Mercyone Des Moines Home Care

“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 staff interview, surveyor observation, policy review and record review the home health agency failed to: ensure the parent home health agency notified the state agency of the proposed intent to add a branch office and obtain approval for the branch office prior to providing services out of the branch office. (G972) The cumulative effects of these systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency’s patients.”

“Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA’s request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This Element is not met as evidenced by: Based on staff interview, home visit observation, surveyor observation, policy review and agency documents review, the agency failed to notify the State agency (SA) of their intent to add a branch location, provide the necessary documentation and obtain approval for a branch location prior to providing services to agency patients from that branch location. Failure to obtain approval for a branch office prior to providing services, placed agency patients at risk for inadequate and unsafe care. Findings include: On 3/10/25 at 11:45 AM, the surveyor entered the office located at 910 N Eisenhower Ave, Mason City, IA 50401. The surveyor observed the office to be staffed and operational. According to agency policy, titled Trinity Health at Home – Governance: Home Health Board of Directors, dated 4/14/24, the Continuing Care Board of Directors is the Governing Body with full responsibility for Trinity Health at Home agencies and is responsible overseeing compliance with the Trinity Health Integrity and Compliance Program and facilitating and recommending actions within the community healthcare system. During an interview on 3/10/25 at 3:05 PM, Administrator reported all patients from the Home Care office located in Mason City had been discharged and readmitted under the Des Moines parent office CCN (CMS Certification Number) starting 2/1/25. “ All current patients in the Mason City branch office would be listed on the Des Moines parent office census. All Mason City branch office patients were notified of the need to discharge and readmit under the Des Moines parent office.” On 3/10/25 at 1:58 PM, the surveyor received an email from the Administrator identifying an attachment. The attachment, dated 3/5/25, on Celerian Group Company (CGS) letter head, identified; this letter updates you on the status of your change of information enrollment application. Your application is required to go through a multi-step review process. CGS Administrators is a CMS Medicare Administrative Contractor (MAC) charged with enrolling providers and suppliers in the Medicare program. We have assessed your enrollment application and forwarded it to the Iowa State Agency for the next step in the process. The State Agency will conduct a review for further compliance with the applicable Federal, State, and local requirements. Once the State Agency’s review is complete, CMS will conduct a final review and issue a decision. We will contact you when your application has completed all stages of review and a decision has been made. Requested changes: Added practice location effective 2/24/25: 910 N Eisenhower Ave, Mason City, IA 50401. Notification of approval must be submitted to the MAC before the changes noted above can be approved. On 3/10/25 at 2:37 PM, the State Agency Program Coordinator received an email from Staff C, VP of Home Care Operations. The email included an attachment, with the completed branch questionnaire and supporting documents for the proposed branch office located at 910 N Eisenhower Ave, Mason City, IA 50401. The attachment, titled Home Health Agency Branch Request Questionnaire, dated 3/5/25, signed by Staff C, VP of Home Care Operations. The Questionnaire identified no services can be provided from this proposed location without prior CMS approval. On 3/11/25 at 11:00 AM, the surveyor completed a home visit observation with Staff D, RN (registered nurse) and Clinical Manager for Patient #1. During an interview at the time of the home visit observation, Patient #1 reported receiving a letter in the mail from the agency informing them of the change in the agency name. On 3/11/25 at 4:00 PM, the Clinical Manager provided the surveyor with a copy of a name change letter, she reported all current Mason City patients on services in February received the letter in February. During an interview on 3/12/25 at 10:20 AM, Administrator reported “Mason City branch office is staffed with Clinical Manager, Document Specialist and Scheduler. Administrator is on site at least 2 times a month if not more frequently.” On 3/12/25 at 10:30 AM, the surveyor was provided a printout of staff schedules for the Mason City office for Tuesday 3/11/25 and Wednesday 3/12/25. Observations on 3/10, 3/11 and 3/12/2025 showed staff were present at the proposed branch location. The agency failed to obtain approval for a branch office prior to providing services to agency patients from the branch office. The above findings were reviewed with the Administrator.”