Moonlight Home Health Care Inc.

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the physician was notified of the missed visits. (G572) The agency failed to ensure the home health aides (HHA) provided the services as ordered. (G580) The agency failed to ensure the physician’s plan of care was reviewed and signed by the physician every 60 days. (G588)”

“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 the physician was notified of the missed visits. This affected three out of three patient records reviewed. (Patient #1, #2 and #3) The census was 223. Findings include: 1. 1. Review of the medical record for Patient #1, and physician’s plan of care dated 08/1525 to 10/13/25, revealed the home health aide (HHA) was to provide service seven days per week to assist with personal care and activities of daily living (ADL). Review of the HHA time sheets from 08/31/25 to 09/28/25 revealed missed visits on 08/31/25, 09/01/25, 09/02/25, 09/04/25, 09/13/25, 09/14/25 and 09/21/25. There was no documented evidence the physician had been notified. 2. Review of the medical record for Patient #2, and physician’s plan of care dated 04/16/25, revealed the HHA was to provide service seven days per week to assist with personal care and ADLs. Review of the HHA time sheets from 05/04/25 through 05/17/25 revealed missed visits on 05/04/25, 05/14/25, 05/15/25, 05/16/25 and 05/17/25. There was no documented evidence the physician had been notified. 3. Review of the medical record for Patient #3, and physician’s plan of care dated 08/17/25, revealed the HHA was to provide services seven days per week to assist with personal care and ADLs. Review of the HHA time sheet for the week of 08/10/25 revealed missed visits on 08/11/25, 08/12/25, 08/14/25 and 08/15/25. Review of the HHA time sheet for the week of 08/17/25 revealed missed visits on 08/18/25, 08/19/25, 08/20/25, 08/21/25 and 08/22/25. There was no documented evidence the physician had been notified of these missed visits. Interview on 10/28/25 at 1:03 PM the Director of Nursing confirmed the physician had not been notified of the missed visits for Patient #1, Patient #2, and Patient #3.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the home health aide (HHA) care plan was reviewed by a registered nurse every 60 days. This affected two out of three HHA records reviewed. (Patient #1 and #3) The census was 223. Findings include: 1. Review of the medical record for Patient #1 and the HHA care plan revealed it was last reviewed and updated by a registered nurse on 06/27/23. 2. Review of the medical record for Patient #3 and the HHA care plan revealed it was last reviewed and updated by a registered nurse 05/15/25. Interview on 10/27/25 at 4:43 PM the Director of Nursing confirmed the HHA care plans were not reviewed by the RN every 60 days.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and staff interview the agency failed to provide skilled nursing services. This affected three out of three records reviewed. (Patients #1, #2 and #3) The census was 223. Review of the medical record for Patients #1, #2 and #3 did not reveal skilled nursing care was provided. Interview on 10/27/25 at 8:35 AM the Director of Nursing (DON) stated the agency no longer does skilled nursing care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the home health aides (HHA) provided the services as ordered. This affected three out of three patients’ records reviewed. (Patient #1, #2 and #3) The census was 223. Findings include: 1. Review of the medical record for Patient #1 and physician’s plan of care dated 08/15/25 to 10/13/25 revealed home health aide (HHA) services were to be provided seven days per week for a total of 36 hours per week to assist with personal care and activities of daily living. Review of the HHA time sheets for the week of 08/32/25 revealed the HHA provided 29 ½ hours. The week of 09/07/25 the HHA went 53 hours. The weeks of 09/14/25 and 09/21/25 the HHA went 42 hours. Interview on 10/27/25 at 4:20 PM the Director of Nursing (DON) confirmed the HHA services provided were not as the physician had ordered. 2. Review of the medical record for Patient #2 and physician’s plan of care dated 04/16/25 revealed HHA services were to be provided seven days per week for a total of 28 hours per week to assist with personal care and activities of daily living. Review of the HHA time sheets revealed no service was provided 06/17/25 through 05/04/25 and 05/14/25 through 05/21/25, when Patient #2 was discharged. Interview on 10/28/25 at 2:00 PM the DON confirmed there were no communication notes or time sheets for these dates. 1. Review of the medical record for Patient #3 and physician’s plan of care dated 08/17/25 revealed HHA services were to be provided seven days per week for a total of 49 hours per week to assist with personal care and ADLs. Review of the HHA time sheets for Patient #3 revealed no service was provided from 08/31/25 through 09/13/25. Interview on 10/28/25 at 2:09 PM the DON confirmed the HHA did not go seven days per week as ordered and was unable to provide the time sheets.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the physician’s plan of care was reviewed and signed by the physician every 60 days. This affected three out of three records reviewed. (Patient #1, #2 and #3) The census was 223. Findings include: 1. Review of the medical record for Patient #1 revealed the physician’s plan of care dated 05/18/25 to 10/13/25 had not been reviewed or signed by the physician. 2. Review of the medical record for Patient #2 revealed the physician’s plan of care dated 04/16/25 to 06/14/25 had not been reviewed or signed by the physician. 3. Review of the medical record for Patient #3 revealed the physician’s plan of care dated 04/19/25 to 06/17/25 had not been reviewed or signed by the physician. Interview on 10/27/25 at 4:53 PM the Director of Nursing confirmed the physician plan of cares were not signed.”

“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 the ordered hours of service was provided. This affected two (Patients #1 and #6) of two patients reviewed. The census was 254. Findings include: 1. Review of the medical record for Patent #1 and the physician’s plan of care dated 09/11/24 through 11/09/24 revealed the home health aide (HHA) was to provide 35-40 hours per week to assist with personal care and light housekeeping. Review of the HHA time sheets for the week of 09/29/24 revealed the HHA provided 20 hours of care. Review of the HHA time sheets for the week of 10/06/24 revealed the HHA provided 16 hours of care. Review of the HHA time sheets for the week of 10/13/24 revealed the HHA provided 24 hours of care. 2. Review of the medical record for Patent #6 and the physician’s plan of care dated 10/24/24 through 12/22/24 revealed the home health aide (HHA) was to provide 15 hours per week to assist with personal care and activities of daily living. Review of the HHA time sheets for the week of 11/10/24 revealed the HHA provided six hours of care and the week of 11/24/24 the HHA provided three hours of care. Interview on 12/05/24 at 12:20 PM the Office Administrator confirmed there was no documentation the physician had been notified of these missed visits.”

“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 the home health aides followed the Aide Care Plan. This affected three (Patients #1, #5 and #6) of three patients reviewed. The census was 254. Findings include: 1. Review of the medical record for Patient #1 and home health aide (HHA) Care Plan by the registered nurse (RN) dated 09/10/24 revealed Patient #1 was to receive a shower with chair and shampoo at every visit. Review of the HHA time sheets revealed the HHA provided service 10/09/24 through 10/11/24, three visits, and provided one bed bath on 10/09/24 and no hair was shampooed. Review of the HHA time sheets revealed the HHA provided service 10/14/24 through 10/16/24, three visits, and provided no shower with chair and no hair was shampooed. 2. Review of the medical record for Patient #5 and home health aide (HHA) Care Plan by the registered nurse (RN) dated 10/14/24 revealed Patient #5 was to receive a bed bath and shampoo at every visit. Review of the HHA time sheets revealed the HHA provided service 11/11/24 through 11/15/24, five visits, and provided one bed bath on 11/12/24 and no hair was shampooed. Review of the HHA time sheets revealed the HHA provided service 11/18/24 through 11/23/24, six visits, and provided three bed baths and no hair was shampooed. 3. Review of the medical record for Patient #6 and home health aide (HHA) Care Plan by the registered nurse (RN) dated 10/22/24 revealed Patient #6 was to receive a shower with chair, shampoo and assist with dressing at every visit. Review of the HHA time sheets revealed the HHA provided service 09/18/24 through 09/20/24, three visits, no shower with chair, hair shampoo or assist with dressing were done this week. Review of the HHA time sheets revealed the HHA provided service 11/14/24 through 11/15/24, two visits this week, no hair was shampooed or assist with dressing were done this week. Review of the HHA time sheets revealed the HHA provided service 11/25/24, one visit this week, no hair was shampooed this week. During an interview on 12/05/24 at 11:46 AM, the Office Administrator confirmed these findings.”

“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 medical record review, policy review, and staff interview, the agency failed to ensure patients received home health services as written in the plan of care for three (Patient #2, #3 and #4)of four patients reviewed. This has the potential to affect all patients receiving services from the agency. The census was 197. 1. Review of Patient #2’s medical record and the physician ordered plan of care for the certification period dated 01/16/24 through 03/15/24 revealed orders for home health aide (HHA) services 10 hours per week. The HHA was to assist with personal care, light housekeeping, making sure patient is safe and surroundings are clear as the patient is blind. Review of the HHA time sheets revealed the agency provided seven hours of aide services the week of 02/04/24 and 17 hours during the week of 02/11/24. The medical record did not contain any aide visits during the week of 01/14/24, 01/21/24, 01/28/24, 02/18/24, 02/25/24, 03/03/24, or 03/10/24. The medical record contained a communication note stating the physician will be notified for missed visits on 01/16/24, 01/18/24, and 01/22/24, however there was no evidence the physician was actually notified. There was no documentation in the medical record that the patient was instructed to activate their back up plan. There was no documentation the physician was notified services were not provided as ordered. Review of the agency policy titled “Plan of Care – CMS #485 and Physician Orders,” revised 2009, revealed the agency staff will promptly alert the physician to any changes that suggest a need to alter the Plan of Care. Interview on 05/08/24 at 9:34 AM Staff C confirmed the findings. 2. Review of Patient #3’s medical record and the physician ordered plans of care for the certification periods of 12/22/23 through 02/19/24, 02/20/24through 04/19/24, and 04/20/24 through 06/18/24 revealed orders for HHA services to provide assistance with personal care and activities of daily living (ADLs) as indicated by limitations on functional and physical status impeding self-care. The medical record contained no evidence the agency provided services from 02/08/24 through 02/19/24. There was no evidence the agency notified the patient, patient’s case manager or the patient’s physician regarding the agency being unable to staff Patient #3’s case from 02/08/24 through 02/19/24. Interview on 05/07/24 at 1:11 PM, Staff B confirmed the findings. Staff C was interviewed on 05/07/24 at 2:18 PM. Staff C reported Patient #3’s aide had quit and the agency did not have a replacement aide. 3. Review of Patient #4’s medical record and the physician ordered plan of care for the certification period dated 03/05/24 through 05/03/24 contained orders for the agency to provide 13.5 hours of HHA services every week for nine weeks. The most recent timesheet in Patient #4’s medical record was dated 01/19/24. The medical record did not contain evidence of Patient #4’s physician being notified of the missed visits. Interview on 05/08/24 10:50 AM Staff E reported Patient #4 was no longer receiving services from the agency. Staff E reported Patient #4 has not received services from the agency in about two to three months. Interview on 05/08/24 at 10:55 AM Staff E confirmed Patient #4 had not received the HHA services in the plan of care. The last time HHA was provided was on 01/19/24. The medical record did not contain evidence of Patient #4’s physician being notified of the missed visits.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on medical record review, policy review and staff interview, the agency failed to ensure the care plans included the frequency and duration of aide visits to be made for two (Patient #1 and Patient #3) of four patients reviewed. This has the potential to affect all patients receiving services from this agency. The agency’s census was 197. 1. Review of Patient #1’s medical record and the physician ordered plan of care for certification period dated 12/29/23 through 02/26/24 revealed orders for aide services to provide assistance with personal care and activities of daily living (ADLs) as indicated by limitations on functional and physical status impeding self-care. There was no frequency or duration of visits ordered for the aide services. Review of the agency policy titled, “Plan of Care – CMS #485 and Physician’s Orders,” revised 2009, revealed the plan of care is established in consultation with the physician. The plan of care includes frequency and duration of visits. Staff B was interviewed on 05/07/24 at 1:34 PM and verified the plan of care for the Patient #1 did not contain a frequency or duration for aide services. 2. Review of Patient #3’s medical record and the physician ordered plans of care for certification periods dated of 12/22/23 through 02/19/24, 02/20/24 through 04/19/24, and 04/20/24 through 06/18/24 revealed orders for aide services to provide assistance with personal care. There were no frequencies or duration of visits ordered for the aide services. Staff B was interviewed on 05/07/24 at 1:11 PM and confirmed the current plan of care dated 04/20/24 through 06/18/24, contained no frequency or duration for home health aide services. Staff B was interviewed on 05/07/24 at 1:27 PM and confirmed the plan of care from 12/22/23 – 02/19/24 and 02/20/24 – 04/19/24 did not contain ordered frequencies or duration for home health aide services.”

“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 personnel file review, staff interview, staffing schedule review, review of the Ohio Administrative Code, and review of policies, the agency failed to 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 agency failed to ensure the Administrator was responsible for day-to-day operations of the agency by not following the agency’s policies on criminal background checks for employment for two home health aides (Staff C and Staff D) of two personnel files reviewed for criminal background checks. (G948). The cumulative effects of these systemic practices resulted in the facility’s inability to ensure the safety of every patient receiving home care services. This had the potential to affect the agency’s 218 patients. See G948.”

“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 medical record review, policy review, personnel file review, review of staffing schedules, review of Ohio Administrative Codes, and staff interview, the agency failed to ensure the Administrator was responsible for day-to-day operations of the agency by not following the agency’s policies on criminal background checks and employment for two home health aides (Staff C and Staff D) out of two personnel files reviewed for criminal background checks. The agency’s active census was 218. 1.Review of the personnel file for Staff D revealed a hire date of 10/26/23. Ther was no evidence the background check had been completed and returned to the facility within 60 days. A letter to the agency dated 10/26/23 stated the result from Staff D’s Bureau of Criminal Identification and Investigation (BCII) background check was mailed. The letter stated to please allow 30 days for processing. If you have not received the results after 30 days, please contact and ask for identification department to check on the progress. Review of the BCI report for Staff D, dated 01/30/24, included convictions 03/14/16 conviction for Falsification (Code 2921.13A5) with one year of probation (03/14/17). Review of the Ohio Administrative Code 3701-60-09, “Disqualifying Offenses Exclusionary Periods; Certificates; Pardons,” for Home Health Agencies, revealed Code 2921.13A5 carries a seven year exclusionary employment period from the date fully discharged from probation. Staff E was interviewed on 03/19/24 at 8:40 AM. Staff E reported they thought Staff D was allowed to continue working due to the time that has passed since Staff D’s convictions. Review of the staffing revealed Staff D provided aide services for Patient #2 from 12/06/23 through 12/13/23. 2. Review of the personnel file for Staff C revealed a hire date of 10/15/23. The personnel file contained no evidence of a BCI report being obtained until 03/19/24. The results of the BCII report dated 03/19/24 revealed Staff C was convicted of Theft (Code 2913.02) on 06/11/17 with 180 days jail served. Staff C was convicted on 07/23/21 of Assault (Code 2903.13). Review of the Ohio Administrative Code 3701-60-09, “Disqualifying Offenses Exclusionary Periods; Certificates; Pardons,” for Home Health Agencies, revealed Code 2913. 02 and 2903.13 each carried a five year exclusionary employment period from the date fully discharged from probation. However, if two or more convictions under the five year category occurred on unrelated events there would be a seven year exclusion from employment for Home Health Agencies. Review of the schedule revealed Staff C provided aide services for Patient #1 from 10/17/23 through 02/09/24. Review of the agency policy titled “Personnel Qualifications,” effective 01/05/13, included prior to employment employees must pass a fingerprint criminal background investigation. Review of the agency policy titled “Criminal Background Check,” effective 01/05/13, included the purpose was to ensure all clients are safe from harm and will not be exploited. The agency will not hire any prospective employee as administrator, direct care staff, case worker or, in any position responsible for a client’s care who has been convicted of or plead guilty of assault and program felony list in Ohio Department of Aging rules. All employees are required to pass a fingerprint background clearance check prior to employment. The agency will request the Bureau of Criminal Identification and Investigation (BCII) to conduct criminal records check for any employee who has applied for a position. If the agency has not received the results of the criminal records check within sixty (60) days after submission, or the employee has been convicted of or plead guilty to any of the numerated offenses, the agency shall terminate the individual’s employment, unless, the nursing supervisor, with the consent of the Administrator, chooses to employ the individual under personal character standards. Review of the agency policy titled “Human Resources: Revised BCI/I Procedures,” effective 01/12/15, included the agency has begun to check all new applicants’ criminal backgrounds before any application process begins as part of its revised pre-hire screening process. If applicants are free of criminal records, the Agency will instruct them to provide current background check (fingerprints) results addressed and mailed to the Agency. After the applicant brings the evidence of the background check, the employment application will be processed. Once all the Agency’s employment qualifications and requirements are satisfied, the applicant will be allowed to work conditionally until Agency receives fingerprint results within 60 days. All new applicants’ fingerprint results will be checked thoroughly to make sure they are eligible to continue working. A week prior to the 60-day wait, the Agency will terminate the conditional employee and request they re-apply as a new applicant. The agency’s process for hiring is to first require that applicants present their social security and identification to allow Agency to look up potential employees’ criminal records before application process starts. Interview with Staff E on 03/19/24 at 2:23 PM confirmed the findings regarding Staff D and Staff C working greater than 60 days without receiving their BCII background checks back and confirmed both had been convicted of disqualifying offenses.”

“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 review of documentation and interview, the agency failed to develop, implement, evaluate, and maintain an effective, ongoing, home health agency (HHA) wide, data-driven Quality Assurance Performance Improvement (QAPI) program per the requirements of: 42 CFR 484.65 On 02/06/24 at 3:00 PM, the surveyor requested information regarding the agency’s QAPI program. No documentation was provided. When asked if the agency had a QAPI program at that time, Staff A stated the agency had nothing like that.”

“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 a qualified home health aide (HHA) was a person who successfully completed a training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or a competency evaluation program that meets the requirements of paragraph (c) of this section; or a nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry (G754). The agency failed to ensure the home health aide (HHA) competency evaluation addressed 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 (G768). The agency failed to ensure the home health aide (HHA) received at least l2 hours of in-service training during each 12-month period (G774). The agency failed to ensure the home health aides (HHA) are assigned to a specific patient by a registered nurse (RN) (G798). The cumulative effect of these systemic practices resulted in the agency’s inability to ensure the patients home health aide needs were met.”

“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 observation, record review and staff interview, the governing body (or designated persons so functioning) failed to assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program (G942). The agency failed to ensure the Administrator was appointed by the Governing Body (G946). The agency failed to ensure the parent agency provides direct support and administrative control of its branches (G974). The cumulative effect of these systemic practices resulted in the agency’s inability to ensure the patients 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 the home health aide (HHA) competency evaluation addressed each of the subjects listed in paragraph (b)(3) of this section and where indicated, subject areas of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. This could affect all patients receiving services from this agency. The census was 303. Findings include: Review of the agency’s personnel files revealed an “Initial On-site competency Checklist” and an “HHA Skills Checklist.” Interview on 02/06/24 at 4:26 PM with Staff B revealed the “Initial On-site competency Checklist” and the “HHA Skills Checklist” were just talked through with the aide and then Staff B would check off that skill. The skills were not checked on a live or pseudo-patient. This deficiency represents non-compliance investigated under Substantial Allegation 104379.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure home health aides (HHA) received at least l2 hours of in-service training during each 12-month period for three of four HHA personnel filed reviewed (Staff D, E, and J). This could affect all patients receiving services from the agency. The census was 303. Findings include: Review of the personnel file for Staff D revealed a hire date of 06/19/23. There was no evidence Staff D completed any inservice training in the remainder of 2023. Review of the personnel file for Staff E revealed a hire date of 12/13/21. There was no evidence Staff E completed any inservice training in 2022 or 2023. Review of the personnel file for Staff J revealed a hire date of 03/20/23. There was no evidence Staff J completed any inservice training in the remainder of 2023. Interview on 02/06/24 at 3:59 PM with Staff AA confirmed Staff D, E, and J did not have any in-service training since hire. This deficiency represents non-compliance investigated under Substantial Allegation 104379.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on staff interviews, the agency failed to ensure the home health aides (HHA) are assigned to a specific patient by a registered nurse (RN). This could affect all patients receiving services from this agency. The census was 303. Findings include: Interview on 02/06/24 at 4:26 PM with Staff B revealed when she opened a new case, she would just leave the HHA care plan in the patient’s home and then the Administrative Assistants assigned the HHA’s to the patients. Interview on 02/06/24 at 4:36 PM with Staff Z confirmed the Administrative Assistants assigned the HHAs to the patients not the registered nurse.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and staff interview, the governing body (or designated persons so functioning) failed to assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This could affect all patients receiving services from the agency. The census was 303. Findings include: On 02/05/24 at 1:50 PM, the surveyor requested the Governing Body meeting minutes. Staff A was asked at that time who the members of the Governing Body were. Staff A repled, “What do you mean? There isn’t a Governing Body. There is just me and the DON (Director of Nursing).” Interview on 02/06/24 at 5:00 PM with Staff B confirmed there was no Governing Body.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure a qualified home health aide (HHA) was a person who successfully completed a training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or a competency evaluation program that meets the requirements of paragraph (c) of this section; or a nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry for seven out of seven home health aide personnel files reviewed (Staff D, E, F, J, K, Q and R). This could affect all patients receiving services from the agency. The census was 303. Findings include: Review of the agency’s home health aide (HHA) job description revealed under the position qualifications, effective 08/14/1990, the nurse’s aide must have successfully completed a state established or other training program that meets the requirements of CFR 484.36(a) and a competency evaluation program, or state licensure program that meets the requirements of CFR 484.36(b), or a competency evaluation program or state licensure program that meets the requirements of 484.36(b). Review of the agency’s “New Hire Checklist” revealed that in order for the personnel record to be considered complete, verification of educational documents, competency test results and skills assessment results must be included. 1. Review of the personnel file for Staff E revealed a start date of 12/31/21. Staff E’s personnel file included no documentation of HHA training or a competency exam. Staff E is currently providing HHA services to patients. 2. Review of the personnel file for Staff J revealed a hire date of 03/20/23. There was no documentation of HHA training, a competency exam, or HHA skills checklist. Staff J is currently providing HHA services to patients. 3. Review of the personnel file for Staff K revealed a hire date of 06/07/23. There was no documentation of HHA training or a competency exam. Staff K did provide services to Patient #8. 4. Review of the personnel file for Staff Q revealed a hire date of 12/27/23. There was no documentation of HHA training, a competency exam, or HHA skills checklist. Staff Q is currently providing HHA services to patients. 5. Review of the personnel file for Staff F revealed a hire date of 10/26/23. Staff J’s personnel filed included no documentation of HHA training or a competency exam. Staff F is currently providing HHA services to patients. 6. Review of the personnel file for Staff D revealed a start date of 06/19/23. Staff D’s personnel filed included no documentation of HHA training or a competency exam. Staff D did provide services to Patient #3. 7. Review of the personnel file for Staff R revealed a hire date of 12/14/22. There was no documentation of HHA training or a HHA competency exam. Staff R did provide services to Patient #2. Interview on 02/01/24 at 11:30 AM with Staff B confirmed the missing training, competency exams or competency check list. This deficiency represents non-compliance investigated under Substantial Allegation 104379.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the Administrator was appointed by the Governing Body. This could affect all patients receiving services from this agency. The census was 303. Findings include: On 02/05/24 at 1:50 PM, the surveyor requested the Governing Body meeting minutes. On 02/05/24 at 3:30 PM Staff A was unable to provide documentation of being appointed by a Governing Body or the name of the person that would act as the administrator in his absence.”

“Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This Element is not met as evidenced by: Based on observation, record review and staff interview, the agency failed to ensure the parent agency provides direct support and administrative control of its branches. This could affect all patients receiving services from this agency. The census was 303. Findings include: Review of agency documentation during offsite preparation revealed the agency still did not currently have any approved branch locations. The agency had been cited previously for having unapproved branch locations in Akron and Canton. Interview on 01/30/24 at 12:38 PM with Staff A revealed the locations in Akron and Canton were “drop-off” sites. Interview on 01/30/24 at 12:48 PM with Staff N revealed they worked at the Canton location 9:00 AM-5:00 PM, Monday through Friday. Interview on 01/30/24 at 12:55 PM with Staff P revealed she had a cell phone to monitor the calls at the Akron location. Staff P stated she just stopped by the Akron location to pick up the home health aide (HHA) time sheets and take them to the main location in Austintown. Staff P stated she would take the HHA call offs for the Akron area and answered any problems the HHA’s may have. Interview on 02/01/24 at 8:40 AM with Former Staff BB revealed the Akron and Canton locations were actual offices. They did the hiring, scheduling, and everything the main location did. The Akron and Canton offices each had four staff that work there Monday through Friday, 9:00 AM to 5:00 PM. Former Staff BB stated when the State was here, the Administrator would call the Akron and Canton offices and tell them to close and work from home. The Administrator would tell the staff to say, “I only pick up the HHA’s time sheets and turn it into the Austintown location”. Review of the personnel files for HHAs Staff D and F revealed Staff P, from the Akron office, did the background checks on Staff D and F. Interview on 02/01/24 at 1:06 PM with Staff A revealed Staff P “works at the Akron office”. Interview on 02/05/24 at 10:22 AM with Staff U, office staff in the Akron office, revealed she did hiring at the Akron and Canton offices. She stated each office did their own fingerprinting. Staff U did the payroll at the Akron office. They also did the staffing, faxing to doctors and case managers, and everything needed to run the office. Staff P was the Administrator at the Akron office and Staff U was the Assistant Administrator. Staff U handled the third party oversight entity requests for documentation, got staff statements, and typed up documentation to send to the third party oversight entity. On 02/05/24 at 1:58 PM Staff A called the Akron and Canton offices to find out who the drivers (staff that drove staff without driver’s licenses to their assignment) were to put them on the organizational chart. Interview on 02/05/24 at 2:05 PM with Staff A revealed Staff N and P both worked in the Akron area and just picked up the HHA paperwork. Interview on 02/06/24 at 1:13 PM Staff A confirmed not knowing who the drivers in the Akron and Canton offices were. An on-site visit was made to the Akron office on 02/06/24, at 9:48 AM. The Akron location was at 1655 West Market Street Suite 455, Akron, Ohio 44313. The suite was located on the fourth floor. On the wall by the door to the suite was a name plate of this agency. Upon entering there was a receptionist area, a break room, an office with Staff P’s name on the door and another office where Staff Y was sitting. Staff Y stated it was the DODD (Department of Developmental Disabilities) office. There was no drop off box or bin (for the HHA’s to drop off their time sheets) located outside or inside this office. This deficiency represents non-compliance investigated under Substantial Allegation 104379.”

“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 services as written in the plan of care for two of five patients reviewed (Patient #1 and #2). This could affect all patients receiving services from the agency. The census was 250. Findings: Review of the agency policy titled, “Plan of Care – CMS #485 and Physician Orders,” revised 2009 revealed the agency staff will promptly alert the physician to any changes that suggest a need to alter the Plan of Care. Review of Patient #1’s medical record and the physician ordered plan of care for the certification period dated 07/10/23 to 11/07/23 revealed orders for home health aide (HHA) services 40 hours per week to assist with personal care and light housekeeping. Review of the HHA time sheets revealed the HHA provided 18 hours of care the week of 08/06/23, eight hours the week of 09/17/23, 36 hours the week of 09/24/23 and 36 hours the week of 10/08/23. There was no documentation in the record that the patient was notified to activate their back up plan and no documentation the physician was notified that services were not provided as ordered. Interview on 12/12/23 at 1:50 PM with Staff A revealed they did not have staff available to provided the services and confirmed there was no documentation in the medical record that the patient was notified to activate their back up plan and no documentation the physician was notified that services were not provided as ordered. 2. Review of Patient #2’s medical record and physician ordered plan of care for the certification period dated 09/19/22 to 11/17/22 revealed orders for skilled nursing services once a week and home health aide (HHA) services to provide assistance with personal care for 18 hours per week. Review of the HHA time sheets revealed the HHA provided nine hours and 15 minutes the week of 09/25/22, nine hours and 45 minutes the week of 10/02/22, 17 hours and 30 minutes the week of 10/09/22, eight hours the week of 10/16/22, seven hours the week of 10/23/22, two hours and 25 minutes the week of 10/30/22, six hours and 30 minutes the week of 11/05/22, and 10 hours and 40 minutes the week of 11/13/22. Review of the physician ordered plan of care for the certification period dated 01/17/23 to 03/17/23 revealed orders for skilled nursing services once a week and HHA services to provide assistance with personal care and activities of daily living for 20-25 hours per week. Review of the HHA time sheets revealed the HHA provided 18 hours the week of 01/15/23 and 20 hours the week of 01/22/23. No HHA visit sheets were provided from 01/29/23 to 03/17/23. There was no documentation in the record that the patient was notified to activate their back up plan and no documentation the physician was notified that services were not provided as ordered. Interview on 12/20/23 at 12:44 PM with Staff B confirmed there was no documentation in the record that the patient was notified to activate their back up plan and no documentation the physician was notified that services were not provided as ordered. This deficiency represents non-compliance investigated under Substantial Allegation 102395, 102375 and 102380.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (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: This Element is not met as evidenced by: Based on record review and staff interview the agency failed to ensure patient complaints/incidents were investigated for three of five incidents reviewed. This could affect all patients receiving services from the agency. The census was 250. Findings include: Review of the agency policy titled, “Variance/Incident Reporting,” revised 2009, revealed the agency will establish a consistent documentation and reporting process. The agency will document and report all incidents (safety and security, alleged/suspected patient abuse, and motor vehicle accidents) that deviate from routine agency operations. Such incidents may include security incidents involving patients. A Variance/Incident Report will be completed on all incidents. The report will be submitted to the immediate supervisor, who is responsible for immediate investigation of the incident and taking any appropriate action. The supervisor will review the Variance/Incident Report and will document awareness of the incident. Follow-up data needed to resolve the incident, e.g. police reports, will be collected by the supervisor. A file will be maintained of all variance/incident reports. 1. Review of the medical record for Patient #4 revealed an email from Staff F (driver for the Akron area) that the agency was made aware of the incident that occurred with the patient on 08/26/23. Patient #4 reported that her card was used by a home health aide (HHA) to go to the store. Later that evening the patient discovered that the card had been used for Cash app and PayPal which was not authorized. The patient stated the bank was investigating this. There had been no other allegations against this aide. The patient was new to the agency, so the patient had not made accusations against other aides before. Staff F stated there was no investigation done by this agency due to the bank doing their own investigation and the police were called. Staff I was asked to come into the office but did not show up. Review of Staff I’s personnel file revealed the Ethical, Professional, Respectful and Legal Service Standards was signed by Staff I on 08/18/23. This document stated the staff shall not engage in any unethical, unprofessional, disrespectful, or illegal behavior including accepting, obtaining, or attempting to obtain money, or anything of value, from the patient or family. There was no documentation regarding this incident or if any disciplinary action was taken. Review of the complaint/incident log did not reveal an incident regarding Staff I taking money or using Patient #4’s debit card for their own use. Interview on 12/18/23 at 11:00 AM with Staff C revealed Staff I was terminated but could not remember when or why. On 12/18/23 at 12:25 PM Staff A presented an email, with no date, from the case manager that the agency was notified regarding Patient #4’s report of a debit card being used inappropriately on 08/28/23. Further interview with Staff A confirmed this incident was not documented or investigated per policy. Staff A confirmed there was no documentation in the personnel file regarding why Staff I was terminated or when. Staff A stated Staff I didn’t come in to make a statement or return to work. They “just disappeared”. 2. Interview on 12/14/23 at 12:00 PM with Staff A revealed she was aware of an incident where a home health aide drove a patient’s car and hit a fence. Staff A confirmed this incident was not documented or investigated per policy. 3. Review of the document, Ethical, Professional, Respectful and Legal Service Standards, updated 07/01/19, revealed the staff shall not engage in bringing a child, friend, relative or anyone else to the patient’s home. Interview on 12/13/23 at 2:10 PM with Staff C revealed she was not aware of any home health aide (HHA) bringing a child or relative to a patient’s home and stated this was not allowed. On 12/13/23 at 3:50 PM, Staff C provided a verbal warning by Staff F, a driver from the Akron office, dated 08/28/23 that was given to Staff J. The verbal warning issued was to not to bring children or anyone else to the patient’s home. Staff J acknowledged this verbal warning and stated they understood the rules. Staff C could not reply when asked why a driver, who was not a supervisor, was providing the corrective action (verbal warning) to staff. This deficiency represents non-compliance investigated under Substantial Allegations 102395, 103312 and 102381.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure all services were provided only as ordered by the physician or allowed practitioner for three of five patients reviewed (Patient #1, #2 and #3). This could affect all patients receiving services from this agency. The census was 250. Findings include: Review of the agency policy titled, “Plan of Care – CMS #485 and Physician’s Orders,” revised 2009, revealed the plan of care is established in consultation with the physician. Care and services provided will be provided according to physician orders. 1. Review of the medical record for Patient #1 did not reveal a physician ordered plan of care for the certification period dated 09/08/23 to 11/06/23. Review home health aide (HHA) time sheets revealed HHA services were provided for eight hours the week of 09/17/23, 36 hours the week of 09/24/23, 46 hours the week of 10/01/23, and 36 hours the week of 10/08/23. Interview on 12/12/23 at 1:45 PM with Staff C confirmed there was no physician ordered plan of care for the certification period dated 09/08/23 to 11/06/23 and no orders for the visits made for this certification period. 2. Review of Patient #2’s medical record and the physician ordered plan of care for certification period dated 11/18/22 to 01/16/23 revealed orders for skilled nursing services once a week and HHA services to provide assistance with personal care. There was no frequency or duration of visits ordered for the HHA services. Review of the HHA time sheets revealed the HHA provided 13 hours of services the week of 11/20/22, 16 hours the week of 11/27/22, 10 hours the week of 12/04/22, six hours the week of 12/11/22, 13 hours the week of 12/08/22, 12 hours and 30 minutes the week of 12/25/22, 14 hours the week of 01/01/23, and 16 hours the week of 01/08/23. Interview on 12/20/23 at 2:58PM with Staff C confirmed there were no physician orders for HHA services for 11/18/22 to 01/16/23. 3. Review of Patient #3’s medical record and physician ordered plan of care dated 09/19/23 revealed an order for skilled nursing services but the plan of care did not have a frequency or duration of visits for the skilled nursing services. Review of the skilled nursing visit notes from 09/20/23 to 11/09/23 revealed nurses visited 12 hours per day, Monday through Thursday. Interview on 12/20/23 at 10:36 AM with Staff C confirmed there were no physician orders for the nursing visits provided 09/19/23 to 11/09/23. This deficiency represents non-compliance investigated under Substantial Allegations 102395, 102380 and 102404.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure a qualified home health aide (HHA) was a person who has successfully completed a training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or a competency evaluation program that meets the requirements of paragraph (c) of this section; or a nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry for four of four HHA’s reviewed (Staff D, G, I and J). This could affect all patients receiving services from the agency. The census was 250. Findings include: Review of the “HHA job description and Staff Minimum Requirements, minimum qualifications, experience, training, skills and knowledge of client” revealed the nurse’s aide must have successfully completed the Competency Evaluation Program conducted by the Ohio Department of Health under section 3721.31 of the Revised Code or the Medicare Competency Evaluation Program Home Health Aides as set forth in 42 CFR 434, without a 24 month lapse in employment. Review of the agency’s “New Hire Checklist” revealed in order for the personnel record to be considered complete verification of Educational Documents and Competency Test Results must be included. Interview on 12/13/23 at 10:38 AM with Staff K revealed the agency only use applicants with one year or more of HHA experience. The HHA then took an HHA Competency test, had an HHA skills check, and then had an on-site skill check by the Director of Nursing (DON) before they worked with a patient. If the HHA did not have documentation of HHA training, then they had to take an HHA training class given by the DON. Interview on 12/13/23 at 11:38 AM with Staff C revealed the only class she taught was just the HHA skills check which was very basic. Staff C stated she did not do any formal class training for the HHA’s. 1. Review of the personnel file for Staff G revealed a hire date 06/19/23. Review of the 15 Section answer sheet for the HHA Competency Exam revealed it was blank, but it was signed by Staff G and dated 06/19/23. The personnel file lacked documentation that Staff G had any formal HHA training. 2. Review of the personnel file for Staff I revealed a hire date 08/21/23. The Application of Employment indicated Staff I was a caregiver from 2013 to 2015 (eight years ago) with responsibilities that included a little housekeeping, and a private caregiver from 03/2022 to 10/2022 (seven months) with responsibilities that included laundry, little cooking and Doctor appointments. Both the on-site HHA Competency checklist and HHA skills checklist in Staff I’s personnel file were not dated. Review of the 15 Section answer sheet for the home health aide (HHA) Competency Exam revealed it was blank, but it was signed by Staff I and dated 08/18/23. The personnel file lacked documentation that Staff I had any formal HHA training. 3. Review of the personnel file for Staff J revealed a hire date 06/19/23. The Application for Employment revealed Staff J worked from 08/2020 to 09/2021 at a job doing dishes and helping around the house. Review of the on-site HHA competency checklist revealed it was not dated. The personnel file lacked documentation that Staff I had taken the HHA Competency Exam or had formal HHA training. 4. Review of the personnel file Staff D revealed a hire date of 07/25/23. Review of Application for Employment revealed Staff D worked in health care from 2019 to 2020. No other healthcare employment was listed after 2020. Review of the Reference Check revealed Staff D worked in home health care from 2019 to 2020 and was eligible for hire on 07/25/23. Review of the Initial on-site HHA Competency checklist and the HHA skills checklist revealed both were not dated. Review of the 15 Section answer sheet for the home health aide (HHA) Competency Exam revealed it was blank. The personnel file lacked documentation that Staff D had any formal HHA training. Interview on 12/13/23 at 10:44 AM with Staff K confirmed the findings in the personnel files. Interview on 12/13/23 at 3:48 PM with Staff C confirmed the four HHA’s had no evidence of any formal training. Staff C also stated they were unaware that the applicant must show documentation of HHA training.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and staff interview, the clinical manager failed to ensure the agency employs qualified personnel for five of five personnel files reviewed (Staff D, G, I, J, and L). this could affect all patients receiving services from the agency. The census was 250. Findings include: 1. Review of the agency policy titled, “Personnel Qualifications,” effective 01/05/13, revealed prior to employment employees must pass a fingerprint criminal background investigation. Review of the “New Hire Checklist” revealed for the personnel record to be considered complete, the Bureau of Criminal Identification and Investigation (BCII) results must be in the employee’s file. Interview on 12/13/23 at 10:09 AM with Staff B revealed if it was not in the personnel file, then the results of the background check were not back. Interview on 12/13/23 at 10:38 AM with Staff K revealed the agency kept a fingerprinting log and the results usually came back in less than 30 days. Review of the BCII log did not reveal the date the fingerprint results were returned or the results of the background check. Review of the personnel file for Staff G revealed a hire date 06/19/23. Review of the “Ohio Automated Registry Check System”, dated 06/22/23, revealed Staff G has not been previously determined eligible for employment and must be fingerprinted. The personnel file did not contain evidence that Staff G was fingerprinted. Review of the personnel file for HHA Staff I revealed a hire date 08/21/23. The personnel did not contain evidence that Staff I was fingerprinted. 2. Review of the Home Health Aide (HHA) Job Description Summary and Position Qualifications revealed the HHA has completed a cardiopulmonary resuscitation (CPR) and First Aide course successfully in the past 12 months. Interview on 12/13/23 at 9:49 AM with Staff C revealed all staff were required to have a current CPR/First Aide certificate. Review of the personnel files for Staff G, Staff I, Staff J, and Staff L revealed no evidence of a current CPR/First Aide card. Interview on 12/13/23 at 10:40 AM with Staff K confirmed there were no CPR/First Aide cards in the personnel files. This deficiency represents non-compliance investigated under Substantial Allegation 102395.”

“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 document review and staff interview, the agency failed to report all branch locations to the state survey agency at the time they proposed to add a branch location. This could affect all patients receiving services from the agency. The census was 250. Findings include: Interview on 12/13/23 at 3:30 PM with Staff C revealed that Staff F, who was a driver in the Akron area, drove the home health aides (HHA) to the patients’ home. Staff C stated around 90% of the HHA’s in that area did not drive or have transportation. Staff F worked from home when not driving staff and assisted with scheduling the HHA’s and collecting their time sheets. Staff F did not work at the Austintown location. During the complaint investigation the Administrator, Staff A, had been calling Staff F for missing documentation in the medical records. Interview on 12/18/23 at 1:50 PM with Staff A revealed Staff F was a driver in the Akron area and also picked up the HHA’s time sheets. Interview on 12/18/23 at 2:50 PM with Staff F revealed they hired HHA’s, completed communication notes, kept in contact with the case managers, reported call offs, and did background checks on new applicants at the location at 1655 West Market Street, Suite 455, Akron, Ohio 44313. Staff F stated they went to this location a couple times a week for a few hours. Review of the job description provided by Staff A for Staff F revealed the position was a “Receptionist/HR Assistant” who reports to the administrator and is under the supervision of the director of nursing. Duties include managing phone lines and prioritizes calls, takes intake and referral information, processes all applications, maintains employee records and schedules orientation. Review of State Agency documentation revealed the agency’s main location address of record was still 5900 Roche Drive, Suite 227, Columbus, Ohio 43229. No Centers for Medicare & Medicaid form 855 had been received to update the agency’s address to 102 Javit Court, Austintown, Ohio 44515 and no information has been received to add a branch location at 1655 West Market Street, Suite 455, Akron, Ohio 44313.”