Northeast Home Health Services

“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 policy review, record review and staff interview, the agency failed to ensure the complaints of mistreatment, neglect, and verbal abuse were investigated. (G0478) The agency failed to ensure the allegations of abuse were documented. G0484)”

“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 policy review, record review, and staff interview, the agency failed to ensure the physician had been notified of the missed visits. This affected three out of three patient records reviewed. (Patient #1, #2 and #3) The census was 90. 1. Review of the complaint log revealed services for Patient #1 were not provided as ordered for the week of 02/16/25. Review of the medical record for Patient #1 revealed start of care 01/27/25. The physician’s plan of care dated 01/27/25 to 03/27/25 revealed the home health aide (HHA) was to provide 45 hours per week to assist with personal care and activities of daily living (ADLs). Review of the HHS time sheets for the week of 02/16/25 revealed only 15 hours were provided. Review of a Communication Note dated 02/19/25 revealed Patient #1 had put the HHA services on hold for a week as they were sick with the flu. Email was sent to the Case Manager. There was no evidence the physician was notified. 2. Review of the complaint log revealed services for Patient #2 were not provided as ordered for the week of 05/04/25. Review of the medical record for Patient #2 and the physician’s plan of care dated 03/25/25 to 05/23/25 revealed the HHA was to provide 42 hours per week to assist with personal care and ADLs. Review of the HHA time sheets for Patient #2 for the week of 05/04/25 revealed 24 hours of service were provided. Review of a Communication Note dated 05/29/25 revealed the Case Manager was made aware of the missed visit. There was no evidence the physician was notified. 1. Review of the medical record for Patient #3 and physician’s plan of care dated 03/03/25 to 05/01/25 revealed the HHA was to provide 40 hours per week to assist with personal care and ADLs. Review of the time sheets for Patient #3 for the week of 04/27/25 revealed only16 hours were provided. Review of Missed Visit Notes revealed no services were provided to Patient #3 on 04/28/25, 04/29/25 and 05/30/25. Review of the medical record for Patient #3 did not reveal documented evidence the physician had been notified of the missed visits. Review of the agency policy title “Missed Visit and Caregiver No Show Policy” revealed all missed visits must be documented, reviewed, and addressed. All missed visits must include reason, notifications made and rescheduling plan. For any missed visit, caregiver no-show, or interruption of care, the Agency must notify the client’s physician if the missed visit affects health, safety, or ordered services. Interview on 11/24/25 at 10:42 AM the Clinical Manager (CM) stated they were not aware the physician needed to be notified when there is a change in the plan of care or missed visits. The CM stated they were told they had 24 hours to notify the Case Manager. The CM stated they did not notify the physician.”

“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 policy review, record review and staff interview, the agency failed to ensure the complaints of mistreatment, neglect, and verbal abuse were investigated. This affected one (Patient #3) out of three patients reviewed. The census was 90. Review of the complaint log revealed a statement by Staff B who reported allegations of verbal abuse and neglect to Patient #3 from the family. Review of Staff B’s statement dated 07/01/25 revealed they never “Put hands on” Patient #3 but the way the family treats Patient #3 is terrible. Patient #3 is always hungry and Staff B would buy Patient #3 food. Staff B would have to buy Patient #3 hygiene products because Patient #3’s mother wouldn’t. Patient #3 used to have to wear dirty clothes because they wouldn’t wash them. The stepdad punched a hole in the wall because Patient #3 stole Staff E’s food that was ordered. The family would send Staff B videos of Patient #3 stealing their food. The parents would lock entrance to the upstairs so Patient #3 would be stuck in the basement. They never gave Patient #3 tissues and Staff B would have to bring her own tissues or wipes. Staff B was very concerned when the stepdad moved in because he would tell Patient #3 he would kill the her if she ever went into his room. He would always pick on Patient #3. He would tell Patient #3 she would never get a man wearing a pull up. Interview on 11/24/25 at 4:18 PM the Clinical Manager stated Patient #3’s family lives in a two-story home. The uncle lives upstairs, the mother and stepdad live on the first floor, and Patient #3 lives in the basement. When asked if this incident was documented or investigated or if Adult Protective Services (APS) were called the Clinical Manager replied “The case manager was notified.” There was no evidence the agency conducted an investigation. Review of the agency’s policy titled “Complaint Resolution.” revised 2010. revealed the Agency will investigate complaints made by a patient, patient’s family or guardian regarding treatment or care. The Director will investigative measures that will be implemented based on the nature of the complaint. Interview on 11/24/25 at 4:33 PM the Clinical Manager and Administrator both confirmed there was no documented evidence the allegation of abuse and neglect were investigated. 2. Per interview on 11/24/25 at 4:20 PM the Clinical Manager stated Staff E hit Patient #3. There was no evidence of an investigation into the incident. Per interview on 11/24/25 at 4:33PM the Clinical Manager confirmed there was no investigation of the incident.”

“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 policy review, record review and staff interview, the agency failed to ensure the allegations of abuse were documented. This affected one (Patient #3) out of three patients reviewed for abuse. The census was 90. Interview on 11/24/25 at 4:20 PM the Clinical Manager stated Staff E hit Patient #3. There was no documentation of this incident. Review of the agency policy titled “Variance/Incident Reporting,” revised 10/2017, revealed the agency will document and report all incidents (accidents, injuries, safety and security hazards) that deviate from routine Agency operations and will result in injury or potential harm to patient/caregiver or Agency staff. Such incidents may include alleged/suspected patient abuse. The Variance/Incident Report: patient or Employee will be forwarded to the QAPI committee for the purpose of reviewing, analyzing, aggregating, trending and making performance improvement recommendations. Follow up data needed to resolve the incident will be collected by the supervisor. A file will be maintained of all reported variance/incident reports, as well as any additional data/information pertaining to the Variance/Incident Report: Patient or Employee. Interview on 11/24/25 at 4:33PM the Clinical Manager confirmed there was no documented evidence of the incident.”