Rrb Home Healthcare, LLC

“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 reviews of policies/procedures, meeting minutes, personnel files (PF) and interview with staff the agency failed to ensure the governing body assumed responsibility for the maintenance of the agency, appointed a qualified Administrator to conduct the day-to-day operations and an alternate to act in their absence and hire a qualified Clinical Manager to provide quality patient care. Findings include: Cross reference: 484.105(a) Governing Body Tag G 0942- the agency governing body failed to appoint a qualified administrator and alternate administrator for one (1) of five (5) PFs reviewed. (PF#1) 484.105(b)(1)(ii) Be responsible for all day-to-day operations of the HHA G 0948- the agency failed to ensure that the administrator is actively involved in the day-to day operations for one (1) of one (1) observation made OBS #1 484.105(b)(2) A Qualified pre-designated person authorized in writing to act in absence of Administrator G 0954 - 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, assumes the same responsibilities and obligations as the administrator when the administrator is not available for one (1) of one (1) observation. 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours G 0956 - the agency failed to ensure the administrator, or an alternate administrator is available during all operating hours for one (1) of one (1) observation made OBS #1. The cummulative effect of the systemic failures led to the agency’s inability to maintain organization and provide quality administrative services to staff and patients. 484.105(c) Clinical Manager G 0958- the agency failed to ensure Clinical Supervisor met the requirements of the job description for one (1) of five (5) files reviewed. PF #4.”

“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 a review of policy and procedure, personnel files (PF), and an interview with the agency staff, the agency governing body failed to appoint a qualified administrator and alternate administrator for one (1) of five (5) PFs reviewed. (PF#1) Findings include: Review of agency policy #1002 titled, “Governing Body” on May 16, 2025, at approximately 3:15 pm states, “The Governing Body (Board of Directors) manages the operation of RRB Home Healthcare, LLC. Procedure:3. The Governing Body appoints an Administrator and a Supervising Nurse...” Review of policy #1020 titled, “The Administrator” on May 16, 2025, at approximately 3:15 pm states, “Policy: The governing body of RRB Home Healthcare, LLC shall appoint an administrator who supervises the provision of all services. A qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, will also be appointed to act in the absence of the administrator. Qualifications: The administrator: May be a physician, or registered nurse OR have a baccalaureate or postgraduate degree in administration in a health or human services field and at least one full year of full-time administrative experience as the administrator of an agency or licensed health care facility; OR have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in home health care, hospice, or related field... Will be available during the agency’s usual working hours along with the alternate administrator...” Review of policy #1021 titled, “The Alternate Administrator” on May 16, 2025, at approximately 3:15 pm states, “1. Purpose 1.1. The guidelines provided are designed to establish a clear framework for the management and operation of RRB Home Healthcare, LLC. Their primary purpose is to ensure that the organization runs efficiently and effectively, with a focus on maintaining high standards of care and service delivery. The guidelines outline the responsibilities and qualifications required for key leadership roles, particularly the administrator and alternate administrator, to ensure that the agency is led by competent and qualified individuals...” Review of the agency’s organizational chart on May 13, 2025, at approximately 1:40 pm revealed no specific persons identified as the Alternate Administrator. A review of personnel files conducted on May 13, 2025, at approximately 2:15 pm revealed the following: PF#1 Date of hire (DOH) 4/26/2024: There was no evidence of a signed job description. Did not contain any documentation showing evidence of being a physician or registered nurse or having a baccalaureate or postgraduate degree in administration in a health or human services field and at least one full year of full-time administrative experience as the administrator of an agency or licensed health care facility; OR have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in home health care, hospice, or related field. An interview with the administrative assistant and Director of Nursing conducted on Tuesday, 5/13/25, at 5 pm, and again on May 16, 2025, via telephone with the administrative assistant at approximately 4:30 pm confirmed the above findings. During an interview with the Director of Nursing on May 13, 2025, at approximately 1:35 pm it was also confirmed the Administrator on file was no longer at the agency. The newly hired Administrator was unavailable in person or over the phone. She reported he was “on a flight to Africa to see his mother.” The Director of Nursing also reported that the agency did not have an alternate administrator involved in the day-to-day operations.”

“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 a review of personnel files (PF), and an interview with the agency staff, agency failed to ensure Clinical Supervisor met the requirements of the job description for one (1) of five (5) files reviewed. PF #4. Findings include: A review of job descriptions conducted on May 13, 2025, at approximately 2:15 PM, revealed the following: Job description titled “Director of Nursing-Orientation” states, “Regulatory Requirements: “Public Health nursing experience desirable with minimum of two (2) years in a community health setting.” A review of personnel files (PF) was conducted on May 13, 2025, at approximately 2:15 PM, revealed the following: PF#4, Date of Hire (DOH) 5/1/24: Did not contain any documentation of two (2) years of experience in a community setting. An interview with the administrative assistant and the Director of Nursing conducted on May 13, 2025, at approximately 5:00 pm confirmed the above findings.”

“Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This Standard is not met as evidenced by: Based on a review of policies/procedures, personnel files (PF), and interview with Agencey staff the agency failed to ensure the appointed Administrator was qualified to assume day to day operations for one (1) of five (5) files reviewed. PF #1. Findings include: A review of the following agency policies conducted on May 16, 2025, starting at approximately 3:15 PM, revealed the following: Policy #1020 states, “The governing body of RRB Home Healthcare, LLC shall appoint an administrator who supervises the provision of all services...The administrator will be responsible for the hiring of qualified personnel, as well as the development of personnel qualifications and policies...The administrator: May be a physician, or registered nurse OR have a baccalaureate or postgraduate degree in administration in a health or human services field and at least one full year of full-time administrative experience as the administrator of an agency or licensed health care facility; OR have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in home health care, hospice, or related field... A review of personnel files (PF) was conducted on May 13, 2025, at approximately 2:15 PM, revealed the following: PF #1 Date of Hire (DOH) 4/26/2024: There was no evidence of a signed job description. Did not contain any documentation showing evidence of being a physician or registered nurse or having a baccalaureate or postgraduate degree in administration in a health or human services field and at least one full year of full-time administrative experience as the administrator of an agency or licensed health care facility; OR have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in home health care, hospice, or related field. An interview with the administrative assistant conducted on May 16, 2025, via telephone at approximately 4:30 pm confirmed the above findings.”

“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 observations (OBS) and interview with agency staff, the agency failed to ensure that the administrator is actively involved in the day-to day operations for one (1) of one (1) observation made OBS #1 Findings include: OBS #1 completed 5/13/25, at the agency location: 501 Cambria Ave, SUITE 111, BENSALEM, PA 19020, at 12:30 pm revealed no Administrator or alternate available in person or over the phone. An interview with the Director of Nursing was conducted on May 13, 2025, at approximately 1:35 pm, confirmed that the Administrator on file with the DOH was no longer at the agency. The new Administrator was unavailable in person and over the phone. She reported he was “on a flight to Africa to see his mother.” The Director of Nursing also reported that the agency did not have an alternate administrator involved in the day-to-day operations. An interview with the administrative assistant and Director of Nursing conducted on Tuesday, 5/13/25, at 5 pm, and again on May 16, 2025, via telephone with the administrative assistant at approximately 4:30 pm 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 observation (OBS), a review of the agency policy and procedures, agency documents and an interview with staff, 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, assumes the same responsibilities and obligations as the administrator when the administrator is not available for one (1) of one (1) observation. Findings include: OBS #1 completed 5/13/25 at 12:30 pm revealed no Administrator or alternate available in person or over the phone. Review of policy #1021 titled, “The Alternate Administrator” on May 16, 2025, at approximately 3:15 pm states, “1. Purpose 1.1. The guidelines provided are designed to establish a clear framework for the management and operation of RRB Home Healthcare, LLC. Their primary purpose is to ensure that the organization runs efficiently and effectively, with a focus on maintaining high standards of care and service delivery. The guidelines outline the responsibilities and qualifications required for key leadership roles, particularly the administrator and alternate administrator, to ensure that the agency is led by competent and qualified individuals...” Review of the agency’s organizational chart on May 13, 2025, at approximately 1:40 pm revealed no specific persons identified as the Alternate Administrator. An interview with the Director of Nursing was conducted on May 13, 2025, at approximately 1:35 pm confirmed the Administrator on file with the DOH was no longer at the agency. The new Administrator was unavailable in person and over the phone. She reported he was “on a flight to Africa to see his mother.” The Director of Nursing also reported that the agency did not have an alternate administrator involved in the day-to-day operations. An interview with the administrative assistant and Director of Nursing conducted on Tuesday, 5/13/25, at 5 pm, and again on May 16, 2025, via telephone with the administrative assistant at approximately 4:30 pm confirmed the above findings.”

“Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This Element is not met as evidenced by: Based on review of polices/procedures, observations (OBS) and interview with agency staff, the agency failed to ensure the administrator, or an alternate administrator is available during all operating hours for one (1) of one (1) observation made OBS #1. Findings include: A review of the following agency policies and position descriptions conducted on May 16, 2025, starting at approximately 3:15 PM, revealed the following: Policy #1020 states, “The governing body of RRB Home Healthcare, LLC shall appoint an administrator who supervises the provision of all services... Will be available during the agency’s usual working hours along with the alternate administrator.” OBS # 1, conducted at agency location: 501 Cambria Ave, SUITE 111, BENSALEM, PA 19020, on Tuesday, 5/13/25, at 12:30 pm, revealed no Administrator or alternate Administrator available during all operating hours. An interview with the Director of Nursing was conducted on May 13, 2025, at approximately 1:35 pm, confirmed the Administrator on file with the Department of Health was no longer at the agency. The new Administrator was unavailable in person and over the phone. She reported he was “on a flight to Africa to see his mother.” The Director of Nursing also reported that the agency did not have an alternate administrator involved in the day-to-day operations. An interview with the administrative assistant and Director of Nursing conducted on Tuesday, 5/13/25, at 5 pm, and again on May 16, 2025, via telephone with the administrative assistant at approximately 4:30 pm confirmed the above findings.”