Every finding on record at Spirit Homecare, Inc

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION OH00105219 The following deficiencies are based upon substantial allegation OH00105219 completed on 04/19/24. Spirit Homecare is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure an order for a patient to have nothing by mouth was included in the plan of care. This affected one (Patient #3) of three patients reviewed. The agency census was 296. Findings include: Record review for Patient #3 revealed a primary diagnosis of acute hypoxic respiratory failure. The diet/nutrition orders included bolus tube feedings every six hours through a percutaneous endoscopic gastrostomy (PEG) tube. The patient was ordered to have nothing by mouth (NPO) except tube feedings. The patient was also ordered to receive tracheostomy management per protocol. A tracheostomy had been placed on 09/13/23. A communication note on 01/08/24 revealed the agency received a call from another agency asking if the agency could take over care as they could no longer staff the patient. The Start of Care OASIS revealed an admission assessment was performed by a registered nurse on 01/08/24. The respiratory assessment noted the patient had dyspnea (difficult or labored breathing), tracheostomy, and oxygen use. Under feeding/eating, the registered nurse selected that the patient was unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy. The physician ordered plan of care for certification periods of 01/08/24 through 03/07/24 and 03/08/24 through 05/06/24 contained no physician order for Patient #3 to be NPO. During an interview on 04/16/24 at 3:07 PM, Staff A confirmed there should be a physician's order for the patient to be NPO in the plan of care.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure a patient received education regarding smoking with the use of oxygen. This affected one (Patient #3) of three patients reviewed. The agency census was 296. Findings include: The medical record of Patient #3 revealed a primary diagnosis of acute hypoxic respiratory failure. The patient was also ordered to receive tracheostomy management per protocol. A tracheostomy had been placed on 09/13/23. Review of discharge orders also revealed that oxygen per nasal canula/tracheostomy at 2 liters/minute was ordered as needed. A communication note on 01/08/24 revealed the agency received a call from another agency asking if the agency could take over care as they could no longer staff the patient. The Start of Care OASIS revealed an admission assessment was performed by a registered nurse on 01/08/24. The respiratory assessment noted the patient had dyspnea (difficult or labored breathing), tracheostomy, and oxygen use. The oxygen risk assessment revealed that the patient was a smoker. The physician was notified of the elevated risk for oxygen safety. The physician ordered plan of care for the certification period of 01/08/24 through 03/07/24 revealed Patient #3 was admitted to the agency with diagnoses including acute respiratory failure with hypoxia, dysphagia (difficulty swallowing), alcohol dependence, esophageal obstruction, gastrostomy, and tracheostomy. The physician ordered the services of a nurse twice a week for two weeks, once a week for seven weeks, and three PRN visits for illness and medication changes. Among other tasks, the nurse was ordered to perform, tracheostomy care, patient/caregiver teaching on care of the stoma and trach, dressing changes, suctioning, patient/caregiver teaching on how to clean reusable medical equipment, and patient/caregiver teaching on self-management of oxygen therapy. A list of medications on the plan of care included oxygen 2 liters as needed. Durable medical equipment listed on the plan of care included oxygen. Skilled nurse visits were conducted by a staff licensed practical nurse (LPN) as ordered. Skilled nursing notes for each visit noted a respiratory assessment that included oxygen use intermittently per nasal cannula, and tracheostomy. The visit notes contained no documentation that any education provided to the patient about the dangers of smoking with oxygen use. The OASIS Recertification visit was performed on 03/05/24. Although this assessment was less comprehensive, the assessment noted the boxes for oxygen use and smoker were selected. It was further noted that the physician was notified of the elevated risk for oxygen safety. A communication note dated 03/08/24 stated the agency LPN spoke with the case manager for the patient’s Medicaid managed care plan. The case manager voiced concerns with Patient #3 smoking with oxygen. The note stated the LPN informed the case manager that the patient had not been observed smoking. During an interview on 04/17/24 at 11:30 AM, a care management supervisor for the patient’s Medicaid managed care plan reviewed the case manager’s notes and stated that the case manager visited the patient’s home on 02/21/24. The patient was observed smoking. The case manager also documented the agency LPN stated she was unaware the patient was smoking. During an interview on 04/16/24 at 3:07 PM, Staff A confirmed that the medical record lacked documentation the agency registered nurse conducting the OASIS assessments which noted the patient’s smoking with oxygen use notified the agency LPN conducting the weekly visits of the patient’s smoking. It was also confirmed that the medical record lacked documentation the patient was provided education on the dangers of smoking with oxygen use.

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 04/14/23, Spirit Homecare is in compliance with the provisions of 42 CFR Part 484,102, Conditions of Participation for Home Health Agencies.

EXTENDED RECERTIFICATION SURVEY SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATIONS 96296, 96246, 96646, 96828, 96827, 96644, and 96542 The following deficiencies are based on the extended recertification survey and allegations contained in substantial allegations 96296 and 96246 completed on 04/14/23. Spirit Homecare Inc. is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies. Spirit Homecare Inc. is precluded from providing it’s 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.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, observation, record review and policy review, the facility failed to review the patient's medications for potential adverse effects, drug reactions and significant side effects. This affected one (Patient #6) of 25 sampled patients. The census was 826. Findings include: Review of the medical record of Patient #6 including the certification periods of 01/27/23-03/27/23 and 03/28/23-05/26/23 revealed the patient had a history of cerebral palsy, deep vein thrombosis, bilateral foot drop, functional quadriplegia, seizures, chronic pain, chronic fatigue syndrome, pulmonary embolism, enterocutaneous fistula, urinary incontinence, and sleep apnea. The patient was admitted for services of the agency on 01/27/23. The OASIS start of care was completed by a physical therapist on 01/27/23 and orders were received for skilled nursing. According to the plan of care the physician ordered skilled nurse visits once a week to observe and assess a stage 2 pressure ulcer on the buttock and report changes to the physician. A Non-OASIS start of care assessment was performed by an agency nurse on 02/01/23. An order for transfer revealed home health services were placed on hold on 02/11/23, as the patient was transferred to the hospital. An OASIS Transfer was completed by a staff nurse on 02/11/23. A review of the hospital records revealed medications listed in the physician’s H&P stated initially the patient’s caregiver was called to confirm the patient’s home medications as there were discrepancies. The caregiver stated she did not have the medications memorized and instructed hospital staff to call the agency who she works for. A progress note stated that a hospital staff member spoke with an agency representative who did not have the medications on file and advised the hospital to call the patient’s pharmacy. The following medication regimen was confirmed by the pharmacy: B 12 1000 mcg daily (a nutrient that helps prevent anemia);Levocarnitine 330 mg three times a day (medication used to prevent and treat a lack of carnitine which plays a critical role in energy production); Gabapentin 1200 mg in the morning and 500 mg in the evening (used to treat epilepsy and nerve pain); Folic Acid 1mg daily (vitamin used to treat certain types of anemia); Furosemide 20 mg daily (medication used to treat fluid retention and swelling caused by medical conditions); Singulair 10 mg daily (used to treat asthma and allergies); Nitrofurantoin 100 mg daily (antibiotic that works against bacteria in urinary tract); Omeprazole 40 mg daily (medication used to treat heart burn); Oxybutynin ER 15 mg daily (muscle relaxant); Topiramate 25 mg twice a day (medication used to treat epilepsy and migraines); Trazodone 50 mg every evening (medication used to improve mood, appetite, and energy level as well as decrease anxiety and insomnia related to depression); Vitamin D 2000 units daily (a fat-soluble vitamin known to help the body absorb and retain calcium and phosphorus); Levetiracetam 500 mg twice a day (Keppra is medication used to treat seizures); Lamotrigine 300 mg twice a day (medication used as a mood stabilizer); Buspirone 10 mg twice a day (medication used to treat anxiety); Alendronate 70 mg every week (medication used to treat and prevent certain types of bone loss); Enoxaparin 60 mg twice a day (medication used to prevent blood clots in patients who are on bedrest); and Risperidone 4 mg twice a day (medication that rebalances dopamine and serotonin to improve thinking, mood, and behavior). During a home visit on 04/04/23 at 12:00 PM, the patient’s medications were reviewed with Staff D. The patient had a large roll of dose packs and a binder containing a Medication Administration Record (MAR). Review of the MAR revealed the following discrepancies: Percocet 5-325 mg every 6 hours as needed for pain (narcotic used to treat moderate to severe pain) and Voltaren 2 g topical ointment used three times daily (nonsteroidal anti-inflammatory medication used to relieve joint pain from arthritis) were listed on the plan of care, but were not listed on either the medication regimen provided by the patient’s pharmacy or the MAR in the home. Gabapentin was listed on the plan of care, the medication regimen provided by the patient’s pharmacy, and the MAR, however the MAR instructed the patient to take 600 mg at bedtime; the pharmacy medication regimen instructed the patient to take 1500 mg in the morning and 500 mg in the evening and the physician-signed plan of care instructed the patient to take 600 mg daily. Tizanidine HCL was scheduled three times a day on the plan of care, however the MAR and the pharmacy medication regimen advised the patient to take every 8 hours as needed. Elavil 25 mg (antidepressant) daily was listed on the plan of care but not listed on the MAR in the home or the pharmacy medication regimen. Trazodone 50 mg every evening was not listed at all on the physician-signed plan of care. Nicotine 2 mg chewing gum (a medicine that can help people quit smoking); chew one piece of gum daily as needed was not listed on the plan of care or the medication regimen confirmed by the patient’s pharmacy. Clotrimazole-Betamethasone apply topically two times a day (medication used to treat skin infections such as athlete’s foot, ringworm, or jock itch was only listed on the MAR in the home. Nyamyc 100,000 units/gm apply to affected area(s) two times a day (antifungal used to treat fungal infections, was not listed on the plan of care or the medication regimen confirmed by the patient’s pharmacy. Alendronate Sodium 70 mg one tablet once a week (medication used to treat and prevent osteoporosis) was listed on the MAR in the home but not on the plan of care or the medication regimen. Ferrous Sulfate 300 mg one tablet each morning (iron supplement) was listed on the MAR but not on the plan of care or the medication regimen. Baclofen 20 mg one tablet three times a day (muscle relaxer) was listed on the MAR but not on the plan of care or the medication regimen confirmed by the patient’s pharmacy. Staff D was interviewed following the home visit that occurred on 04/04/23. Staff D stated that this visit was the first time the patient didn’t refuse to provide current medications in order for the RN to perform a medication reconciliation. During interview on 04/04/23 at 5:00 PM, Staff A confirmed there were numerous medication discrepancies between the medication regime confirmed by the patient’s pharmacy, the MAR in the home, and the physician-signed plan of care despite the indication that the patient’s medications had been reconciled. Nurses should perform a reconciliation of medications during every visit to the home. Review of the policy titled “Medication Reconciliation”, revised March 2018, documented the agency will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy. At the time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that the patient is taking at home, including dose, strength, route, and frequency. Any concerns or discrepancies will be reconciled by a RN with the patient’s physician.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure a resumption of care assessment was completed within 48 hours of the patient’s return. This affected one (Patient #6) of 25 sampled patients. The census was 826. Findings include: Review of the medical record of Patient #6 including the certification periods of 01/27/23-03/27/23 and 03/28/23-05/26/23 revealed the patient had a history of cerebral palsy, deep vein thrombosis, bilateral foot drop, functional quadriplegia, seizures, chronic pain, chronic fatigue syndrome, pulmonary embolism, enterocutaneous fistula, urinary incontinence, and sleep apnea. The patient saw her primary care physician on 01/13/23 to rule out a deep vein thrombosis. Although no deep vein thrombosis was seen with the performance of a lower extremity duplex ultrasound, a left lower hematoma was noted, and the patient’s caregivers were advised to wrap the area with an Ace bandage. Orders were received for the home health agency to evaluate the patient for services. The start of care order stated the referral for home health services was received on 01/25/23 and the patient requested a scheduled visit on 01/27/23. The patient was admitted for services of the agency on 01/27/23. The OASIS start of care was completed by a physical therapist on 01/27/23 and orders were received for skilled nursing. According to the plan of care the physician ordered skilled nurse visits once a week to observe and assess a stage 2 pressure ulcer on the buttock and report changes to the physician. A Non-OASIS start of care assessment was performed by an agency nurse on 02/01/23. An order for transfer revealed home health services were placed on hold on 02/11/23, as the patient was transferred to the hospital. An OASIS Transfer was completed by a staff nurse on 02/11/23. According to the patient’s hospital records, the patient was discharged from the hospital on 02/15/23. A communication note dated 02/21/23 stated the facility received an incoming call from the patient requesting a physical therapist to resume her services. The OASIS Resumption of Care was performed by the physical therapy on 02/28/23, 13 days after the patient was discharged from the hospital. Orders were received for the resumption of skilled nursing once a week. During the interview on 04/12/23 at 4:35 PM, Staff A confirmed the resumption of care did not occur within 48 hours of the patient being discharged from the hospital as required. Staff A stated that the patient requested that the physical therapist perform the resumption of care and he was unavailable until 02/28/23. Staff A confirmed the only communication about the resumption of care was dated 02/21/23, six days after the patient was discharged from the hospital which was still beyond the 48-hour requirement.

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 record review, observation, interview and policy review, the facility failed to ensure staff observed and assessed a pressure ulcer according to the physician orders. This affected one (Patient #6) of 25 sampled patients. The census was 826. Findings include: Review of the medical record of Patient #6 including the certification periods of 01/27/23-03/27/23 and 03/28/23-05/26/23 revealed the patient had a history of cerebral palsy, deep vein thrombosis, bilateral foot drop, functional quadriplegia, seizures, chronic pain, chronic fatigue syndrome, pulmonary embolism, enterocutaneous fistula, urinary incontinence, and sleep apnea. The patient saw her primary care physician on 01/13/23 to rule out a deep vein thrombosis. Although no deep vein thrombosis was seen with the performance of a lower extremity duplex ultrasound, a left lower hematoma was noted and the patient’s caregivers were advised to wrap the area with an Ace bandage. A physician’s note stated he/she was concerned about the patient’s hygiene and lack of personal care. Per the physician, the patient was visibly dirty with very poor peri care. The patient was wearing briefs that were too large. The patient wet and soiled her clothes while in the physician’s office. Orders were received for the home health agency to evaluate the patient for services. The start of care order stated the referral for home health services was received on 01/25/23 and the patient requested a scheduled visit on 01/27/23. The patient was admitted for services of the agency on 01/27/23. The OASIS start of care was completed by a physical therapist on 01/27/23 and orders were received for skilled nursing. According to the plan of care the physician ordered skilled nurse visits once a week to observe and assess a stage 2 pressure ulcer on the buttock and report changes to the physician. A Non-OASIS start of care assessment was performed by an agency nurse on 02/01/23. Under the section titled “orders for discipline and treatment” it stated the patient had a stage II pressure ulcer of buttock requiring skilled observation and assessment of wound and report changes to the physician. There was no assessment of the pressure ulcer with measurements or a description of the wound in the medical record. On 2/11/23, Patient #6 was transferred to the hospital. Review of the hospital record revealed a history and physical (H & P) for Patient #6. The H & P documented a hematoma to the lower extremity that was open and bleeding, sacral wounds and chest wounds. The physician stated that he suspected the sacral wounds were pressure-induced, given their location. The physician also stated the cause for the chest wounds was “apparently dropped cigarettes.” The hospital’s continuity of care form listed recommendations for wound care treatment that included dressing/treatment for chest wounds: cleanse daily with sage wipes then apply Citric Aid Clear liberally to chest wound. Buttocks wounds: once a day peel back Mepilex Border to sacrum and apply Therahoney Gel to wound beds. Re-adhere Mepilex and change every three days and as needed. Left lower LLE wound: once a day peel back Mepilex Border Ag. Place a new strip of Aquacel Ag in undermining of wound then re-adhere Mepilex Border Ag and change every three days and as needed. These treatment orders were not on the physician ordered plan of care for Patient #6. A communication note dated 02/21/23 stated the facility received an incoming call from the patient requesting a physical therapist to resume her services. A Non-OASIS Start of Care assessment was performed by a staff RN, on 03/03/23. The narrative stated “the patient refused skin check to backside and states her husband and aide apply ointment to buttocks pressure ulcers.” There was no documentation the clinical manager/Director of Nursing was notified of the patient’s refusal to assess and observe the patient’s wounds. A skilled nurse visit was conducted by Staff D on 03/08/23. Review of the integumentary/skin section of the skilled nurse visit form revealed only that the patient’s skin was dry. The wound(s) selection box was not checked. The visit narrative did not indicate that an attempt was made to assess and observe the wounds on the patient’s buttocks that were previously identified as a stage II. A skilled nurse visit was conducted by Staff D on 03/14/23. Again, the only skin descriptor that was selected was the box describing the patient’s skin as dry. The visit narrative stated: “According to wound care orders from the wound clinic patient has pressure ulcers to her buttocks.” The narrative further stated that the patient declined wound care or assessment. There was no documentation the clinical manager/Director of Nursing was notified of the patient’s refusal to assess and observe the patient’s wounds. The OASIS Recertification dated 03/23/23, documented Patient #6 had at least one unhealed pressure ulcer/injury at Stage II or higher. It was documented the patient had refused a skin check. Observation of Patient #6 was made during a home visit on 04/04/23 at 12:00 PM. During the visit, Staff D obtained the patient’s vital signs which were within a normal range. Staff D asked Patient #6’s caregiver how her buttocks looked. The caregiver replied they were looking good an healing. Staff D made no attempt to observe or provide care to the Stage 2 pressure ulcers on the patient’s buttocks. Staff D was interviewed immediately following the home visit. Staff D stated she was only able to visualize the sacral wounds after care was resumed after the patient’s hospitalization. Staff D stated that the patient continues to refuse to allow the nurse to look at the sacral wounds. During interview on 04/04/23 at 4:20 PM, Staff A confirmed Patient #6 was admitted for services of the agency to observe and assess Stage 2 sacral wound. Staff A confirmed the medical record contained no documentation of any wound assessment or notification to the agency that Patient #6 continued to refuse to allow staff to assess the wounds. s and the medical record lacked documentation of an assessment of any wounds. Review of the policy titled “Wound Care” documented RN Case Managers are responsible for reviewing wound care orders provided by referral source upon initial start of care assessment. Each individual wound should be labeled according to wound assessment compiled and provided by referral source. RN Case Manager is responsible for identifying location of wound upon initial nurse assessment. Clinicians completing wound care documentation after initial start of care assessment must reflect plan of care wound numbering and labeling format in clinical documentation. Clinicians are responsible for wound measurement every seven days. Furthermore, best practice is capturing images of each wound and uploading to patient’s chart each time wound is measured. The policy instructs staff nurses to utilize best nursing protocol for up to 24 hours in the event wound care orders have not been created/sent by the physician. If wound care orders have not been created or sent by physician by hour 24, the nurse cannot continue to provide wound care treatment and the patient must be referred to a physician or local ED for further treatment.

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 record review and interview, the facility failed to ensure the agency had a Clinical Manager/Director of Nursing (DON) responsible for overseeing clinical operations (G958) and failed to ensure a Clinical Manager/DON was available during agency operating hours (G950). This had the potential to affect all patients serviced by the agency. The census was 826.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure a Director of Nursing/Clinical Manager was available during operating hours. This had the potential to affect all patients admitted to the agency for services and clinical staff. The census was 826. Findings include: Review of the agency’s table of organization identified Staff D as the Director of Nursing (DON)/Clinical Manager. Staff A was interviewed on 04/13/23 at 11:55 AM. Staff A stated that he and Staff D take turns being on call for the agency. Staff D was interviewed on 04/04/23 at 12:00 PM. Although Staff D reported sometimes getting calls from other staff nurses with questions, Staff D denied being on-call for the agency. These facts were confirmed with Staff A on 04/14/23 at 3:55 PM. It was confirmed that Staff D denied taking any required call for the agency as outlined in the job description for a DON. The agency’s job description for the Director of Nursing documented the Director of Nursing is a Registered Nurse who has graduated from an accredited school of nursing. If an RN, the Director of Nursing is available at all times during operating hours and participates in all activities relevant to professional services, including the development of qualifications and assignment of personnel. The responsibilities listed in the job description included the following: 1). Participates in developing standards which ensure safe and therapeutically effective service to patients and families 2). Participates in developing objectives for the agency 3). Consults with the Administrator to determine a staffing pattern which will accomplish stated objectives and promote maximum level of utilization of health personnel 4). Participates in planning for the orientation of new employees. Conducts selected orientation classes. 5). Provides 24 hour/day, seven days/week on-call coverage.

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 record review and interview, the agency failed to ensure a Director of Nursing/Clinical Manager was employed full time to provide oversight of clinical operations. This had the potential to affect patients receiving services from the agency. The census was 826. Findings include: The table of organization was provided by Staff A on 03/30/23. Staff D was listed as the Interim Director of Nursing (DON). During interview on 04/04/23 at 12:00 PM, Staff D stated Staff A told her that she was the DON. Staff D stated the agency needed to get a DON. She said when previous DON left the position in September 2022, she did agree to help out with some of the duties of a DON until one was hired, however, her duties are primarily out in the field taking care of patients. Staff D stated she did attend monthly meetings in the office but she did not oversee clinical staff, provide education for clinical staff or take call for the agency after business hours. During interview on 04/12/23 at 4:45 PM, Staff L stated that most of the agency functions are handled by the Administrator and the Marketing Director. During interview on 04/13/23 at 11:55 AM., the Administrator stated finding nurses is difficult since the onset of Covid -19. The agency’s job description for the Director of Nursing documented the Director of Nursing is a Registered Nurse who has graduated from an accredited school of nursing. If an RN, the Director of Nursing is available at all times during operating hours and participates in all activities relevant to professional services, including the development of qualifications and assignment of personnel. The responsibilities listed in the job description included the following: 1). Participates in developing standards which ensure safe and therapeutically effective service to patients and families 2). Participates in developing objectives for the agency 3). Consults with the Administrator to determine a staffing pattern which will accomplish stated objectives and promote maximum level of utilization of health personnel 4). Participates in planning for the orientation of new employees. Conducts selected orientation classes. 5). Provides 24 hour/day, seven days/week on-call coverage.

Substantial Allegation Survey Substantial Allegation 94164, 93755, 93773 and 71907 The following deficiency is based upon the substantial allegation 93773 completed on 11/07/22. No deficiencies were issued in regard to allegations contained in substantial allegations 94164, 93755 or 71907. Spirit Homecare, Inc 368175, is not in compliance with the requirements at 42 CFR Part 485, Subpart B, C for Home Health Agencies.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure a comprehensive assessment was completed within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date for one of one patient records reviewed with a resumption of care (Patient #3). The total sample was five. The patient census was 233. Findings include: Review of Patient #3's medical record revealed a start of care (SOC) of 06/08/22 and the certification period reviewed was from 08/07/22 to 10/05/22. Further review revealed a hospital history and physical (H & P) dated 08/30/22. The H & P revealed the patient was transferred to the hospital from hemodialysis on 08/30/22 for complaints of hypoxia, and complaints of nausea, and slurred speech with numbness to both hands. Patient #3 was recently diagnosed with a stroke. The plan was deep vein thrombosis prophylaxis with intermediate to high risk on Heparin subcutaneously. Review of a communication note dated 08/28/22 per the hospital Epic record revealed Patient #3 was admitted to the hospital on 08/27/22 and is expected to discharge on 08/29/22. There was a note to place the transfer in Patient #3's Axxess record at this time and the community liaison would continue to follow. Review of a communication noted dated 09/14/22 revealed a phone call from Patent #3 who voiced anger that she has been home for two weeks and has not seen her nurse for home care services. Patient #3 reported that she contacted the office on several occasion and no one has answered the phone. The patient threatened to contact the State Agency to report the agency as negligent. Review of a communication note dated 09/14/22 revealed the nurse spoke to Patient #3 to schedule the resumption of Care (ROC) visit. Patient #3 requested the ROC visit be 09/19/22. Review of a communication note dated 09/14/22 revealed Patient #3's hospital Epic record reflected the patient was discharged from the hospital on 08/30/22. Orders were placed on 08/27/22 for a ROC. Review of a communication noted dated 09/18/22 revealed the nurse talked to the patient to schedule a resumption of care (ROC) visit as previously discussed for 09/19/22. The patient states she is not available on 09/19/22 due to her roommate having surgery. The RN rescheduled the ROC visit for 09/22/22 as the patient requested. There was no evidence in the patient's record the physician was notified the ROC assessment was not completed timely or that the patient requested another date for the assessment to be completed. This finding was confirmed in an interview at 9:10 AM on 11/07/22 with Staff A prior to the exit conference. This deficiency represents non-compliance investigated under Substantial Allegation 93773.