Every finding on record at Staff Mates Inc.

An unannounced survey visit concluded on June 28, 2024, for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations § 484.102, Condition of Participation for Home Health Agencies. The agency was in compliance with the requirements at the time of the survey .

An unannounced survey visit concluded on June 28. 2024, for the purpose of a Home Health Agency recertification. Standard Level deficiencies were identified at the time of the visit

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on agency record review and interview with agency personnel, the Governing Authority failed to ensure an ongoing program for Quality Assurance Performance Improvement (QAPI) was reestablished, implemented, and maintained. The findings include. Review of the agency documentation, with the Administrator/Governing Authority/Owner and Supervisor of Clinical Services (SCS) on 6/24/24 at 11:00am, identified that the agency has been without an active Quality Assurance Performance Improvement (QAPI) committee since March 2023, due to unforeseen circumstances. The Administrator identified, they have attempted to fill the vacancies, within the committee, but as of this date, they have no active members or candidates. The agency failed to ensured participation of active members within the QAPI program and failed to ensure that the required agency clinical record review was conducted quarterly since March 2023 in accordance with agency policy Review of the agency policy identifies that at least quarterly, a committee of health professionals in active practice, or by peer review process, select a sample of active and discharged clinical records to be reviewed, to assure that the agency policies are followed, and that agency services are delivered within the agency's defined scope of practice, safety practices and current standards. Subsequent to this surveyor inquiry, the agency Administrator produced Professional Advisory Committee meeting minutes for the years 2023 and 2024, disclosing annual clinical and organizational reviews with quality improvement plan submission for the agency.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on review of the agency in-service educational records, and personnel interviews, for six of six aide staff members, and three of five skilled nursing personnel, the agency failed to ensure at least 12 hours of In-service training for each 12 month period. The findings include. Interview and review of the aide and skilled professional staff educational records for January 2022 through December 2022 and January 2023 through December 2023, with the agency Business/Human Resources partner on 6/25/24 at 10:50am, identified that in-service education was afforded to all aide and skilled professional staff personnel, but failed to identify the agency and Supervisor of Clinical Services ensured the completion of the required 12 hours of in-service training in a 12 month period for the years 2022 and 2023. Interview with the Supervisor of Clinical Services on 6/26/24 at 2:30 pm identified aide and skilled professional staff are expected to completed all in-service training annually, but failed to identify the completion of the 12 hours of in-service training requirement within a 12 month period for 2022 and 2023.

Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on review of the agency in-service educational records, and personnel interviews, for six of six aide staff members, the agency and Supervisor of Clinical Services failed to ensure at least 12 hours of aide staff In-service training for each 12 month period. The findings include. Review and interview of the aide and skilled professional staff educational records for January 2022 through December 2022 and January 2023 through December 2023, with the agency Business/Human Resources partner on 6/25/24 at 10:50am, identified that in-service education was afforded to the aide and skilled professional staff personnel, but failed to identify the Home Health Agency ensured the completion of the required 12 hours of in-service training in a 12 month period for the years 2022 and 2023. Interview with the Supervisor of Clinical Services on 6/26/24 at 2:30 pm, identified that aide and skilled professional staff are to complete 12 hours of in-service training every 12 month period, but failed to identify the completion of the aide in-service training requirement within a 12 month period for 2022 and 2023.

Unannounced visit concluded on 5/11/23 at Staff Mates Home Care for the purpose of a complaint investigation. Standard-level deficiencies were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel, for one of three patients (Patient #1) in the survey sample, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs. The findings include: Patient #1 had a start of care date of 11/10/22 and diagnoses that included opioid dependence, varicose veins of the left lower extremity with ulcer of the left ankle and aseptic necrosis of the pelvis and femur. The physician's orders for the certification period of 11/10/22 to 1/08/23 included nursing services seven times a week for medication administration and assessments. Interview and review of the initial nursing assessment dated 11/10/22 with the Supervisor of Clinical Services/SCS on 5/04/23 at 11:30 AM, identified two chronic stasis ulcers on the left and right lower extremities, but failed to identify the development of a comprehensive care plan that included the need for wound care to the chronic ulcers on the right and left lower extremities.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policies and interview with the agency personnel, for one of one patient (Patient #1) requiring wound care, the agency nurses failed to follow agency policies on wound measurements. The findings include: Patient #1 had a start of care date of 11/10/22 and diagnoses that included opioid dependence, varicose veins of the left lower extremity with ulcer of the left ankle and aseptic necrosis of the pelvis and femur. The physician's orders for the certification periods of 11/10/22 to 5/08/23 included nursing services seven times a week for medication administration and assessments. On 12/11/22, RN #2 indicated in a nursing note that Patient #1 was complaining of pain in the right shin wound, there were no orders for wound care, the right shin was cleansed with soap and water, a dry clean dressing was applied and the SCS was notified. Subsequently, physician’s orders were obtained to cleanse the right shin wound with normal saline, apply Medi honey to the wound bed followed by Xeroform and a dry protective dressing twice weekly. Interview and review of the clinical record from 12/11/22 to 3/28/23 with the SCS on 5/11/23 at 10 AM indicated that wound measurements are identified on the Wound Care Kardex weekly, and failed to identify weekly wound measurements were obtained. Review of the agency policy on wound assessment and documentation directed to update the Wound Care Kardex weekly to reflect current procedure changes, materials, and equipment to be used and measure and stage the wounds weekly including length, width and depth of the wound in centimeters.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on review of the clinical record, interview with agency personnel and review of agency policies, for one of three patients (Patient #1) in the survey sample, the agency nurses failed to communicate with the physician involved in the plan of care. The findings include: Patient #1 had a start of care date of 11/10/22 and diagnoses that included opioid dependence, varicose veins of the left lower extremity with ulcer of the left ankle and aseptic necrosis of the pelvis and femur. The physician's orders for the certification period of 11/10/22 to 1/08/23 included nursing services seven times a week for medication administration and assessments. Interview and review of the initial nursing assessment dated 11/10/22 with the Supervisor of Clinical Services/SCS on 5/04/23 at 11:30 AM, identified two chronic stasis ulcers on the left and right lower extremities but failed to identify communication with the physician for orders for wound care to the chronic ulcers on the right and left lower extremities.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on review of the clinical record, staff interviews and review of the agency policies, the agency failed to ensure skilled professionals provided input into and participated in the implementation of the agency’s QAPI program. The findings include: Review of the violations from the re-licensure survey dated 8/03/22, review of agency documentation and interview with the Supervisor of Clinical Services (SCS) on 5/04/23 at 1:00pm, failed to identify members to participate in the QAPI program and failed to ensure that the required agency clinical record review was conducted quarterly since 8/03/22 in accordance with agency policy. Review of the agency policy identifies that at least quarterly, a committee of health professionals in active practice, or by peer review process, select a sample of active and discharged clinical records to be reviewed, to assure that the agency policies are followed, and that agency services are delivered within the agency's defined scope of practice, and current standards.

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 agency record review, review of personnel files and interview with agency personnel, the Agency Administrator failed to ensure appointment, in writing, for the alternate Supervisor of Clinical Services/SCS and/or the Registered Nurse/RN with other responsibilities and/or failed to maintain a contract for Physical Therapy/PT services under arrangement according to their home health agency application. The findings include: a. During the entrance conference and review of the agency organizational chart with the Administrator on 5/04/23 at 10 AM, RN #1 was identified as the alternate SCS and the RN with other responsibilities, although, review of RN #1’s personnel file failed to identify the appointment of the two positions, in writing according to the Regulations of Connecticut State Agencies Section 19-13-D68 General requirements (e) Supervisor of Clinical Services (5) and/or Section 19-13-D69 Services (d) Homemaker-Home Health Aide Service (4) (C). b. Interview with the SCS on 5/04/23, during the entrance conference, the SCS indicated that Physical Therapy (PT) services are identified on their home health agency application although, since their last survey, 8/03/22, there have been no PT cases. Subsequent interview and review of agency documentation for referrals “not taken up”, identified 6 (six) Physical Therapy/PT referrals declined due to the unavailability of a contracted Physical Therapist.

Services under arrangement CFR(s): 484.105(e)(1) The HHA must ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of this part and the requirements of section 1861(w) of the Act (42 U.S.C. 1395x (w)). This STANDARD is not met as evidenced by: Based on review of agency documentation and interview with agency personnel, the agency failed to provide services under arrangement according to their home health agency application. The findings include: Interview with the SCS on 5/04/23, during the entrance conference, the SCS indicated that Physical Therapy (PT) services are identified on their home health agency application although, since their last survey, 8/03/22, there have been no PT cases. Subsequent interview and review of agency documentation for referrals “not taken up”, from 8/02/22 to 5/04/23, identified 6 (six) Physical Therapy/PT referrals declined and indicated that, at present, there is not a contracted PT available.

Unannounced visits were concluded at Staff Mates Homecare on 6/29/2021 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits were concluded at Staff Mates Homecare on 6/29/21 for the purpose of recertification. Standard-level defciencies were identified.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel, for one of eight patients (Patient # 5) in the survey sample, the agency staff failed to update and/or revise the comprehensive assessment within the last five days of the previous sixty-day certification period. The findings include: Patient #5 had a start of care date of 2/04/11 and diagnoses that included mild intellectual disabilities and type II diabetes mellitus. The physician's orders for the recertification period of 10/24/20 to 12/22/20 included nursing services to assess cardiovascular, neurological, endocrine and psychosocial status and weekly pre-pouring of medications status. Review of the nurse's notes indicated that during the previous certification period (ending on 10/23/20), a licensed practical nurse/LPN last visited Patient #5 on 10/16/20. Interview and review of the nursing documentation with the SCS on 6/29/21 at 12:45 PM, failed to identify an RN visit between 10/19/20 and 10/23/20 (the last five days of the recertification period ending on 10/23/20) to update and/or revise the comprehensive assessment. Further review of the nurse's notes indicated that the revised assessment was not completed by RN # 1 until 10/26/20, two days into the new certification period, instead of being completed during the last five days of the previous recertification period.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on review of the clinical records and interview with agency personnel, for four of eight patients (Patient's #1, 3 5, and 8 ) in the survey sample, the agency failed to ensure the supervision of nursing services. The findings include: a. Patient #1 had a start of care date of 8/05/14 and diagnoses that included type II diabetes mellitus, depression and right-sided hemiplegia. The physician's orders for the certification period of 4/30/21 to 6/28/21 included nursing services weekly for assessment of neurological and diabetic status and pre-pouring of medications. Interview and review of the clinical record from 5/04/21 to 6/15/21 with the Supervisor of Clinical Services (SCS) on 6/29/21 at 1:30 PM identified weekly visits made by the Licensed Practical Nurses (LPN), (7 consecutive visits) and failed to identify a Registered Nurse (RN) assigned to monitor and evaluate the LPN's performance in the provision of services, provision of treatments, patient education and data collection regarding the patient's status and health needs. b. Patient #3 had a start of care date of 12/7/17 and a diagnosis that included major depressive disorder, schizoaffective disorder, and type II diabetes mellitus. The physicians orders for the certification period of 5/20/21 to 7/18/21 included nursing services daily for medication administration, ensure compliance, assess behavioral health status including appearance, effect, behavior, perception, thought processes, memory and coping and assess and instruct in proper use of fasting blood sugar log and to report FBS above 300 or below 70 to MD. Interview and review of the clinical record from 5/20/2021 to 6/26/2021 with the Supervisor of Clinical Services (SCS) on 6/29/21 at 1:30 PM identified daily visits made by the Licensed Practical Nurses (LPN), (5 consecutive visits) and failed to identify a Registered Nurse (RN) assigned to monitor and evaluate the LPN's performance in the provision of services, provision of treatments, patient education and data collection regarding the patient's status and health needs. c. Patient #5 had a start of care date of 2/04/11 and diagnoses that included mild intellectual disabilities and type II diabetes mellitus. The physician's orders for the certification period of 10/24/20 to 12/22/20 included nursing services to assess cardiovascular, neurological, endocrine and psychosocial status and weekly pre-pouring of medications status. Interview and review of the clinical record from 10/30/20 to 12/11/20 with the Supervisor of Clinical Services (SCS) on 6/29/21 at 1:30 PM identified weekly visits made by the Licensed Practical Nurses (LPN), (7 consecutive visits) and failed to identify a Registered Nurse (RN) assigned to monitor and evaluate the LPN's performance in the provision of services, provision of treatments, patient education and data collection regarding the patient's status and health needs. d. Patient #8 had a start of care date of 12/1/2017 and a diagnosis of post traumatic stress disorder, type II diabetes mellitus, schzophrenia and obesity. The physicians orders for the ceritification period fo 5/14/21 to 7/12/21 included nursing visits daily for medication administration to ensure compliance with medication regime, assess behavioral health statu, s check vitals signs weekly, assess and instruct in proper nutrition, hydration and compliance with diabetic diet and to notify the MD for fasting blood sugar over 200 or below 60. Interview and review of the clinical record from 5/14/2021 to7/12/2021 with the Supervisor of Clinical Services (SCS) on 6/29/21 at 1:30 PM identified daily visits made by the Licensed Practical Nurses (LPN), ( 7 consecutive visits) and failed to identify a Registered Nurse (RN) assigned to monitor and evaluate the LPN's performance in the provision of services, provision of treatments, patient education and data collection regarding the patient's status and health needs Interview and review of agency nursing assignments, scheduling and surveyor observations with the SCS on 6/29/21 at 1:30 PM indicated that the LPN carried a caseload and conducted most of the scheduled visits to the patient, and the agency employed one full-time registered nurses (RN) to provide aide supervision, recertification visits, initial certification visits, and failed to identify assignment of each patient to a Primary Care Nurse (RN) for coordination of care.

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 review of the clinical records and interview with agency personnel, for four of eight patients (Patient's #1, 3 5 and 8 ) in the survey sample, the agency Administrator failed to ensure the development of appropriate policies and procedures for the supervision of nursing services. The findings include: a. Patient #1 had a start of care date of 8/05/14 and diagnoses that included type II diabetes mellitus, depression and right-sided hemiplegia. The physician's orders for the certification period of 4/30/21 to 6/28/21 included nursing services weekly for assessment of neurological and diabetic status and pre-pouring of medications. Interview and review of the clinical record from 5/04/21 to 6/15/21 with the Supervisor of Clinical Services (SCS) on 6/29/21 at 1:30 PM identified weekly visits made by the Licensed Practical Nurses (LPN), (7 consecutive visits) and failed to identify a Registered Nurse (RN) assigned to monitor and evaluate the LPN's performance in the provision of services, provision of treatments, patient education and data collection regarding the patient's status and health needs and/or failed to identify a policy for the supervision of nursing services. b. Patient #3 had a start of care date of 12/7/17 and a diagnosis that included major depressive disorder, schizoaffective disorder, and type II diabetes mellitus. The physicians orders for the certification period of 5/20/21 to 7/18/21 included nursing services daily for medication administration, ensure compliance, assess behavioral health status including appearance, effect behavior, perception, thought processes, memory and coping and assess and instruct in proper use of fasting blood sugar log blood and to report FBS above 300 or below 70 to MD. Interview and review of the clinical record from 5/20/2021 to 6/26/2021 with the Supervisor of Clinical Services (SCS) on 6/29/21 at 1:30 PM identified daily visits made by the Licensed Practical Nurses (LPN), (5 consecutive visits) and failed to identify a Registered Nurse (RN) assigned to monitor and evaluate the LPN's performance in the provision of services, provision of treatments, patient education and data collection regarding the patient's status and health needs. c. Patient #5 had a start of care date of 2/04/11 and diagnoses that included mild intellectual disabilities and type II diabetes mellitus. The physician's orders for the certification period of 10/24/20 to 12/22/20 included nursing services to assess cardiovascular, neurological, endocrine and psychosocial status and weekly pre-pouring of medications status. Interview and review of the clinical record from 10/30/20 to 12/11/20 with the Supervisor of Clinical Services (SCS) on 6/29/21 at 1:30 PM identified weekly visits made by the Licensed Practical Nurses (LPN), (7 consecutive visits) and failed to identify a Registered Nurse (RN) assigned to monitor and evaluate the LPN's performance in the provision of services, provision of treatments, patient education and data collection regarding the patient's status and health needs and/or failed to identify a policy for the supervision of nursing services. d. Patient #8 had a start of care date of 12/1/2017 and a diagnosis of post traumatic stress disorder, type II diabetes mellitus, schzophrenia and obesity. The physicians orders for the ceritification period fo 5/14/21 to 7/12/21 included nursing visits daily for medication administration to ensure compliance with medication regime, assess behavioral health status check vitals signs weekly, assess and instruct in proper nutrition, hydration and compliance with diabetic diet and to notify the MD for fasting blood sugar over 200 or below 60. Interview and review of the clinical record from 5/14/2021 to7/12/2021 with the Supervisor of Clinical Services (SCS) on 6/29/21 at 1:30 PM identified daily visits made by the Licensed Practical Nurses (LPN), ( 7 consecutive visits) and failed to identify a Registered Nurse (RN) assigned to monitor and evaluate the LPN's performance in the provision of services, provision of treatments, patient education and data collection regarding the patient's status and health needs