits.” A physical therapist assistant usually sees patients for all the other visits. There are instances where I see patients for treatment but relatively rare… During the first visit, [the complainant] was relatively cordial, very specific and demanding. [They] asked if I could come out for all the visits. I told [them] there is no guarantee but if [they] wanted to, [they] could call the office and ask for me.” Regarding the discharge visit, the physical therapist stated, “It was not great. [The complainant] started cussing at my company, angry, and told me to leave. I got up, apologized, and left.” During the second interview with the physical therapist on 10/25/22 at 3:45 PM, the physical therapist stated, “[Name of a physical therapist assistant] was going to be the physical therapist assistant who would have seen the patient.” When asked whether the patient's family member asked the physical therapist whether they spoke to the Executive Director on 2/21/22, the physical therapist stated, “I don’t believe so if [they] did, I don’t remember. I don’t know for sure when I found out when the patient was going to be discharged. I don’t remember if it was that morning or the night before. But I don’t remember the exact timing. I was a little nervous about the last visit because [they were] not the friendliest individual and so I was a little nervous about the visit. When the visit happened, I was fearful because [they were] being very loud, and was using some very harsh language so I was kind of fearful.” During a second interview with the Clinical Director on 10/24/2022 at 2:30 PM, the Clinical Director was asked if there was any documentation by the Executive Director regarding a phone conversation they had with Patient #1's adult child. The Clinical Director stated “It is not in the chart, and [they were] no longer working here. I don’t have anything formally. I have no idea. I am not sure who [Patient #1's adult child] spoke to first. I know we [the Executive Director] and I both spoke to [Patient #1's adult child]. I don’t know the order of that. I spoke to the [adult child] the same day as the home visit by the physical therapist.” The agency failed to follow the process outlined in their own policy and procedure of documenting the complaint made by Patient #1's representative. The Clinical Director admitted that the Executive Director had a phone conversation with Patient's #1's adult child but there was no documentation provided. Review of the policy and procedure revised on 05/01/22 and titled, "GRIEVANCE PROCEDURE, PATIENT COMPLAINTS" revealed "1. Staff receiving complaints either in person, by phone, or through the mail shall document the patient complaint. Agencies will document the complaint within the information system; the Executive Director or Clinical Director will receive an automated workflow regarding the complaint for follow-up. Agencies using Continulink, will document the complaint by using the Patient Complaint Form located in the online Policy and Procedure Manual and notify the Executive Director within 24 hours of the complaint. 2. The Executive Director or Clinical Director interviews the patient, family, and involved staff or other individuals and takes appropriate actions to resolve the issue... If the Executive Director or Clinical Director is unable to resolve the complaint, the Executive Director and/or Area Executive Director/Regional Vice President are notified for further investigation and analysis." During an exit interview with the Interim Executive Director on 11/2/2022 at 1:39 PM, when discussing the reason why the agency sent the physical therapist to the patient's home to do a discharge if the Executive Director and the Clinical Director felt it was unsafe, the Interim Executive Director stated "Yes it is not consistent with the threat... I know what you are saying. [Name of the Clinical Director] did not know what [name of the Executive Director] was thinking because [name of the Executive Director] did not write it down so the incomplete documentation is certainly a problem in this instance where you can't go back and look at it and what the thought was during the discussion with the patient. So I totally understand."