Diversified Health Management, Inc.

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on record review, interview and policy review, the facility failed to ensure an allegation of misappropriation was thoroughly investigated, failed to have an Abuse, Neglect and Misappropriation policy, and failed to log the existence of a complaint and resolution or educate staff on abuse, neglect and misappropriation.. This affected one (Patient #8) of three patients reviewed. This could affect all patients receiving services from the agency. The active census was 57. See G478 and G484”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on record review, interview and policy review, the facility failed to ensure an allegation of misappropriation was investigated and brought to resolution. This affected one (Patient #8) of three patients reviewed. The active census was 57. Findings include: Review of the physician ordered plan of care revealed Patient#8 was admitted on 03/17/23. He had diagnoses that included chronic obstructive pulmonary disease, chronic systolic congestive heart failure, malignant neoplasm of bronchus or lung, pain of thoracic spine and other chronic pain. He used a walker, and a cane. For the certification period 05/10/24 to 07/08/24 the individuals home health aide services were on hold as of 04/06/24. The patient was looking for a new home health aide (HHA) to start his services. Document review from an outside source revealed the facility was contacted on 06/18/24 and informed them Patient #8 was short for April and May’s rent due to the HHA, Staff C, taking Patient #8’s money order and money for April. Patient #8 fired Staff C approximately two months prior, around 04/08/24. The allegation had not been reported to the facility by Patient #8 or Staff C. Review of the facility’s response to the outside source included Staff C’s time sheets for the week of 03/31/24 to 04/06/24, the last time sheet turned in. Patient #8 let the aide go after 04/06/24. Staff C worked 35 hours a week 7:00 A.M. to 12:00 P.M. on weekdays and 4:00 P.M to 9:00 P.M. on the weekends. There was no unworked or partially work shifts. A Communication Note included Patient #8 communicated to the case manager that he was admitted to the hospital on 04/11/24. He forgot to let the agency know he let Sraff C go. Patient #8 did not report any incident regarding the money and the agency was completely unaware of any issue. Patient #8 just noted that Staff C did not have his preferred timeframe he desired so he let the aide go. It was not until the call from his case manager on 06/18/24 that the facility became aware Patient #8 thought Staff C took money. Document review revealed no evidence of an investigation being conducted into misappropriation once the facility became aware of the allegation. There was no evidence of Patient #8 or Staff C were interviewed regarding the allegation. There was no conclusion or resolution from the agency. The facility was not able to provide a policy or procedure regarding allegations of Abuse, Neglect and Misappropriation. Review of three personnel records revealed the facility did not educate staff during orientation or annually on abuse, neglect or misappropriation. During interview on 07/18/24 at 2:24 P.M., Staff A verified there was not an investigation into the misappropriation allegation. She did not investigate because Staff C was no longer employed by the agency and the allegation occurred months ago. Staff A verified the agency did not have a policy or procedure on abuse, neglect or misappropriation. During an interview 07/18/24 at 4:04 P.M., Staff B verified the agency did not do an investigation into the misappropriation and the agency did not have a policy or procedure on abuse, neglect or misappropriation. During an additional interview on 07/31/24 at 10:54 A.M., Staff A again verified the agency did not have a policy or procedure on abuse, neglect or misappropriation and do not educate staff on abuse, neglect or misappropriation.”

“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 interview, the facility failed to document both the existence of a complaint and the resolution of complaint. This affected one (Patient #8) of three patients reviewed. This had the potential to affect all the patients of the facility. The active census was 57. Findings include: Review of the physician ordered plan of care revealed Patient#8 was admitted on 03/17/23. He had diagnoses that included chronic obstructive pulmonary disease, chronic systolic congestive heart failure, malignant neoplasm of bronchus or lung, pain of thoracic spine and other chronic pain. He used a walker, and a cane. For the certification period 05/10/24 to 07/08/24 the individuals home health aide services were on hold as of 04/06/24. The patient was looking for a new home health aide (HHA) to start his services. Document review from an outside source revealed the facility was contacted on 06/18/24 and informed them Patient #8 was short for April and May’s rent due to the HHA, Staff C, taking Patient #8’s money order and money for April. Patient #8 fired Staff C approximately two months prior, around 04/08/24. The allegation had not been reported to the facility by Patient #8 or Staff C. Review of the facility’s response to the outside source included Staff C’s time sheets for the week of 03/31/24 to 04/06/24, the last time sheet turned in. Patient #8 let the aide go after 04/06/24. Staff C worked 35 hours a week 7:00 A.M. to 12:00 P.M. on weekdays and 4:00 P.M to 9:00 P.M. on the weekends. There was no unworked or partially work shifts. A Communication Note included Patient #8 communicated to the case manager that he was admitted to the hospital on 04/11/24. He forgot to let the agency know he let Sraff C go. Patient #8 did not report any incident regarding the money and the agency was completely unaware of any issue. Patient #8 just noted that Staff C did not have his preferred timeframe he desired so he let the aide go. It was not until the call from his case manager on 06/18/24 that the facility became aware Patient #8 thought Staff C took money. Document review revealed no evidence of an investigation being conducted into misappropriation once the facility became aware of the allegation. There was no evidence of Patient #8 or Staff C were interviewed regarding the allegation. There was no conclusion or resolution from the agency. The facility provided no evidence of a complaint log. During an interview on 07/18/24 at 2:24 P.M., Staff A verified the facility did not have any evidence of a complaint log including the resolution of the complaint. During an interview on 07/18/24 at 4:04 P.M., Staff B verified the agency did not have a policy or procedure related to how to address complaints brought forth to the agency.”