House of Heaven Health 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 record review, interview and policy review, the agency failed to establish a governing body. The agency failed to ensure the governing body appointed the Administrator, failed to annually evaluate the Administrator’s performance, failed to ensure that a clinical manager was available during all operating hours, failed to have a governing body appoint a qualified person to act in place of the administrator and failed to ensure there was a registered nurse (RN) to oversee all patient care services and personnel. See G942, G946, G950, G954 and G958.”

“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 agency failed to establish a governing body. This could potentially affect all patients and staff. The census was one. Findings include: During an interview on 08/06/24 at 11:10 AM, the governing body meeting minutes were requested from the Administrator. The Administrator did not know what the governing body was. She stated she reported to the Registered Nurse who worked for the agency. As of 08/06/24 at 3:00 PM, the Administrator was unable to provide who was part of the governing body or provide any meeting minutes. Review of the agency’s policy titled “Governing Body”, revised 2017, revealed the Governing Body (or designated persons so functioning) assumes 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. The Governing Body will have bylaws (or equivalent) which will be reviewed and revised annually and as needed. These bylaws will define terms of office/frequency of meetings, attendance requirements, definition of a quorum, conflict of interest disclosure requirements and overall responsibilities. The Governing Body is comprised of individuals with relevant expertise, business knowledge and professional relationships specific to the Agency’s philosophy, mission and purpose. For each member of the Governing Body the Agency maintains the name, address, credentials and professional/business affiliation. The Governing Body meets at least annually to review the operation of the Agency and documents all meetings by minutes.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on interview and policy review, the agency failed to ensure there was a registered nurse (RN) to oversee all patient care services and personnel. This could potentially affect all patients and staff. The census was one. Findings include: During an interview on 08/06/24 at 10:49 AM, Registered Nurse (RN) Staff B stated he is not on call for this agency. He only completes admission and recertification assessments. During an interview on 08/06/24 at 11:40 AM, the Administrator stated there was no Director of Nursing or Clinical Supervisor and confirmed there was no on call Registered Nurse (RN). Review of the agency policy titled “On-Call Policy”, no effective date, revealed it shall be the policy of this agency to assure patients have access to nursing resources after hours (whenever office is closed) as indicated to answer questions and provide medical support when his/her condition dictates. The on-call staff will serve as a routing mechanism only; the nurse will make decisions as to seriousness and how calls are to be handled. The Nurse decides as to the need for a nursing visit, if the EMS response unit should be summoned or if a telephone call to the physician will suffice. The on-call nurse is responsible for ensuring that a physician’s order is obtained to cover home visits not covered on the patient’s plan of care.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the governing body appointed the Administrator and failed to annually evaluate the Administrator’s performance. This could potentially affect all patients and staff. The census was one. Findings include: During an interview on 08/06/24 at 11:15 AM, the Administrator stated she was not appointed by a governing body. Review of the personnel file for the Administrator revealed there was no annual performance evaluation completed. During an interview, the Administrator verified this finding. Review of agency policy titled “Governing Body”, revised 2017, revealed the governing body appoints the Administrator or approves an Administrator selected by the corporation or another group and annually evaluates the Administrator’s performance.”

“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 record review and interview, the agency failed to ensure that a clinical manager was available during all operating hours. This could potentially affect all patients and staff. The census was one. Findings include: There was no table of organization showing a DON or Clinical Manager for the agency. During an interview on 08/06/24 at 10:49 AM, Registered Nurse Staff B stated he only does admissions and recertification assessments. RN Staff B stated he is not available during all operating hours. During an interview on 08/06/24 at 11:40 AM, the Administrator stated there was no Director of Nursing (DON) or Clinical Manager employed by the agency.”

“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 record review and interview, the agency failed to have a Governing Body appoint a qualified person to act in place of the Administrator. This could potentially affect all patients and staff. The census was one. Findings include: During an interview on 08/06/24 at 11:10 AM, the Administrator, the governing body meeting minutes were requested. The Administrator did not know what the governing body was. She stated she reported to the Registered Nurse who worked for the agency and there was no one to act in her place during an absence. As of 08/06/24 at 3:00 PM, the Administrator was unable to provide who was part of the governing body or provide any meeting minutes.”