Nu-Day Healthcare LLC

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on interviews and record review, the agency failed to inform the patient and the patient’s physicians who would be responsible for providing care and services to the patient after discharge from the home health care agency that a discharge for cause was being considered in 1 of 3 discharge records reviewed (Patient #1). Findings include: AGENCY POLICY According to an agency policy dated, August 2022, and titled, Transfer/Discharge Criteria, (read in pertinent parts): “Patients are transferred or discharged to alternative care when the following conditions exist: -The goals of the patient have been met -Patient choice -When the Agency and the Physician agree that agency can no longer meet the patient’s needs -Patient has moved out of service area -The patient or the payor will no longer pay for services -Patient dies -Additional services are needed which the Agency is unable to provide -The Agency ceases to operate Discharge for Cause -Behavior of the patient or caregiver interferes with the Agency’s ability to provide care -If the Agency has determined that the patient or caregiver or others have behavior that is a barrier to the patient’s success, or the safety of the staff and discharge may be considered: -The Agency must document all efforts to resolve the issues -The Agency must provide the patient and or authorized representative with the verbal and written information that discharge is being considered and how the issues may be resolved -The Agency must contact the physician, or allowed practitioner issuing orders for the home health plan of care, and the patients primary care practitioner or other health care professionals who will be responsible for providing care and services to the patient after Discharge that discharge is being considered -The Agency must be aware and follow any state regulations regarding a discharge for Cause or immediate discharge. In the event of an emergent discharge the Agency will notify the health department, the case manager (if applicable), the MD [medical doctor] within 48 hours of the need for an emergent discharge.” 1. The clinical record for Patient #1 was reviewed on 6/5/24. The plan of care for the certification period dated 4/3/24 to 6/1/24, revealed a start of care date of 2/3/24; diagnoses included encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus, hypothyroidism, obstructive sleep apnea, Asperger’s syndrome, depression, encounter for attention to colostomy, encounter for change or removal of surgical wound dressing, and long-term use of aspirin. Plan of care orders included skilled nursing (SN) visits four times a week for one week and seven times a week for eight weeks, effective 4/3/24, with two as needed visits (PRN) for assessment and education, medication management including medication set-up once per week, and ostomy care; certified nursing aide (CNA) visits one time a week for one week and three times a week for eight weeks, effective 4/3/24, for personal care (which included elimination care, hair care, showering, skin care, dressing, and check for pressure areas) and light housekeeping. a. The agency failed to notify the patient verbally and in writing that discharge for cause was being considered. Review of Patient #1’s clinical record showed on 5/28/24 at 7:13 p.m. Patient #1 phoned the agency and spoke with the director of clinical services (DCS) to discuss his unhappiness with how the DCS had handled ordering ostomy bag supplies for Patient #1. Patient #1 accused the administrator, alternate administrator and DCS of lying to him; he stated he was having an emotional crisis, that he felt abused, neglected and mistreated; and he stated the DCS was incompetent. During this phone conversation, Patient #1 raised his voice multiple times and used curse words several times. Review of agency documentation showed on 5/29/24 at 10:13 a.m., the DCS contacted the Department to inform the Department the agency would like to complete a 10 day emergent discharge with Patient #1 due to Patient #1 yelling and cursing at agency staff on multiple occasions. Review of Patient #1’s clinical record showed the DCS left Patient #1 a voicemail on his home phone and cell phone on 5/29/24 at 11:09 a.m. stating the DCS had some updates for Patient #1 and to inform Patient #1, CNA #4 would not be providing him care on 5/29/24, and asked for a phone call back as soon as possible. Review of Patient #1’s clinical record showed the DCS sent a text message to Patient #1 on 5/29/24 at 11:24 a.m. which stated the DCS had heard from (licensed practical nurse) LPN #5 that Patient #1 was “too stressed out to talk” and to contact the DCS at the office (phone number provided) so the DCS could update Patient #1. Patient #1 responded to the DCS asking her to respond to communicate with him via text or email. The DCS stated “No sir.” Review of Patient #1’s clinical record showed the DCS left Patient #1 a voicemail on his home phone and cell phone on 5/29/24 at 1:58 p.m., stating the following: DCS was hoping to speak with Patient #1; the agency was completing a 10 day emergent discharge for cause (failed to provide the reason or what was being done to attempt to resolve the issue); the agency would send Patient #1 a certified letter out today (failed to state the purpose of the letter); the DCS would provide Patient #1 care for the next 10 days and stated Patient #1 was not to contact his primary SN, LPN #5, or CNA #4: the DCS would work with Patient #1’s case manager to help find Patient #1 a different home health care agency; the agency informed Patient #1’s physicians of the discharge; the agency informed the Department regarding the discharge; the agency filed an Adult Protective Services (APS) report on Patient #1’s behalf and provided the case number; and for Patient #1 to contact the DCS at the office to schedule his visits for the next 10 days. Review of Patient #1’s clinical record on 6/7/24 at 11:44 a.m., showed the agency sent a certified letter on 5/29/24 at 3:05 p.m. with expected delivery on 5/31/24 with a discharge notice to Patient #1 stating effective 5/30/24 the agency would put into place a 10 day emergent discharge from the agency; a report had been filed with Healthcare Policy and Finance, Patient #1’s physicians had been notified, and the agency would work with Patient #1’s single entry point case manager to help provide him with a list of available agencies for him to choose from for continued care after the discharge. During an interview on 6/7/24 at approximately 11:45 a.m., the administrator stated the post office informed the agency, Patient #1 did not sign for the certified letter. Review of Patient #1’s clinical record failed to show the agency attempted to contact the patient verbally and/or in writing to inform him a discharge for cause was being considered and the reason a discharge for cause was being considered prior to issuing him a verbal and written discharge notice. During an interview on 6/4/24 at 1:57 p.m., Patient #1 stated the agency had a problem with securing ostomy bags for his colostomy care and he filed a complaint against the agency with APS for elder abuse/neglect on 5/28/24. Patient #1 stated he then was notified the agency was discharging him for cause, completing a 10 day emergent discharge. Patient #1 stated the DCS instructed him to not contact LPN #5 or CNA #4 and the DCS would provide him with care. Review of an email sent to the surveyor by Patient #1 on 6/5/24 at 8:23 a.m., Patient #1 documented he never received the certified letter sent to him by the agency notifying him in writing of the agency’s intention to discharge him from the agency and to provide him any information which showed the agency attempted to communicate with Patient #1 that a discharge was being considered for him. During an interview on 6/7/24 at 11:14 a.m., the DCS stated the agency initiated the process for a 10 day emergent discharge for cause with Patient #1 for many reasons which included: the agency management staff (which included the DCS, the administrator and alternate administrator) felt Patient #1 was attempting to pit LPN #5 and CNA #4 against each other and the agency administrative staff; the agency’s administrative staff’s inability to discern which physician was following Patient #1, in particular, to provide orders for ostomy bag supplies; Patient #1 asking the DCS to lie to one of his providers stating he planned to continue care with the provider, when Patient #1 had told DCS he had no intention of continuing care with the provider, but wanted the provider to sign orders for more ostomy bags; and due to Patient #1’s behavior the week leading up to the agency attempting to provide Patient #1 with the verbal and written notice of a 10 day emergent discharge on 5/29/24 which included cussing and yelling at staff members. During continued interview, the DCS stated she attempted to speak with Patient #1, to discuss his behavior and the agency management staff feeling discharging Patient #1 might be the best course of action prior to sending the voicemail and certified letter regarding discharging Patient #1, but Patient #1 would not answer the DCS’s phone calls. The DCS stated she did not document all of her attempts to contact Patient #1 prior to sending Patient #1 the 5/29/24 1:59 p.m. voicemail in which the DCS informed Patient #1 the agency would be discharging him in 10 days. During continued interview, the DCS stated Patient #1 called the DCS on 5/28/24 on her personal cell phone and the alternate administrator answered the phone. The DCS stated Patient #1 was yelling and cursing at the alternate administrator as he was frustrated about not receiving ostomy bag supplies. The DCS stated she observed the alternate administrator attempt to calm Patient #1 down and to deescalate the situation, but Patient #1 continued to yell at the alternate administrator. The DCS then took the phone from the alternate administrator and DCS stated Patient #1 informed her LPN #5 and CNA #4 were incompetent and Patient #1 stated he was upset/flustered about his lack of ostomy supplies. The DCS stated she and the alternate administrator went immediately over to Patient #1’s home to provide him with ostomy bags the DCS had secured for him from a vendor, but Patient #1 would not allow the DCS or the alternate administrator to come into his home. The DCS stated, CNA #4 was at Patient #1’s home at the time the DCS and alternate administrator arrived to bring Patient #1 his ostomy bags, and Patient #1 allowed CNA #4 to retrieve the supplies from the DCS and alternate administrator for him. The DCS acknowledged she did not document the 5/28/24 telephone conversation or the 5/28/24 visit to deliver ostomy bags to Patient #1. The DCS stated she did not inform Patient #1 verbally or in writing prior to issuing the verbal discharge notice via voicemail on 5/29/24 as directed per regulation, as Patient #1 would not answer her phone calls. During an interview on 6/7/24 at 11:16 a.m., the alternate administrator stated he spoke with Patient #1 the morning of 5/28/24 on the DCS’s personal cell phone. The alternate administrator stated Patient #1 was upset about his ostomy bag supplies and was yelling and cursing at the alternate administrator. The alternate administrator stated he attempted to calm Patient #1 down and to deescalate the situation, but the calmer the alternate administrator became the more agitated Patient #1 became. The alternate administrator confirmed he went with the DCS to deliver more ostomy bags to Patient #1 on 5/28/24 and Patient #1 would not speak to the DCS or the alternate administrator and sent CNA #4 down to retrieve the ostomy bags. The alternate administrator stated he failed to document his 5/28/24 telephone conversation with Patient #1, his visit to Patient #1’s home to deliver supplies or any of the other phone calls the alternate administrator had received from Patient #1 in the week leading up to the DCS calling Patient #1 to inform him the agency was going to discharge him on 5/29/24. During an interview on 6/7/24 at 12:02 p.m., the administrator stated the agency discharged Patient #1 due to behavior toward agency staff and the administrator did not feel the agency could meet Patient #1’s needs. The administrator stated during the last week of May 2024, Patient #1 called the agency multiple times yelling, cursing, and expressing his frustration in not being provided the ostomy bags he requested. The administrator stated she did not document any of the phone calls she had with Patient #1 during this week and acknowledged the DCS and alternate administrator also failed to document all the phone calls they had with Patient #1. The administrator stated she was aware of the federal and state regulations regarding discharging a patient for cause, and thought the agency was following them when the agency notified the patient they would be discharging him verbally with the voicemail, via a certified letter, and to notify the Department of the agency’s plan to discharge a patient for cause (emergent discharge). During continued interview, the administrator acknowledged the agency failed to inform Patient #1 verbally, and in writing, the agency was considering discharging him for cause and the reason for the discharge as required by regulation, prior to providing him with discharge notification. The administrator also acknowledged the discharge notifications Patient #1 received verbally from the DCS in a voicemail on 5/29/24 and the discharge letter sent via certified mail on 5/29/24 to Patient #1 did not provide a reason for the discharge or the steps the agency took to attempt to resolve the issue leading to the discharge for cause prior to discharge (Cross Reference G470). Instead, the verbal and written discharge notifications to Patient #1 contained a statement the agency would be discharging Patient #1 and the steps the agency would take to facilitate this discharge. b. The agency failed to notify Patient #1’s physician(s) issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who would be responsible for providing care and services to the patient after discharge from the agency (if any) that a discharge for cause was being considered. Review of Patient #1’s clinical record failed to show the agency contacted Patient #1’s gastroenterologist (GI) doctor, Dr. #7, the physician who signed his 4/3/24 to 6/1/24 plan of care on 5/31/24, or his primary care physician that a discharge for cause was being considered. During an interview on 6/7/24 at 11:37 a.m., the DCS stated the agency had struggled to discern who Patient #1’s following physician was. The DCS stated Patient #1 changed his mind multiple times, but by the last week of May 2024, the agency was aware Patient #1’s GI doctor, Dr. #7 was the doctor providing orders for his ostomy bags and would be signing his orders for care. The DCS stated prior to calling Patient #1 on 5/29/24 and leaving Patient #1 a voicemail to inform him the agency was discharging Patient #1 for cause on an emergent basis, the DCS called Dr. #7’s office and informed a member of Dr. #7’s staff, to inform Dr. #7 that Patient #1’s behavior had escalated, agency staff members had voiced a preference to not return to working with Patient #1 as a result of his recent behavior, and thus, the DCS planned to provide Patient #1 with his SN and CNA care for the next 10 days, the agency would assist Patient #1 with finding another agency and planned to discharge Patient #1 after the 10 day period. The DCS acknowledged she failed to document this conversation anywhere in Patient #1’s record. The DCS stated she had not had time, but planned to get this information documented. During an interview on 6/7/24 at 1:46 p.m., the DCS stated she documented which physician and the person at the office she spoke to regarding Patient #1’s discharge, in the discharge OASIS she completed between the interview conducted at 11:37 a.m. on 6/7/24 and the interview conducted at 1:46 p.m. on 6/7/24. During an interview on 6/7/24 at 12:18 p.m., the administrator stated the agency struggled to discern who Patient #1’s following physician was due to a multitude of reasons, but by 5/29/24, it was clear to the administrator, Patient #1’s GI doctor, Dr. #7 was, Patient #1’s following physician. The administrator stated she also phoned Patient #1’s GI doctor, Dr. #7’s office (she could not recall who she spoke to or what time she called), on 5/29/24 to inform Dr. #7 of Patient #1’s unhappiness with the agency, his escalating behavior, the agency’s inability to meet Patient #1’s needs. The administrator stated she also informed Dr. 7’s office of the agency’s plan to provide Patient #1 with care by the DCS for 10 days, to assist Patient #1 to find another agency and then to discharge Patient #1. The administrator stated she failed to document her conversation with Patient #1’s GI doctor, and stated she was aware of the saying in healthcare “if it was not documented, it did not happen.” The administrator stated she also attempted to contact Patient #1’s GI doctor, on 5/30/24 when Patient #1 would not answer the DCS’s phone calls to attempt to see Patient #1 on 5/29/24 and 5/30/24, but she failed to document these phone calls as well. 2. During an interview on 6/7/24 at 1:46 p.m., the administrator, alternate administrator and DCS all acknowledged they failed to follow regulatory requirements for discharging Patient #1 for cause as they failed to document all conversations they had with Patient #1, the agency staff who provided care to Patient #1 and his physicians.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on interview and record review, the agency failed to document the problems that led to the agency discharging a patient for cause and the efforts made to resolve the problems for 1 of 3 discharge patient records reviewed (Patient #1). Findings include: AGENCY POLICY According to an agency policy dated, August 2022, and titled, Transfer/Discharge Criteria, (read in pertinent parts): “Patients are transferred or discharged to alternative care when the following conditions exist: -The goals of the patient have been met -Patient choice -When the Agency and the Physician agree that agency can no longer meet the patient’s needs -Patient has moved out of service area -The patient or the payor will no longer pay for services -Patient dies -Additional services are needed which the Agency is unable to provide -The Agency ceases to operate Discharge for Cause -Behavior of the patient or caregiver interferes with the Agency’s ability to provide care -If the Agency has determined that the patient or caregiver or others have behavior that is a barrier to the patient’s success, or the safety of the staff and discharge may be considered: -The Agency must document all efforts to resolve the issues -The Agency must provide the patient and or authorized representative with the verbal and written information that discharge is being considered and how the issues may be resolved -The Agency must contact the physician, or allowed practitioner issuing orders for the home health plan of care, and the patients primary care practitioner or other health care professionals who will be responsible for providing care and services to the patient after Discharge that discharge is being considered -The Agency must be aware and follow any state regulations regarding a discharge for Cause or immediate discharge. In the event of an emergent discharge the Agency will notify the health department, the case manager (if applicable), the MD [medical doctor] within 48 hours of the need for an emergent discharge.” 1. The clinical record for Patient #1 was reviewed on 6/5/24. The plan of care for the certification period dated 4/3/24 to 6/1/24, revealed a start of care date of 2/3/24; diagnoses included encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus, hypothyroidism, obstructive sleep apnea, Asperger’s syndrome, depression, encounter for attention to colostomy, encounter for change or removal of surgical wound dressing, and long-term use of aspirin. Plan of care orders included skilled nursing (SN) visits four times a week for one week and seven times a week for eight weeks, effective 4/3/24, with two as needed visits (PRN) for assessment and education, medication management including medication set-up once per week, and ostomy care; certified nursing aide (CNA) visits one time a week for one week and three times a week for eight weeks, effective 4/3/24, for personal care (which included elimination care, hair care, showering, skin care, dressing, and check for pressure areas) and light housekeeping. a. The agency failed to document the problems that led to the agency discharging Patient #1 for cause and the efforts made to resolve the problems prior to issuing the discharge notification. Review of text messages between Patient #1 and the director of clinical services (DCS) from 4/1/24 through 5/29/24 showed Patient #1 requested assistance from the DCS with helping Patient #1 order ostomy bags 24 times and he expressed concerns about not having enough bags nine times. The DCS responded to each request as follows: responded with which durable medical equipment (DME) company would Patient #1 like the agency to use (4/9/24), assisted Patient #1 to get a coverage letter for additional ostomy bags signed by Patient #1’s gastroenterologist, Dr. #7 (4/10/24) ; that the DCS would assist Patient #1 with getting his ostomy supplies by talking to a DME representative 13 times (4/10/24, 4/18/24, 4/27/24, 5/1/24, 5/2/24, 5/3/24, 5/6/24, 5/9/24, 5/13/23, 5/14/24, 5/15/24, and 5/28/24); that the DCS would speak with his GI doctor, Dr. #7 two times (4/9/24 and 5/6/24): that the DCS would go see Dr. #7 in person one time (5/9/24); that the DCS spoke with Patient #1’s primary care physician two times (5/14/24),;that the DCS spoke with the surgeon who performed Patient #1’s colostomy surgery two times (5/28/24 and 5/29/24); and that the DCS would follow up with a doctor on 5/8/24, but the name of the doctor was not provided. Review of the agency quality assurance and performance improvement (QAPI) documentation showed on 2/1/24 at 10:30 a.m., Patient #1 complained to the DCS that he did not want a male providing him with his start of care visit. The investigation the DCS completed was to speak with Patient #1 regarding which staff he would permit to see him, and Patient #1 requested to see the staff before they provided him care. The DCS stated Patient #1 was agreeable to current staff and would inform the agency of his needs moving forward. The DCS documented Patient #1 was informed of the resolution to the complaint on 2/1/24. Review of the agency QAPI documentation showed on 5/2/24 at 11:05 a.m., the DCS documented Patient #1 made a complaint about not having enough ostomy bags and the order to obtain more bags was not signed by his physician. The DCS documented the resolution to Patient #1’s complaint was, she met with a DME representative on 5/3/24, who provided the DCS with 50 ostomy bags and flanges (the device that sticks to a patient’s skin to provide protection from stool and to provide a place for the ostomy bag to attach) which the DCS provided to Patient #1. Review of Patient #1’s clinical record showed on 5/1/24 at 1:05 p.m., the DCS documented in Patient #1’s journal notes the following regarding Patient #1: - GI doctor, Dr. #7 - his stoma (the opening to his colon after his colostomy surgery) support was physician’s assistant (PA #9, an assistant to Dr. #8) with her phone number, and - the order number with the name of the DME company the order for supplies was made through. Review of the clinical record showed on 5/7/24 at 11:32 a.m. the DCS documented a journal note which stated the DME company called and stated they were waiting for a signed order from a doctor’s office in order to send out ostomy supplies. Review of the agency QAPI documentation showed on 5/15/24, no time provided, the DCS documented Patient #1 made a complaint about not having enough ostomy bags. The DCS documented she met with a different DME representative who provided her with another 50 bags and flanges, which the DCS delivered to Patient #1. Review of the agency QAPI documentation showed on 5/29/24, the DCS documented CNA #4 made an initial complaint on 5/28/24 at 1:57 p.m. that Patient #1 was yelling at her as he was unhappy the ostomy bags provided to him that day did not fit his flanges. CNA #4 reported to the DCS, Patient #1 had six ostomy bags in his home that did fit his flanges. The DCS documented CNA #4 reported she was uncomfortable with Patient #1’s behavior and CNA #4 did not want to see Patient #1 due to his behavior. The DCS documented she contacted Patient #1 who was yelling at the DCS stating the agency was abusing him and the DME company was trying to “kill him” and was an “idiot.” The DCS documented she contacted the DME representative to confirm delivery of the ostomy supplies ordered for him and informed Patient #1 of his pending delivery of supplies. The DCS documented she informed CNA #4 if she was uncomfortable with completing visits with Patient #1, the DCS could complete the visits. The DCS documented she contacted Patient #1 to inform him she would complete his CNA visit, and he refused. The DCS also documented, CNA #4 reported to her, Patient #4 called CNA #4 and stated he would report CNA #4 for abuse if she did not provide his visit. CNA #4 contacted the agency administrative staff and informed them she would provide his next visit on 5/29/24. Continued review of this document showed the DCS documented after CNA #4 made her 5/29/24 visit to Patient #1, CNA #4 contacted the administrator and told the agency administrator Patient #1 was “going to go after everyone in the office,” and CNA #4 asked to not be scheduled to provide Patient #1 with care in the future. The DCS also documented CNA #4 reported Patient #1 informed CNA #4 that licensed practical nurse (LPN) #5, Patient #1’s primary SN, informed Patient #1 she agreed the agency had failed to provide Patient #1 with ostomy bags, LPN #5 had filed an adult protective services (APS) elder abuse report for Patient #1 against the agency, and LPN #5 planned to follow Patient #1 to another agency. The DCS documented on 5/29/24 at 3:18 p.m., she contacted LPN #5 who stated she did not intend to follow Patient #1 to another agency and Patient #1 misinterpreted what she had told him. Continued review of the complaint documentation made by CNA #4 on 5/29/24, showed the DCS documented “Due to patient creating this conflict between staff and refusing other staff, agency does not have any more staff to see him.” The DCS documented the DCS planned to provide Patient #1 with his care. The DCS documented she contacted Patient #1 to inform him of this decision and he had not answered his phone, thus the agency called the police to do a welfare check, the DCS had completed daily visits to Patient #1’s building, but Patient #1 was not admitting the DCS to the building to allow her to provide him with care or acknowledging her to verbally refuse the care. Review of the agency QAPI documentation showed on 5/28/24 at 5:30 p.m., the administrator stated Patient #1 called the DCS upset regarding not receiving 100 ostomy bags as he requested. The administrator stated the DCS attempted to explain to Patient #1, the agency could not get the surgeon who performed his colostomy procedure, Dr. #8, or Dr. #8’s physician assistant, PA #9, to sign an order for the extra ostomy bags he requested, as Dr.#8 or PA #9 had not seen Patient #1 since February of 2024, and Patient #1’s gastroenterologist (GI), Dr. #7, at a different medical center, would only sign an order for 20 ostomy bags. The administrator documented Patient #1 was claiming abuse and neglect and that he was out of ostomy bags. Review of the investigation of Patient #1’s 5/28/24 complaint showed the administrator contacted LPN #5 and CNA #4, who provided Patient #1 with regular care, and both LPN #5 and CNA #4 reported Patient #1 still had ostomy bags, denied seeing signs of abuse or neglect and both clinicians reported to the administrator receiving borderline harassment from Patient #1. Review of the resolution to Patient #1’s 5/28/24 complaint, showed the administrator documented the agency filed a report with APS (on Patient #1’s behalf against the agency) and with the Department to inform them on the agency’s plan to discharge Patient #1 for cause. The administrator documented the agency attempted to contact Patient #1 multiple times and the DCS attempted to call Patient #1 multiple times, leaving voicemails as Patient #1 did not answer. Additionally, the DCS attempted to make multiple visits with Patient #1 and was unable to get into his building. The administrator documented the agency contacted Denver Police Department to conduct a welfare check without a resolution and the agency informed Patient #1 they would conduct an emergent discharge following state regulations in 10 days. The administrator also documented the complainant was informed of the resolutions to his 5/28/24 complaint on 6/1/24. Review of the clinical record showed on 5/28/24 at 3:51 p.m., the DCS documented a journal note which stated Dr. #7’s office was contacted to determine when he was last seen by Dr. #7 and to inquire if Dr. #7’s office would supply orders for supplies for Patient #1. The DCS documented who she spoke to at Dr. #7’s nurse line and the person on the nurseline informed the DCS, Patient #1 was seen by Dr. #7 last on 5/15/24 for his ostomy and Dr. #7’s office would sign for 20 ostomy bags for Patient #1. Review of Patient #1’s clinical record showed on 5/28/24 at 7:13 p.m. Patient #1 phoned the agency and spoke with the DCS to discuss how the DCS had handled ordering ostomy bag supplies for Patient #1. Patient #1 accused the administrator, alternate administrator and DCS of lying to him; he stated he was having an emotional crisis, that he felt abused, neglected and mistreated; and he stated the DCS was incompetent. During this phone conversation, Patient #1 raises his voice multiple times and uses curse words several times. Review of Patient #1’s clinical record showed the DCS left Patient #1 a voicemail on his home phone and cell phone on 5/29/24 at 11:09 a.m. stating the DCS had some updates for Patient #1 and to inform Patient #1, CNA #4 would not be providing him care on 5/29/24, and asked for a phone call back as soon as possible. Review of Patient #1’s clinical record showed the DCS sent a text message to Patient #1 on 5/29/24 at 11:24 a.m. which stated the DCS had heard from LPN #5 that Patient #1 was “too stressed out to talk” and to contact the DCS at the office (phone number provided) so the DCS could update Patient #1. Patient #1 responded to the DCS text with a text requesting the DCS reply to him via text or email. The DCS texted back to Patient #1’s request to reply via text or email “No sir.” Review of Patient #1’s clinical record showed the DCS left Patient #1 a voicemail on his home phone and cell phone on 5/29/24 at 1:58 p.m., stating the following: DCS was hoping to speak with Patient #1; the agency was completing a 10 day emergent discharge for cause (failed to provide the reason or what was being done to attempt to resolve the issue); the agency would send Patient #1 a certified letter out today (failed to state the purpose of the letter); the DCS would provide Patient #1 care for the next 10 days and stated Patient #1 was not to contact his primary SN (LPN #5 or CNA #4: the DCS would work Patient #1’s case manage to help find Patient #1 a different home health care agency; the agency informed Patient #1’s physicians of the discharge; the agency informed the Department regarding the discharge; the agency filed an APS report on Patient #1’s behalf and provided the case number; and for Patient #1 to contact the DCS at the office to schedule his visits for the next 10 days. During an interview on 6/5/24 at 3:47 p.m., CNA #4 confirmed she was Patient #1’s primary CNA and had provided him care in April and May of 2024. CNA #4 stated her understanding of why Patient #1 was discharged from the agency was Patient #1 was frustrated with not receiving the number of ostomy bags he thought he needed. CNA #4 stated Patient #1 had not complained to her about not receiving his ostomy bags until May of 2024. CNA #4 stated on 5/27/24 he started to yell at agency administration to express his frustration about not receiving his ostomy bags/supplies during her CNA visit with him, but CNA #4 state she failed to document in her notes her observation of Patient #1’s yelling while on a telephone conversation. CNA #4 stated she informed Patient #1 to work the issue of not having ostomy bags out with the alternate administrator. CNA #4 documented in her 5/28/24 visit note, Patient #1 was hostile during his visit with her. CNA #4 documented Patient #1 was upset about the lack of supplies for ostomy bags and spent 30 minutes of the CNA visit on the phone threatening all the reports he would make because there was not a prescription for additional ostomy bags. CNA #4 stated after her visit with Patient #1 on 5/28/24, she informed the DCS of Patient #1’s complaints, including how he was yelling during her treatment on 5/28/24 and that Patient #1 stated LPN #5 filed an APS complaint on the agency on Patient #1’s behalf for elder abuse/neglect for not supplying him with his ostomy bags. CNA #4 stated she informed the DCS she was not comfortable continuing to provide Patient #1 care if he continued to yell during the treatments. CNA #4 stated the DCS informed her she did not have to go to her 5/29/24 visit with Patient #1. CNA #4 stated on 5/29/24 she received a text from Patient #1 asking why she wasn’t coming to complete her scheduled CNA visit with him. CNA #4 stated she texted him back stating the DCS told her not to come on 5/29/24 or 5/30/24 while the situation (with the ostomy bags) was sorted out and that “hopefully everything will be worked out for when I return, they will put you back in my schedule. I do not know, however I was instructed to mark as a missed visit. I will be calling [the DCS] soon to see where things are at and the plan moving forward.” Patient #1 responded “This is blatant and illegal retaliation.” CNA #4 texted back “I talked to [the DCS] and I am heading your way now.” CNA #4 stated she also informed Patient #1 that she was willing to provide Patient #1 continued care but would like him to focus while she was there on the job she could provide to Patient #1, assistance with activities of daily living/personal care and to not yell about the ostomy bags during her visit. CNA #4 stated Patient #1 then threatened to call APS on her for elder abuse for stating CNA #4 was stating he could not speak during her visits. CNA #4 explained to Patient #1 that she did not request he didn’t speak during her visits, but to avoid speaking about his ostomy bag supply issues as she was unable to solve these issues. CNA #4 stated she offered Patient #1 assistance with personal care, but he declined and asked her to provide him only assistance with his transcutaneous electrical nerve stimulation (TENS) machine. CNA #4 stated after that visit she informed the DCS she was uncomfortable providing Patient #1 care if he was going to twist her words around and threaten to report her. CNA #4 stated she then received an interoffice communication which stated Patient #1 was being discharge in 10 days and the DCS would provide all care to Patient #1, CNA #4 was not to correspond with Patient #1, and if Patient #1 contacted her she was to inform the agency administrative staff and they would communicate/assist Patient #1. During an interview on 6/5/24 at 4:24 p.m., LPN #5 confirmed she was Patient #1’s primary SN and provided him assistance seven days a week with ostomy care, medication administration and set-up. LPN #5 stated she was aware Patient #1 was complaining about not getting ostomy bags as requested and was aware Patient #1 had been yelling at various people, but not at her. LPN #5 stated Patient #1 never yelled at her or was threatening to her. LPN #5 stated after her 5/29/24 visit with Patient #1, the DCS called her to ask her how her visit with Patient #1 went. LPN #5 stated she reported to the DCS, Patient #1’s frustration about his ostomy supplies, how she had coordinated with the DME company and Patient #1’s GI doctor, Dr. #7 to help facilitate getting more ostomy supplies for Patient #1. LPN #5 stated the DCS asked her if she had filed an APS report against the agency for Patient #1 and LPN #5 informed the DCS she did not file the report but Patient #1 informed her he had filed a complaint with APS about the agency for alleged abuse and neglect on 5/28/24. LPN #5 stated the DCS also asked her if she planned to leave the agency with Patient #1 to go work at another agency and provide care to Patient #1. LPN #5 stated she informed the DCS she did not have any plans to quit the agency and to go work at another agency with Patient #1. LPN #5 stated she had planned to go see Patient #1 on 5/30/24, but then received a text message and interagency message through the communication application the agency used, informing her Patient #1 was being discharged from the company and the DCS would provide care to Patient #1 until he was discharged 10 days later and to not communicate with Patient #1 directly and instead refer him to agency management. Further review of the clinical record, agency QAPI documentation, the communication notes between staff regarding Patient #1 from 4/4/24 through 6/5/24, text messages between Patient #1 and the DCS and phone calls between the agency and Patient #1 from 5/28/24 through 5/31/24 failed to show any further complaints made by Patient #1 or staff regarding Patient #1. Additional review of the clinical record, phone calls, interagency communication, and text messages failed to show the agency provided Patient #1 with a reason for the discharge for cause (Cross Reference G464) or documented evidence of what the agency did to attempt to resolve the problems leading up to the discharge for cause, prior to providing Patient #1 with verbal notification of a discharge during the 5/29/24 phone message left for Patient #1 left at 1:58 p.m. During an interview on 6/4/24 at 1:57 p.m., Patient #1 stated the agency had a problem with securing ostomy bags for his colostomy care and he filed a complaint against the agency with APS for elder abuse/neglect on 5/28/24. Patient #1 stated he then was notified the agency was discharging him for cause, completing a 10 day emergent discharge. Patient #1 stated the DCS instructed him to not contact LPN #5 or CNA #4 and the DCS would provide him with care. Review of an email sent to the surveyor by Patient #1 on 6/5/24 at 8:23 a.m., Patient #1 documented he never received the certified letter sent to him by the agency notifying him in writing of the agency’s intention to discharge him from the agency and to provide him any information which showed the agency attempted to communicate with Patient #1 that a discharge was being considered for him. During an interview on 6/7/24 at 11:14 a.m., the DCS stated the agency initiated the process for a 10 day emergent discharge for cause with Patient #1 for many reasons which included: the agency management staff (which included the DCS, the administrator and alternate administrator) felt Patient #1 was attempting to pit LPN #5 and CNA #4 against each other and the agency administrative staff; the agency’s administrative staff inability to discern which physician was following Patient #1, in particular, to provide orders for ostomy bag supplies; Patient #1 asking the DCS to lie to one of his providers stating he planned to continue care with the provider, when Patient #1 had told DCS he had no intention of continuing care with the provider, but wanted the provider to sign orders for more ostomy bags; and due to Patient #1’s behavior the week leading up to the agency providing Patient #1 with the verbal and written notice of a 10 day emergent discharge on 5/29/24 which included cussing and yelling at staff members. The DCS stated she attempted to speak with Patient #1, to discuss his behavior and the agency management staff feeling discharging Patient #1 might be the best course of action prior to sending the voicemail and certified letter regarding discharging Patient #1, but Patient #1 would not answer the DCS phone calls. The DCS stated she did not document all of her attempts to contact Patient #1 prior to sending Patient #1 the 5/29/24 1:59 p.m. voicemail in which the DCS informs Patient #1 the agency would be discharging him in 10 days. During continued interview, the DCS stated Patient #1 called the DCS on 5/28/24 on her personnel cell phone and the alternate administrator answered the phone. The DCS stated Patient #1 was yelling and cursing at the alternate administrator as he was frustrated about not receiving ostomy bag supplies. The DCS stated she observed the alternate administrator attempt to calm Patient #1 down and to deescalate the situation, but Patient #1 continued to yell at the alternate administrator. The DCS then took the phone from the alternate administrator and DCS stated Patient #1 informed her LPN #5 and CNA #4 were incompetent and Patient #1 stated he was upset/flustered about his lack of ostomy supplies. The DCS stated she and the alternate administrator went immediately over to Patient #1’s home to provide him with ostomy bags the DCS had secured for him from a vendor, but Patient #1 would not allow the DCS or the alternate administrator to come into his home. The DCS stated, CNA #4 was at Patient #1’s home at the time the DCS and alternate administrator arrived to bring Patient #1 his ostomy bags, and Patient #1 allowed CNA #4 to retrieve the supplies from the DCS and alternate administrator for him. The DCS acknowledged she did not document the 5/28/24 telephone conversation or the 5/28/24 visit to deliver ostomy bags to Patient #1. Additionally, the DCS acknowledged she failed to document all her attempts to solve the issue of Patient #1 yelling at staff through the week of 5/27/24 through 5/30/24. The DCS stated she did not document her attempts to resolve the issues that led to Patient #1 being discharged for cause as required by regulation. During an interview on 6/7/24 at 11:16 a.m., the alternate administrator stated he spoke with Patient #1 the morning of 5/28/24 on the DCS personnel cell phone. The alternate administrator stated Patient #1 was upset about his ostomy bag supplies and was yelling and cursing at the alternate administrator. The alternate administrator stated he attempted to calm Patient #1 down and to deescalate the situation, but the calmer the alternate administrator became the more agitated Patient #1 became. The alternate administrator confirmed he went with the DCS to deliver more ostomy bags to Patient #1 on 5/28/24 and Patient #1 would not speak to the DCS or the alternate administrator and sent CNA #4 down to retrieve the ostomy bags. The alternate administrator stated he failed to document his 5/28/24 telephone conversation with Patient #1, his visit to Patient #1’s home to deliver supplies or any of the other phone calls the alternate administrator had received from Patient #1 in the week leading up to the DCS calling Patient #1 to inform him the agency was going to discharge him on 5/29/24. During an interview on 6/7/24 at 12:02 p.m., the administrator stated the agency discharged Patient #1 due to behavior toward agency staff and the administrator did not feel the agency could meet Patient #1’s needs. The administrator stated during the last week of May 2024, Patient #1 called the agency multiple times yelling, cursing, and expressing his frustration in not being provided the ostomy bags he requested. The administrator stated she did not document any of the phone calls she had with Patient #1 during this week and acknowledged the DCS and alternate administrator also failed to document all the phone calls they had with Patient #1. The administrator stated she was aware of the federal and state regulations regarding discharging a patient for cause, and thought the agency was following them when the agency notified the patient they would be discharging him verbally with the voicemail, via a certified letter, and to notify the Department of the agency’s plan to discharge a patient for cause (emergent discharge). The administrator acknowledged the agency failed to inform Patient #1 verbally, and in writing, the agency was considering discharging him for cause and the reason for the discharge as required by regulation or the attempts the agency made to resolve the issues, prior to providing him with discharge notification. The administrator also acknowledged the discharge notifications Patient #1 received verbally from the DCS in a voicemail on 5/29/24 and the discharge letter sent via certified mail on 5/29/24 to Patient #1 did not provide a reason for the discharge or the steps the agency took to attempt to resolve the issue leading to the discharge for cause prior to discharge. Instead, the verbal and written discharge notifications to Patient #1 contained a statement the agency would be discharging Patient #1 and the steps the agency would take to facilitate this discharge. 2. During an interview on 6/7/24 at 1:46 p.m., the administrator, alternate administrator and DCS all acknowledged they failed to follow regulatory requirements for discharging Patient #1 for cause as they failed to document all conversations they had with Patient #1, the agency staff who provided care to Patient #1 and his physicians.”