Every finding on record at Spring Valley Home Hlth Agency

A survey with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 9/25/23 through 9/26/23, during a recertification survey. The agency is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 9/25/23 to 9/26/23 a recertification survey was conducted. This resulted in an extended survey at Spring Valley Home Health Agency. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The Condition of Participation 42 CFR 484.105 at G940, Organization and administration of services and the Condition of Participation 42 CFR 484.110 Clinical Records at G1008 were found not met. The cumulative effects of these findings resulted in the Home Health Agency's inability to ensure provision of quality of care. In addition to the recertification, the following complaints were reviewed. H72265925C, H72265926C and H72265924C as a result no deficiencies were issued as a result of the complaint investigation. Unduplicated census: 0 Total home visits conducted: 0 Number of records reviewed: 3 Hours of Operation: Not operating since 8/2/22. No branch offices.

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 interview and document review, the agency failed to meet the Conditions of Participation (CoP) for Organization and administration of services, 42 CFR § 484.105 at G0940. The agency had discharged all of their patients and did not have skilled services available for any future patients the agency may admit. See G0982 During entrance interview on 9/25/23, at 8:30 a.m. Vice President of Patient Services (VPPS) indicated the agency hadn't served home care clients since 8/2/22. She stated the agency terminated the director of nursing (DON) on 6/28/23 and due to insufficient staffing, they determined they would transfer all 29 clients to another agency and suspend providing home care services. Documents reviewed revealed all 29 skilled and nonskilled clients received a letter from the agency, dated 7/1/22, indicating the agency would not continue providing home care needs as of 8/1/22 due to staffing shortages. The agency had no home care staff employed. No organization chart was available due to the agency not having any staff and was unable to operate as a home health agency.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to provide skilled nursing services and at least one other therapeutic service for over 12 months. The agency was unable to provide any services if they were to admit patients. During entrance interview on 9/25/23, at 8:30 a.m. Vice President of Patient Services (VPPS) indicated the agency had not served home care clients since 8/2/22. She stated the agency terminated the director of nursing (DON) on 6/28/23 and due to insufficient staffing, they determined they would transfer all 29 clients to another agency and suspend providing home care services. Documents reviewed revealed all 29 skilled and nonskilled clients received a letter from the agency, dated 7/1/22, indicating the agency would not continue providing home care needs as of 8/1/22 due to staffing shortages. The agency had no home care staff employed. No organization chart available due to no staff and agency not operating.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and document review, the agency failed to meet the Conditions of Participation (CoP) for Clinical records, 42 CFR § 484.110 at G1008. See G1026, Retention of records and G1030, Retrieval of records. The agency had not paid for their electronic medical record and no longer had access to patient records.

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to retain clinical records of home care clients served in the last five years affecting 29 patients were were discharged to another agency. During entrance interview on 9/25/23, at 8:30 a.m. Vice President of Patient Services (VPPS) indicated the agency had not served home care clients since 8/2/22. She stated the agency terminated the director of nursing (DON) on 6/28/23 and due to insufficient staffing, they determined they would transfer all 29 clients to other agencies and suspend providing home care services. VPPS further stated the agency stopped paying for use of software system, Point Click Care (PCC), therefore they could not access/provide documentation of services provided to their clients. They had not kept any of the records in a retrieval form. Review of three clinical records (P1, P2, and P3) revealed the agency had many provider orders, signed documents, and visit notes stored in their previous software system, Point Click Care (PCC). Agency staff was not able to access any patient records. Therefore the surveyor was not able to determine compliance with most Conditions of Participation (CoP's).

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to retain clinical records of previous clients served in the last five years affecting 29 patients. During entrance interview on 9/25/23, at 8:30 a.m. Vice President of Patient Services (VPPS) indicated the agency hadn't served home care clients since 8/2/22. She stated the agency terminated the director of nursing (DON) on 6/28/23 and due to insufficient staffing, they determined they would transfer all 29 clients to other agencies and suspend providing home care services. VPPS further stated the agency stopped paying for use of software system, Point Click Care (PCC), therefore they could not access/provide documentation of services provided to their clients. Review of three patient clinical records (P1, P2, P3) revealed the agency had many provider orders, signed documents, and visit notes stored in their previous software system, Point Click Care (PCC), which was not accessible.