Every finding on record at Sympathy Home Health Care Inc

Extended Substantial Allegation Survey Substantial Allegation OH00124543 and OH00123604 The following deficiencies are based upon substantial allegation OH00124543 completed on 08/12/21. No deficiencies were issued as a result of the substantial allegation OH00123604. Sympathy Home Health Care Inc 369007, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C. Sympathy Home Health Care Inc 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.

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: Based on record review and staff interview, the agency failed to document both the existance of complaints and the resolution of the complaint for one patient (Patient #7). This could affect all patients receiving services from this agency. The census was 63. Findings include: Review of the agency policy titled, "Complaint Resolution" last revised 2010, for a prompt resolution of patient complaints and a mechanism for use by the patient to assure response and resolution of complaint in a timely manner. To provide administrative staff an opportunity to review responses to the complaints. The Agency will investigate complaints made by a patient or family regarding treatment or care that is, or fails to be furnished. The agency will document both the existence and resolution of the complaint. Review of the agency complaint log revealed no patient complaints documented after 01/05/21. Per interview on 08/10/21 at 7:10 PM, Staff P stated when a patient wanted to transfer to another agency, they were called and asked why they were leaving and they always said it was the aide service. When asked why the patients' complaints regarding care was not documented in the complaint log, Staff P replied,"I never got around to it". Per interview on 08/11/21 at 9:00 AM, Staff P stated Patient #7 called the morning of 08/10/21 and stated the aide did not show up. The patient had reported it to Staff W and requested another aide. No aide came and no contact was received back from Staff W. Staff P stated she told Staff W to follow up on this. This patient called Staff P at 9:00 PM on 08/10/21 and stated no aide came and no contact was received from Staff W. Staff P confirmed at that time that the complaint by Patient #7 of no aide service was not documented or investigated by the agency.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and staff interview, the agency failed to develop, implement, evaluate and maintain an effective, ongoing, home health agency wide, data-driven quality improvement program. The Governing Body failed to ensure the program reflected the complexity of its organization and services and involved all home health services. The Governing Body failed to ensure a program focused on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions, and failed to take action that addressed the home health agency's performance across the spectrum of care, including the prevention and reduction of medical errors. The home health agency failed to maintain documentary evidence of its Quality Improvement Program and must be able to demonstrate its operation to CMS per the requirements of: 42 CFR Part 484.65 The surveyor requested evidence of the agency's Quality Assessment Performance Improvement (QAPI) program. Per interview on 08/04/21 at 2:25 PM the Administrator stated there was no QAPI program.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure all home health aides had competency skills tested while providing care to a patient or on a pseudo-patient (G768). The agency failed to ensure home health aides successfully completed a competency evaluation prior to working with a patient (G770). The agency failed to ensure qualified home health aides provided services to patients (G786). The agency failed to ensure home health aides provided services ordered by the physician and included in the plan of care (G800). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patient's personal care needs would be met.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure all home health aides had competency skills tested while providing care to a patient or on a pseudo-patient for eleven of eleven home health aide personnel files reviewed (Staff I, X, Z, BB, CC, DD, HH, SS, WW, E5E and L12L). This could affect all patients receiving services from this agency. The census was 63. Findings inlcude: Review of personnel files revealed Staff I, X, Z, BB, CC, DD, SS, WW, E5E and L12L, who were all hired after January 2018, did not have competency skills tested while providing care to a patient. Review of the personnel file for Staff HH revealed a Certified Home Health Aide Skills Checklist dated 06/26/19. The checklist was signed by the Staff HH, the home health aide, and Staff W who was not a Registered Nurse. Per interview on 08/11/21 at 12:40 PM, Staff P stated the agency did not have the equipment to check the skills of the home health aides.

Unsatisfactory competency evaluation CFR(s): 484.80(c)(4) A home health aide is not considered competent in any task for which he or she is evaluated as unsatisfactory. An aide must not perform that task without direct supervision by a registered nurse until after he or she has received training in the task for which he or she was evaluated as "unsatisfactory," and has successfully completed a subsequent evaluation. A home health aide is not considered to have successfully passed a competency evaluation if the aide has an "unsatisfactory" rating in more than one of the required areas. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure home health aides successfully completed a competency evaluation prior to working with a patient for ten of eleven home health aide personnel files reviewed (Staff I, X, BB, CC, DD, SS, WW, E5E, L12L and M13M). This could affect all patients receiving services from this agency. The census was 63. Findings include: Review of personnel files revealed: 1. Staff WW did not take a competency exam. 2. As of 08/04/21, Staff X, BB, CC, DD and SS did not have their competency exam graded prior to working with patients. 3. Review of personnel files revealed the following staff missed two or more qualified areas on the home health aide competency exam: - Staff I - hired 03/27/21 - unsatisfactory grade in physical, emotional, developmental needs and patient rights; transfers and ambulation; and normal range of motion. Staff I's first patient assignment was on 04/19/21 and the patient required assistance with ambulation. - Staff E5E - hired 04/06/21 - unsatisfactory grade in personal hygiene and normal range of motion. Staff E5E's first patient assignment was on 04/19/21 and the patient required personal care and range of motion. - Staff L12L - hired 03/27/21 - unsatisfactory grade in emergency procedures and physical, emotional, developmental needs and patient rights. L12L's first patient assignment was on 04/20/21. - Staff M13M - hired 05/07/21 - unsatisfactory grade in infection control and physical, emotional, developmental needs and patient rights. M13M's first patient assignment was on 05/24/21 and the patient required the use of universal precautions. There was no documentation the any re-education was completed or re-taken exams. Staff P confirmed these findings in an interview on 08/12/21 at 4:00 PM.

Unqualified HH aide providing services CFR(s): 484.80(f)(2) (2) Permitted an individual who does not meet the definition of a "qualified home health aide" as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure qualified home health aides provided services to patients for three of eleven home health aide personnel files reviewed (Staff VV, Staff SS and Staff FF). This could affect all patients receiving services from this agency. The census was 63. Findings include: 1. Review of Staff VV's personnel file revealed Staff VV had not worked as home health aide for the 24 months prior to their hire date of 03/05/19. Additionally, there was no evidence of Staff VV completing any home health aide training and competency evaluation program or evidence they were a state tested nurse aide. Staff VV had a patient assignment on 03/19/19 and as of 08/12/21 was currently working. 2. Review of the personnel file for Staff SS revealed no evidence they completed any home health aide training and competency evaluation program or evidence they were a state tested nurse aide. Staff SS was hired on 03/11/21 and provided patient care starting 04/12/21 and as of 08/12/21 is currently working. 3. Review of personnel file for Staff FF revealed a Temporary Nurse Aide Certificate dated 09/22/20 received after completing an online course. There was no evidence Staff FF completed any home health aide training and competency evaluation program or evidence they were a state tested nurse aide. Staff FF was hired 10/28/20 and they were assigned their first patient on 11/02/20. As of 08/12/21 Staff FF was currently working. Per interview on 08/11/21 at 5:00 PM, Staff P confirmed these findings.

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 record review and staff interview, the agency failed to ensure home health aides provided services ordered by the physician and included in the plan of care for two of three patients reviewed. (Patient #3 and #5). This could affect all patients receiving services from the agency. The census was 63. Findings include: Review of the undated agency policy titled "Home Health Aide Documentation" revealed the agency will ensure accurate documentation of the care performed by the home health aide (HHA). The HHA will document services provided to the patient as directed in the Aide Care Plan. The HHA and patient will sign the document at the end of services each day. The Nursing Supervisor is responsible for reviewing the aides charting. 1. Review of medical record for Patient #3 revealed physician orders dated 11/22/20 to 01/20/21 for the home health aide to provide 15 hours per week for assistance with activities of daily living, personal care, and light housekeeping. Review of the home health aide time sheet for the week of 12/06/20 and 12/20/20 revealed the home health aide did not mark that any services were provided. Per interview on 08/11/21 at 12:33 PM, Staff P confirmed no services were marked as provided. 2. Review of medical record for Patient #5 revealed physician orders dated 04/23/21 to 06/21/21 for the home health aide to provide 20 hours per week to assist with personal care and light housekeeping. Review of the Aide Care Plan for the same time period revealed the aide was to provide the following at every visit: light housekeeping, make the bed, assistance with dressing, check pressure areas, comb hair, foot care, nail care, oral hygiene denture care, pericare, skin care, and tub bath. The following was to be provided once a week: change the linen and shampoo hair. The following was to be provided as requested: backrub/massage, complete bath, partial bath/sponge bath, and shave as needed. Review of home health aide time sheets revealed the weeks of 04/25/21, 05/02/21, 05/09/21, 05/16/21, 05/23/21, 05/30/21, and 06/06/21 the only personal care documented as provided was skin care. Per interview on 08/12/21 at 1:00 PM, Staff P confirmed the findings. This deficiency substantiates Substantial Allegation OH00123604.

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 staff and non-staff interviews, the agency failed to ensure the Administrator was responsible for all day to day operations of the agency (G948). The cumulative effect of these systemic practices resulted in the agency's inability to ensure patient's needs would be met.

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 record review and staff and non-staff interviews, the agency failed to ensure the Administrator was responsible for all day to day operations of the agency for one of four patient records reviewed (Patient #1). The census was 63. Findings include Review of a document titled Falsifying Documentation revealed a Home Health Aide that fails to report to his/her client on schedule visit and attempts to have their client sign for services not provided will be Immediately terminated. Forging a client's signature will not be tolerated and will also in result in Immediate Termination. It's against the law to falsify/sign medical documents if services have not been provided. Review of Patient #1's medical record revealed the patient was admitted to the agency 03/30/18. Review of the plan of care for the certification period dated 05/12/21 through 07/10/21 revealed orders for home health aide services 35 hours per week for personal care and light housekeeping. Review of a letter from the agency dated 07/28/21 in response to a Request for Documentation dated 07/27/21 revealed the agency received a call from Patient #1's case manager stating the aide had not been providing services to the patient. The agency replied that they were not aware the aide was not going to the patient's home and that the aide would be pulled from the case and the patient's services were placed on hold until the agency could find a replacement aide. Per interview on 08/05/21 at 1:20 PM, Staff W stated the family of Patient #1 had complained about the home health aide and wanted them changed. Staff W stated the aide was pulled and the patient's service was put on hold for 30 days due to no aide available. Interview on 08/03/21 at 3:00 PM with Patient #1's Social Worker/Case Manager revealed the aide's house had burned down. Further interview revealed Patient #1 felt bad for the aide and signed the time sheets for the week of 06/14/21 - 06/19/21, but no care was provided. Per interview on 08/04/21 at 2:25 PM the Administrator stated the aide was not paid for the week of 06/14/21 and confirmed the aide falsified the time sheet. Interview with Staff W on 08/05/21 at 1:25 PM revealed the aide was not terminated. Further interview with Staff W on 08/11/21 at 10:45 AM revealed the aide falsified the time sheet by signing all days and times ordered, but did not provide the services. The time sheet was not turned into billing; however, Staff W was unable to provide this time sheet. This deficiency substantiates Substantial Allegation OH00123604.

Substantial Allegation Survey Substantial Allegation OH00122386 An entrance conference was conducted on 06/15/21 at 10:15 AM with the Director of Clinical Services. An exit conference was conducted on 06/16/21 at 4:55 PM with administrative staff. The following deficiency is based upon Substantial Allegation OH00122386 completed on 06/16/21. Sympathy Home Health Care Inc 369007, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 and staff interview, the agency failed to ensure patients received home health as written in the plan of care for one of three records reviewed (Patient #2). This could affect all patients receiving services from the agency. The census was 84. Findings include: Review of the medical record for Patient #2 revealed the patient was admitted on 07/29/19. Review of physician orders dated 03/20/21 revealed orders for skilled nursing once a week for 60 days for assessment and medication management and home health aide (HHA) services for 65 hours per week for 60 days for assistance with personal care and light housekeeping due to hemiplegia following a cerebrovascular accident (stroke). Per interview on 06/15/21 at 12:30 PM Staff B stated the HHA's were to go to Patient #2's home Monday through Friday for nine hours and Saturday and Sunday for 10 hours. Review of the HHA visit sheets for Patient #2 between 03/20/21-05/15/21 revealed the HHA worked 35 hours the week of 03/21/21, eight hours the week of 04/18/21, 18 hours the week of 04/25/21. The medical record lacked documentation of any HHA visits after 04/28/21. Patient #2 was discharged on 05/15/21. Per interview on 06/15/21 at 4:35 PM Staff C confirmed the HHA did not work 65 hours per week as ordered. Further review of Patient #2's record revealed no missed visit notices or documentation the patient's physician was notified that HHA services were not provided as ordered. Per interview on 06/15/21 at 4:45 PM Staff B confirmed there were no missed visit forms and no documentation the patient's physician was notified. Per email on 06/16/21 at 2:28 PM Staff C stated the agency was unable to provide the 65 hours per week due to staffing issues. This deficiency substantiates Substantial Allegation OH00122386.