Qcn 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 interview, the agency failed to ensure the home health agency was functioning under the supervision of an Administrator who was present and responsible for all day-to-day operations (G948); failed to ensure the Clinical Manager was available at all times during operating hours (G950); and, failed to ensure a qualified alternate, was available to function in the Administrator’s absence (G954). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.105 Organization and Administration of Services.”

“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 interview, the agency failed to ensure the home health agency was functioning under the supervision of an Administrator who was present and responsible for all day-to-day operations since 5/30/25, when the administrator left their position. Findings include: On 6/17/25 at 9:30 a.m., upon arrival to this agency, a staff person inquired of the nature of the visit and stated, “No one is here from that company. Let me see if I can find someone who can help you.” A person who identified herself as the Controller inquired of the nature of the visit and stated she was unfamiliar with the survey process. The Controller then stated, “We don’t currently have an Administrator, but someone recently accepted our offer and are set to start in two weeks. I can call you and we can reschedule for a later date.” When queried as to how long the agency has been without an Administrator, the Controller responded, “That Administrator’s husband is active-duty military. He got called for duty, so they moved across the country. Her (Administrator) last day at the company was 5/30/25.” The agency failed to ensure an Administrator was available and responsible for all day-to-day operations. The Controller acknowledged the findings during the above interview.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on interview, the Administrator failed to ensure a Clinical Manager was available at all times during operating hours since May of 2025 when the Clinical Manager left. Findings include: On 6/17/25 at 9:30 a.m., upon arrival to the agency, this writer was greeted and informed by the Controller who reported that the agency doesn’t have a Clinical Manager. The Controller then stated, “There is a nurse here who could possibly help you.” When asked if the nurse was affiliated with this agency or would be able to answer questions regarding patient concerns, the Controller responded, “No.” When queried as to how long the agency had been without a Clinical Manager, the Controller was unable to answer. The agency failed to ensure a Clinical Manager was available during all hours of operation. The Controller acknowledged the findings during the above discussion.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on interview, the agency failed to ensure a qualified alternate, was available to function in the Administrator’s absence, resulting in the potential for uncoordinated agency functions. Findings include: On 6/17/25 at 9:30 a.m., upon arrival to this agency, a staff person inquired of the nature of the visit and stated, “No one is here from that company. Let me see if I can find someone who can help you.” A person who identified herself as the Controller inquired of the nature of the visit and stated she was unfamiliar with the survey process. The Controller then stated, “We don’t currently have an Administrator, but someone recently accepted our offer and are set to start in two weeks. I can call you and we can reschedule for a later date.” When queried as to how long the agency has been without an Administrator, the Controller responded, “That Administrator’s husband is active-duty military. He got called for duty, so they moved across the country. Her (Administrator) last day at the company was 5/30/25.” When asked if there was an Alternate Administrator, the Controller said, “No. We don’t have and Administrator or an Alternate Administrator.” The agency failed to ensure an Alternate Administrator was available to function in the absence of the Administrator. The Controller acknowledged the findings during the above interview.”