Every finding on record at Serenity Home Health Care Services, LLC

AMENDED 08/19/24 SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION 107553 EXTENDED SURVEY The following deficiencies are based upon substantial allegation 107553 completed on 07/30/24. Serenity Home Healthcare Services is not in compliance with the requirements found at Health 42 CFR Part 484, Subpart B, C, Home Health Agencies. Serenity Home Healthcare Services is precluded from providing its own home health aide training and competency testing or competency evaluation program for a period of two years from the date of the receipt of the deficiency report (2567) for this survey.

Condition of Participation: 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 record review, interview and policy review, the facility failed to ensure allegations of neglect were thoroughly investigated. This affected one (Patient #191) of three patients reviewed. This could affect all patients receiving services from the agency. The active census was 198. See G478 and G484

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, 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 HHA. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, he facility failed to ensure allegations of neglect were thoroughly investigated. This affected one (Patient #191) of three patients reviewed. This could affect all patients receiving services from the agency. The active census was 198. Findings include: Review of Patient #191's medical record revealed the start of care was 08/11/23. Diagnoses included legally blind, dementia, and hypertension. The patient is a current active patient of the facility. The patient's paid caregiver was her family member, Staff K, who was employed by the agency. Review of the Home Health Certification and Plan of Care dated 02/07/24 to 04/06/24 and 06/06/24 to 08/04/24 documented Patient #191 was forgetful. Functional limitations included endurance, ambulation, legally blind and dementia. Activities permitted were up as tolerated, independence at home, and use of a cane and walker. She had a fair prognosis. Patient had dyspnea, a cough, edema, fatigue and weakness. Home health aide (HHA) services were ordered for 36 hours a week. HHA assist orders included assist with personal care, activities of daily living, assist with meal preparation and medication reminders, assist with light housekeeping as needed, assist with bathing, grooming, ambulating, skin and foot care. Report to the registered nurse any changes, concerns, especially falls, injuries, emergency room visits, and hospital stays. She was at risk for falls, keep pathway clear, and it states she had an emergency plan developed. The record indicated the patient’s emergency plan was another family member who lived out of state and no phone number was provided. Review of an outside source request for information, dated 04/16/24, revealed Patient #191 was found by the social worker on 03/29/24 with dirty dishes in the sink. She was in a recliner with no food or drink near he. he said she was scared, hungry and thirsty. She was wearing a soiled incontinent brief and had a stage II pressure wound on her buttocks. For the period of 03/31/24 to 04/06/24 the aide's time sheets show Patient #191 received 30 hours of personal care services the week of 03/3l/24 to 04/06/24, but she was authorized to receive 36 hours per week on the service plan. The facility provided no evidence this allegation was investigated. There was no evidence anyone from the agency visited Patient #191's home to corroborate the allegation. The facility was notified again on 07/19/24 by another outside source of an incident report/ inquiry related to neglect. They received a report from the police that the paid caregiver had not been by in days to feed or care for the patient and they were requesting time sheets. The facility responded that they were trying to get nursing services weekly to check on the patient, the doctor approved it, but the insurance company denied it. Review of time sheets revealed only 31 hours of care were provided the week of 06/30/24. The week of 07/07/24, 26 hours of care were provided with no care provided on 07/12/24 or 07/13/24. The week of 07/14/24, only 18 hours of service were provided. There were no services provided 07/14/24, 07/15/24, 07/17/24 or 07/18/24. There were no communication notes as to why the days were missed, no evidence the physician was notified and no evidence the patient’s back up plan was implemented. There was no evidence the facility went to the patient’s home to investigate the allegation of neglect. During interview on 07/23/24 at 11:50 A.M., Patient #191 stated she stays in bed until Staff K gets her out. She stays up until Staff K puts her to bed. She can dress herself if given the clothes. She will feed herself if provided the food. She has been blind for 10 years. Where she lives now is not the same place she lived when she could see. She is afraid to go up or down steps, afraid to walk herself because she doesn't know where things are. She has no steps in her home. During an interview on 07/24/24 at 2:20 P.M., Staff G stated no one noticed days missing in July when the time sheets were provided. Staff G stated she would investigate. On 07/25/24 at 4:00 P.M. Staff G emailed a Communication Note dated 07/23/24 stating Staff K turned in her time sheets and she was short two hours for the week of 07/14/24 to 07/20/24. An incident report with a second warning for Staff K was dated 07/25/24. Staff K was brought in and discussed missed visits, not adhering to a schedule, failure to notify office of schedule changes, late time sheet submission and was given a new schedule of hours to provide care. The patients’ hours were increased to 43 hours per week as of 07/16/24. Patient #191 now has another family member as a back up. When asked about the facility not addressing their staff missing whole days of work with no provisions in place for a blind patient to be assisted to bed, the bathroom, out of bed and provided meals Staff G wrote in an email dated 07/25/24 5:16 P.M. email this was all addressed with the final warning. They were unaware of services not being provided. The employee was re-educated on the importance of timesheets and communication. After the verbal warning, they went straight to the last chance due to not following directions. Staff G stated Staff K said she is at Patient #191’s home 90 percent of the time and Patient #191 will push her life alert button even when Staff K is in the home. Review of the facility's MANDATORY REPORTING OF ABUSE, NEGLECT, EXPLOITATION, AND REPORTABLE CONDUCT revised 2009 included: The following policy is provided to all patients/clients admitted to this Agency regarding patient information and the mandatory reporting of Abuse, Neglect, Exploitations, and Reportable Conduct. If the agency has reason to believe that b patient has been abused, neglected, and/or exploited by an Agency employee, the Agency must report the information to: • Ohio Department of Aging and Elder Services: (866) 635-3748 • Domestic Abuse I Violence Hotline: (800) 799-7233 Definitions: Neglect: Failure to care for or, to disregard or pay no attention to. Neglect can be passive (unintentional), or active (intentional failure to fulfill a caretaking obligation to inflict physical or emotional stress or injury). . Procedure I If any Agency employee or contactor is suspected of abuse, neglect, or exploitation, the employee or contractor will be suspended immediately, and an investigation conducted by the Agency and the appropriate agency. If the Agency finds that kind of abuse, neglect, or exploitation occurred, the employee or contractor will be terminated, and the incident(s) reported to the appropriate staff) department, licensing board, or law enforcement official. The Agency's director and physician shall be notified of the Agency's intent to report. All health care professionals, whether employed or contracted by the Agency, who suspect neglect or abuse or exploitation ·have the legal obligation to report such to the Domestic Abuse I Violence Hotline at (800) 799-7h33 All Agency employees and contractors are required to report any unprofessional conduct by a licensed health care professional to the professional's licensing board and to his or her supervisor, if any. All agency employees and contractors will report immediately any suspected abuse, neglect, and exploitation to their agency supervisors and to the Department of Protective Services (DPRS) or other state agencies as required by law. Any nurse or other professional who suspects that a patient is a victim of family violence has the legal obligation to provide information at ion in the form of a written notice mandated by the state of Ohio. The provision of the completed notice plus documentation of reason(s) why abuse is suspected shall be documented~ by the Agency. All reports of suspected abuse,[neglect, or exploitation shall be documented by Agency and such documentation will be kept confidential by the Agency to the extent required by Ohio law. Documentation shall report only observations and statements by the people involved. Included in reportable offenses included inadequate supervision with resulting effect on activity of daily living provision, e.g., bathing, toileting, food, etc. The Director of Clinical Services will communicate assessment findings to the physician and the appropriate agency according to state regulations/laws. All findings and communications will be documented in the patient's medical record. The Agency will report allegations, observations and suspected cases of exploitation, abuse and/or neglect to appropriate authorities.

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: AMENDEDED 08/19/24 Based on record review and interview, the facility failed to provide evidence of a current complaint log. This had the potential to affect all the patients of the facility. The current active census was 198. Findings include: Review of the the facility's complaint log revealed there were no entries since 2021. The facility was unable to provide a current complaint log on 07/22/24 during the survey. Staff C documented in an email on 07/23/23 at 3:01 P.M. related to a complaint log "These sorts of communications seem to have been done electronically, which we are working to see if we can compile efficiently." The log was not forwarded. Staff C documented in an email on 07/23/24 at 4:54 P.M. the facility did have a place to log complaints in the Electronic Medical Records (EMR) system, therefore they don’t use a paper log. The current complaint log, which was asked for on entrance, was not provided to the survey team.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, interview and policy review, the facility failed to ensure services were provided as written in the individualized plan of care, and failed to ensure the physician was notified of missed visits This affected one (Patient #191) of three patients reviewed. This could affect all patients receiving services from the agency. The active census was 198. See G572

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 record review, interview and policy review, the facility failed to ensure services were provided as written in the individualized plan of care, and failed to ensure the physician was notified of missed visits This affected one (Patient #191) of three patients reviewed. This could affect all patients receiving services from the agency. The active census was 198. Findings include: Review of Patient #191's medical record revealed a start of care date of 08/11/23. Diagnoses included legally blind, dementia, and hypertension. The patient is a current active patient of the facility. Patient #191's family member, Staff K, was her paid caregiver through the agency. Review of the most current 485 Home Health Certification and Plan of Care for the certification periods of 02/07/24 to 04/06/24 and 06/06/24 to 08/04/24 included the patient was forgetful. Functional limitations included endurance, ambulation, legally blind and dementia. Activities permitted were up as tolerated, independence at home and use of a cane and walker. She had a fair prognosis. Patient had dyspnea, a cough, edema, fatigue and weakness. Home health aide (HHA) services were ordered for 36 hours a week. HHA assist orders included assist with personal care, activities of daily living, assist with meal preparation and medication reminders, assist with light housekeeping as needed, assist with bathing, grooming, ambulating, skin and foot care. Report to the registered nurse any changes, concerns, especially falls, injuries, emergency room visits, and hospital stays. She was at risk of falls, keep pathway clear, and it stated she had an emergency plan developed. The record stated the patient’s emergency plan was another family member who lived out of state and no phone number was provided. Review of an outside source request for information, dated 04/16/24, revealed Patient #191 was found by the social worker on 03/29/24 with dirty dishes in the sink. She was in a recliner with no food or drink near here. She said she was scared, hungry and thirsty. She was wearing a soiled incontinent brief and had a stage II pressure wound on her buttocks. For the period of 03/31/24 to 04/06/24 the aide's time sheets show Patient #191 received 30 hours of personal care services the week of 03/3l/24 to 04/06/24, but she was authorized to receive 36 hours per week on the service plan. There was no documentation showing the agency notified the patient, backup plan, physician and case manager that the patient would have shortened hours in for personal care service. Review of time sheets for the week of 03/31/24 revealed Staff K provided services from 5:00 A.M. to 7:00 A.M. for two hours and from 5:00 P.M. to 7:00 P.M. for two hours for a total of four instead of five hours a day, there were no services provided 04/01/24. On 04/02/24 services were provided from 5:00 to 7:00 A.M. for two hours and 9:00 P.M. to 10:00 P.M. for one hour instead of the five hours a day. The patient received 27 of 36 hours of care allotted for the week of 03/31/24. There was no evidence Staff K informed the facility or patient of her absence. There was no evidence of an emergency backup plan being put in place. There was no evidence of the physician being notified of a missed visit and shortened hours. There was no evidence of the facility going to the patient’s home to investigate the neglect concern after they were made aware by PCG. The facility was notified 07/19/24 by another outside source of an incident report/ inquiry related to neglect. They received a report from the police that the paid caregiver’s daughter had not been by in days to feed or care for the patient and they were requesting time sheets. The facility responded that they were trying to get nursing services weekly to check on the patient, the doctor approved it, but the insurance company denied it. Review of time sheets revealed only 31 hours of care were provided the week of 06/30/24. The week of 07/07/24, 26 hours of care were provided with no care provided on 07/12/24 or 07/13/24. The week of 07/14/24, only 18 hours of service were provided. There were no services provided 07/14/24, 07/15/24, 07/17/24 or 07/18/24. There were no communication notes as to why the days were missed, no evidence the physician was notified and no evidence the patient’s back up plan was implemented. During interview on 07/23/24 at 11:50 A.M., Patient #191 stated she stays in bed until Staff K gets her out. She stays up until Staff K puts her to bed. She can dress herself if given the clothes. She will feed herself if provided the food. She has been blind for 10 years. Where she lives now is not the same place she lived when she could see. She is afraid to go up or down steps, afraid to walk herself because she doesn't know where things are. She has no steps in her home. Review of Staff K's personnel record included an original hire date of 10/13/19 and rehire 05/03/21. No disciplinary action was in Staff K’s personnel record. During an interview 07/24/24 at 2:40 P.M., Staff G stated Staff K did not come in for counseling and the education was verbal, thus no entry into the personnel record for the March/April missed visits. The facility provided a Personal Communication note dated 04/16/24 written by Staff M that stated Staff K was in the office and missed visits and time sheets were discussed. Staff K indicated it would not happen again; she was sick. The facility obtained a written statement 04/16/24 from Staff K that said she was sick to account for the absence. She wrote she is at Patient #191’s home 80 percent of the time 365 days a year. She gave no reason for not notifying the facility of her absence. The statement did not say if she informed Patient #191 she was not going to be there. There was no mention of Staff K initiating an emergency backup plan. During an interview on 07/24/24 at 2:20 P.M., Staff G stated no one noticed days missing in July when the time sheets were provided. Staff G stated she would investigate. On 07/25/24 at 4:00 P.M. Staff G emailed a Communication Note dated 07/23/24 stating Staff K turned in her time sheets and she was short two hours for the week of 07/14/24 to 07/20/24. An incident report with a second warning for Staff K was dated 07/25/24. Staff K was brought in and discussed missed visits, not adhering to a schedule, failure to notify office of schedule changes, late time sheet submission and was given a new schedule of hours to provide care. Another family member was initiated as the back up plan. When asked about the facility not addressing their staff missing whole days of work with no provisions in place for a blind patient to be assisted to bed, the bathroom, out of bed and provided meals Staff G wrote in an email dated 07/25/24 5:16 P.M. email this was all address with the final warning. They were unaware of services not being provided. The employee was re-educated on the importance of timesheets and communication. After the verbal warning, they went straight to the last chance due to not following directions. Staff G stated Staff K said she is at Patient #191’s home 90 percent of the time and Patient #191 will push her life alert button even when Staff K is in the home. There was no evidence provided prior to exit that the physician was notified of the missed visits. Review of the facility's policy titled "Missed Visit Policy", undated, stated the facility would notify the physician of missed visits. Review of the facility's policy titled "Attendance and Reporting Policy", revised 2009, stated if an employee expects to be delayed for any reason they notify and inform their supervisor of the reason for the late arrival and expected arrival time. Review of the facility policy titled "Field Employee Standards", undated, stated you are expected to arrive on time for all assignments that you have accepted. However, in an emergency or any situation should cause you to be five minutes late or more, or to be totally absent from the assignment you must notify the agency immediately. You may call the agency 24 hours a day if you need to cancel or reschedule your assignment. A no-call, no show is grounds for termination.

Substantial Allegation Survey Substantial Allegation OH00120654 COVID 19 Focused Infection Control Survey The following deficiency is based upon substantial allegation OH00120654 completed on 03/17/21. Serenity Home Health Care Services, LLC 368021, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at 42 CFR Part 484.70 related to Infection Control and 42 CFR Part 484.102(b)(5) related to Emergency Preparedness.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure the home health aide (HHA) provided services included in the plan of care for one of three patient medical records reviewed (Patient #2). The agency census was 215. Findings include: Review of the medical record for Patient #2 revealed the patient was admitted to the agency on 04/08/2020 with the primary diagnosis of cerebral palsy. Review of the certification period dated 02/02/21 to 04/02/21 revealed the patient was to receive HHA services 21 hours per week for 60 days. Review of the HHA plan of care revealed the patient was to receive a shower and shampoo of hair every week and hair care, oral care, skin care, and assistance with dressing every day. Review of the HHA timesheet revealed no documented evidence these services were provided for the weeks of 01/31/21, 02/07/21, 02/14/21, 02/21/21, or 03/01/21 nor was there any indication the patient refused those services. Interview with the Administrator on 03/16/21 at 2:00 PM confirmed the findings.