Precious Home Health Care Inc.

“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, interview and policy review, the facility failed to ensure all allegations of misappropriation were documented. This affected one (Patient #3) of three patients reviewed. This could potentially affect all patients at this agency. The census was 48. Findings include: Review of the complaint log revealed a complaint dated 12/16/24 from Patient #3. The complaint does not mention anything about Staff C borrowing money. There was no other complaints regarding borrowing money. Review of Staff C’s statement dated 12/17/24 revealed Staff C denied borrowing any money from Patient #3. During an interview on 01/14/25 at 4:07 PM, the Director of Nursing (DON) stated after Patient #3 notified the agency of this complaint regarding another issue, the agency notified the Case Manager (CM) who then called Patient #3. The CM then called the DON. The DON stated the CM must have said something about Staff C borrowing money from Patient #3, because Staff C denied borrowing money in a statement. The DON confirmed the conversation with the CM was not documented and the allegation of Staff C borrowing money from Patient #3 was not documented. Review of the agency policy titled “Complaint Resolution” revised 03/2018 revealed the agency will investigate complaints made by a patient. The Agency maintains records of grievances/complaints and their outcomes and includes this information in the annual Quality Assurance/Performance Improvement report.”

“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 record review, interview and policy review, the agency failed to ensure all staff used the Electrical Visit Verification (EVV) system to document their time. This affected one (Patient #3) of three patients reviewed. This could affect all patients and staff. The census was 48. Findings include: Review of the Electrical Visit Verification (EVV) record from 07/30/24 to 12/16/24 for Staff C revealed an inconsistency in clocking in and out since October 2024. Staff B called Staff C in the office, in the middle of October, to go through the EVV procedure. Staff C demonstrated they knew how to use it. On 10/15/24, Staff C clocked in at 10:36 AM, not at 9:00 AM per the timesheet. Staff C did not clock out. On 11/07/24, Staff C clocked in at 9:16 AM but did not clock out. On 12/09/24, Staff C did not clock in and clocked out at 1:14 PM. Review of Patient #3’s medical record and time sheets from 11/04/24 to 12/13/24 revealed Staff C worked 9:00 AM to 5:00 PM, five days per week. Review of the personnel file for Staff C did not reveal any corrective actions. During an interview on 01/15/25 at 1:10 PM, Staff B confirmed Staff C only used the EVV program once in October, once in November and twice in December. Staff B confirmed they did not monitor the EVV on Staff C for November and December and confirmed they did not follow the agency’s EVV Policy. Review of the agency Electrical Visit Verification (EVV) policy revealed the system verifies when staff visits occur and documents the precise time services begin and end. All staff should follow the timekeeping instructions for the EVV system provided and in and out times are required each time services are provided. Time IN and OUT should match your time in and out on documentation sheet. At the end of each shift both the Customer and employees should sign the documentation sheet. The Customer should review the time sheet at the end of each shift to ensure it is complete, accurate, and in accordance with the Customer’s Plan of Care. Once the Customer verifies the accuracy and completeness of the time sheet, he or she will approve and sign it prior to submission to the agency. If customer is unable to sign due to physical restriction, he or she will verify service through voice note on EVV device or via phone. EVV Non-Compliance occurs if no EVV visits are in the system, more than two visits from the time sheet are missing in the EVV system, more than five visits on the time sheets do not match call times in the system. If non--compliance is determined, verbally remind the staff that it is mandatory for staff to use the EVV timekeeping system and to report exact hours worked. If staff fail to comply with EVV review requirements with the staff and document in a case note. Second Non-Compliance within a six-month period the staff should be verbally and in writing informed that if staff continues Not to comply with EVV, they will be terminated. Document in a Case Note and put a copy in the staff’s personnel file. Third Non-Compliance within a six-month period staff is terminated.”