Grand View Home Care

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care (SOC) date, for two (2) of seventeen (17) clinical records (CR) reviewed (CR#3, CR#8). Agency policy reviewed January 10, 2025 at approximately 2:45 p.m. No specific policy related to to completing the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care (SOC) date was provided. A review of CRs was completed on January 10, 2025 at approximately 2:15 p.m. The patients start of care (SOC) is listed below. CR#3 SOC 11/12/24: Referral from (physician) on 11/06/24. No physician ordered start of care date specified. Documentation of initial assessment visit by a speech language pathologist on 11/12/24. (6 days). CR#8 SOC 12/09/23: Referral from (physician) on 12/06/23. No physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse on 12/09/23. (3 days). An interview conducted with agency Administrator on January 10, 2025 at approximately 2:45 p.m. confirmed the above findings.”

“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 a review of agency policy, a review of the agency Governing Body minutes, and an interview with the agency Administrator, agency failed to ensure the governing body appointed a qualified administrator for one (1) of one (1) Governing Body meeting minutes reviewed (Review #1). Agency policy reviewed January 10, 2025 at approximately 2:45 p.m. Policy ‘HC104’ ‘Grand View Home Care Administrative Staff.’ (This policy does not include the regulatory requirement of the Administrator being appointed by the agency Governing Body.) Review #1: The agency Governing Body meeting minutes showing the appointment of the Administrator were requested. Documentation provided of ‘Board of Trustees’ meeting minutes dated April 18, 2023. The meeting minutes included but was not limited to “The Board unanimously approves (employee #9) as Administrator for Grand View Home Care effective October 4, 2022 ....” (The appointment was made retroactively, approximately six (6) months prior to the meeting dated 4/18/23.) An interview conducted with agency Administrator on January 10, 2025 at approximately 2:45 p.m. confirmed the above findings.”

“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 a review of agency policy and an interview with the agency Administrator, the agency failed to ensure the appointment of a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, who will assume the same responsibilities and obligations as the administrator for one (1) of one (1) interviews performed (Interview #1). Agency policy reviewed January 10, 2025 at approximately 2:45 p.m. Policy ‘HC104’ ‘Grand View Home Care Administrative Staff.’ (This policy does not include the regulatory requirement of the the Alternate Administrator being authorized in writing by the administrator and the governing body.) Interview #1: An interview was conducted with the Administrator on 01/10/25 at approximately 12:45 p.m. The Administrator was asked who has been assigned the position of alternate Administrator. The Administrator stated (employee #10). No documentation provided of (employee #10) being authorized in writing by the administrator and the governing body. An interview conducted with agency Administrator on January 10, 2025 at approximately 2:45 p.m. confirmed the above findings.”