Tender Heart Home Health LLC

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Findings include: Patient # 1: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 1 as 12/04/2024. Inactive Clinical Record-Patient # 1: Record review of the clinical record for Patient # 1 revealed a POC for the certification period of 10/10/2024 to 12/08/2024. Review of the POC revealed a start of care date of 10/10/2024 with a primary diagnosis of dehydration (when the body does not have enough fluids to conduct and maintain normal functions). The POC was dated 10/10/2024 and electronically signed by RN A. The POC contained an order for skilled nursing visits one time per week for one week, two times per week for two weeks, one time per week for six weeks, and two as needed visits for falls. Continued review of the record revealed a discharge summary (as part of the Discharge OASIS) signed by the DON and dated 12/04/2024. Review of the discharge summary revealed a discharge date of 12/04/2024. Further review of Patient # 1’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 12/04/2024. The record did not include a written NOMNC. During an onsite complaint investigation (on 02/20/2025) the surveyor reviewed the agency’s complaint records. Review of the records revealed a “Complaint Form” dated 12/13/2024. Review of the complaint form revealed that the complaint was received by the Admin. The Admin and DON signed the form on 12/18/2024. Continued review of the form revealed that Patient # 1’s family member called with the grievance that Patient # 1 was discharged by the agency with a possible urinary tract infection not being resolved. The complaint records also included screenshots of text messages between the family member and RN A. Review of the screenshots revealed that on 11/25/2024 the family member text RN A and asked, “Did you ever get a urine test scheduled for [Patient # 1]?” RN A replied I have not heard back from the [doctor] yet…” The family member replied, “That’s an awful long time to not hear back from the doctor…” During an interview on 02/25/2025 at 3:08 p.m. with the family member of Client # 1 the family member stated that RN A came out to conduct a visit with Patient # 1 and forgot to do a uranalysis (a urine test for the detection of infection). The family member stated that RN A did not tell her initially that an order from Patient # 1’s physician (Identifier 100) was needed. She stated that she would have called the physician and asked for an order. The family member stated that the agency told her that (Identifier 100) said to discharge Patient # 1. The family member stated that when she asked (Identifier 100’s) office staff if the physician had told the agency to discharge Patient # 1, they stated that they did not tell the agency to discharge Patient # 1. The family member stated that the agency discharged Patient # 1 without testing for a urinary tract infection. The family member stated that she was not given (as far as she can remember) a written notice prior to discharge, on 12/04/2024. The family member stated that when Patient # 1 was finally evaluated for a urinary tract infection, the test was positive. During an interview on 02/28/2025 at 2:52 p.m. with Identifier 100’s office nurse (Identifier 200), the surveyor asked if the physician had given orders for the home health agency to discharge Patient # 1. Identifier 200 stated that (Identifier 100’s) office did not send order any orders to the agency to discharge Patient # 1. Patient # 2: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 2 as 09/26/2024. Inactive Clinical Record-Patient # 2: Record review of the clinical record for Patient # 2 revealed a POC for the certification period of 07/31/2024 to 09/28/2024. Review of the POC revealed a start of care date of 02/02/2024 with a primary diagnosis of cirrhosis of the liver (scarring and destruction of liver tissue that prevents it from functioning properly). The POC was dated 07/30/2024 and electronically signed by RN B. The POC contained an order for skilled nursing visits one time per week for nine weeks and two as needed visits for falls or change in condition; PT visits one time per week for one week and two times per week for two weeks; and OT one time per week for one week and two times per week for two weeks. Continued review of the record revealed a discharge summary (as part of the Discharge OASIS) signed by RN B. Review of the discharge summary revealed a discharge date of 09/26/2024. Continued review of the discharge summary (OASIS) revealed a box to check if a “written notice of discharge was provided to patient with an area to document the scheduled discharge date. RN B did not check the written notice box or enter a discharge date. Further review of Patient # 2’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/26/2024. The record did not include a written NOMNC. During an onsite complaint investigation (on 02/20/2025) the surveyor reviewed the agency’s complaint records. Review of the records revealed a “Complaint Form” dated 09/30/2024. Review of the complaint form revealed that the complaint was received by the Admin. The Admin and DON signed the form on 09/30/2024. Continued review of the form revealed that Patient # 2’s family member called to speak with the DON regarding Patient # 2’s need for physical therapy. The family member stated that during the call, with the DON, the DON “…yelled…was harsh and dry…” The complaint records also included screenshots of text messages between the family member and Hha A. Review of the screenshots revealed that on 09/26/2024 the family member text Hha A and stated that Patient # 2 had seen the doctor a few weeks ago to try to get physical therapy orders: the doctor’s office faxed everything to the agency, and “I tried to check on it just a bit ago and apparently…the nurse is coming to discharge her so I called [the DON] and she seem very cut and dry with me. Wouldn’t let me ask questions and when I did, she spoke over me…” During an interview on 02/25/2025 at 3:08 p.m. with the family member of Client # 2 the family member stated that Patient # 2 was no longer with the agency, because [the DON] yelled at the family member and the physician’s office nurse. The family member stated that she called and spoke with the agency’s Admin. about her grievances. The surveyor asked why Patient # 2 was discharge from the agency. The family member stated because the DON stated that Patient # 2 did not have any more therapy visits available. The surveyor asked if the agency provided written notice prior to discharge. The family member stated that the agency did not provide a written notice of intent to discharge prior to discharge on 09/26/21024. Patient # 3: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 3 as 08/06/2024. Inactive Clinical Record-Patient # 3: Record review of the clinical record for Patient # 3 revealed a POC for the certification period of 08/01/2024 to 09/29/2024. Review of the POC revealed a start of care date of 08/01/2024 with a primary diagnosis of osteoarthritis of left shoulder (a chronic disease of the joints where bone and cartilage break down and causes pain and stiffness). The POC was dated 08/01/2024 and electronically signed by RN B. The POC contained an order for skilled nursing visits one time per week for one week, and PT visits one time per week for one week to evaluate and treat. Continued review of the POC revealed that RN B determined that Patient # 3 met homebound criteria to receive skilled home health services and was admitted to the agency. Continued review of Patient # 3’s record revealed a PT evaluation dated 08/06/2024. PT Sup. dated and signed the evaluation on 08/06/2024. Review of the evaluation determined that PT Sup. determined that Patient # 3 did not meet the homebound criteria and was not eligible to receive skilled physical therapy services from the agency. Further review of the record revealed a PT discharge OASIS dated 08/06/2024 and signed by PT Sup. Further review of Patient # 3’s records did not reveal that the patient received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 08/06/2024. The record did not include a written NOMNC. During an interview on 02/21/2025 at 12:45 p.m. with Patient # 3, Patient # 3 stated that someone from the agency came to her home and conducted the initial assessment. Patient # 3 stated that she only remembered PT Sup. coming to do an assessment. Patient # 3 stated that she called the agency and spoke with the DON about one week after the assessment to ask why no one came back to provide therapy. Patient # 3 stated that the DON told her that she had been discharged because she was not homebound. Patient # 3 stated that she was not told prior to discharge that she was going to be discharged. Patient # 3 stated that PT Sup. never came back and did not provide other options. Patient # 3 stated that she did not receive written notice prior to discharge, on 08/06/2024, of the agency’s intent to discharge. Patient # 3 stated that she asked the agency to mail her written information on why she was discharged. Patient # 3 stated that she never received any written information regarding her discharge from the agency. During an interview with PT Sup. and Admin on 03/03/2025 at approximately 10:25 a.m. the surveyor asked PT Sup. how she determined that the patient was not home bound when RN B had determined the patient was homebound. The PT Sup. stated that the first time she went to conduct the PT evaluation Patient # 3 was not home. The PT Sup stated, “From what I remember she had poor compliance.” The PT Sup. stated that Patient # 3 was not homebound because she was driving in the community and was going on a pre-planned vacation. The surveyor asked if PT Sup. informed Patient # 3 that she would be discharged from the agency. PT Sup. stated that she did not tell Patient # 3 that she would be discharged from the agency, but that she would be discharged from PT services. The surveyor asked if the PT Sup. had provided Patient # 3 with a written 2- day NOMNC. The PT Sup. stated that she did not provide a written notice, “I sent a message to the supervisor (DON).” During an interview with RN B and the Admin on 03/03/2025 at approximately 10:36 a.m. the surveyor asked RN B if she completed the admission assessment for Patient # 3. RN B stated that yes, she completed the assessment. The surveyor asked if RN B determined that Patient # 3 met homebound criteria. RN B replied, “Yes.” The surveyor asked if patient # 3 was admitted to the agency for services. RN B replied, “Yes.” The surveyor asked RN B to describe the criteria that caused Patient # 3 to be homebound. RN B stated that Patient # 3 was weak, was using an assistive device (example: a cane or walker), she had left shoulder pain, and she was forgetful. The surveyor asked if RN B was aware that PT Sup. conducted and evaluation five days later and determined that Patient # 3 was not home bound. RN B replied, “Yes, I do believe they did a discharge. I read it in the notes at that time.” The surveyor asked if RN B knew who was responsible for providing a written notice prior to discharge. RN B replied, “I just did the start of care.” During an interview with the DON and Admin on 03/03/2025 at 10:58 a.m., the surveyor asked the DON to explain the agency’s discharge processes and policies. The DON stated the agency had case conferences and discussed which patients were coming up for recertification and have they met their goals. The agency reviewed whether; discharge visits had been schedules, discharge notices had been given, the nurses had turned in the notices to the front desk. The surveyor asked who at the agency was responsible for ensuring that the agency was following those processes and policies. The DON replied, “Ultimately, me. The primary for handling those notices is the nurse in the home.” The surveyor reviewed the findings for Patients # 1, 2, and 3 and asked how the failure could adversely affect the patients. The DON stated, “It could cause a delay in whatever was needed to become more independent.” At 11:07 a.m. the surveyor asked why the agency was not following the agency processes and policies regarding admissions, discharges, and transfers. The DON replied, “I have been repeatedly at case conferences reminding them that the notices must be given. It is an ongoing problem. I have not found an answer.” During an interview with RN A on 03/03/2025 at 11:22 a.m., the surveyor asked who was responsible for providing a written notice of discharge to the agency’s patients. RN A stated the nurse who would see the patient before discharge. The surveyor asked RN A if she provided a written discharge notice to Patient # 1 or her representative. RN A replied, “I don’t believe so.” The surveyor asked how the failure could adversely affect the patient. RN A stated that the patient might not know that they were being discharged and if they did not follow up with their physician, it would affect them. Review of agency policy titled, “Patient/Client Transfer and Discharge Notices PE.30” last reviewed 05/01/2024 read in part: “ ... III. The Agency will deliver the Notice of Medicare Non-Coverage (an OMB-approved Medicare form) to the patient/client, or representative, at least two (2) calendar days before Medicare covered services end, or the second to last day of service if care is not provided daily... B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client, or representative (if any) when providing notice of discharge... C. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received...” Review of agency policy titled, “Patient/Client Rights and Responsibilities” dated 05/01/24 read in part: “…VI. The patient/client has the right to…H. Be advised orally and in writing, of…I. Receive proper written notice, in advance of a specific service being furnished…in advance of the Agency reducing or terminating on-going care…””

“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 and interview the agency failed to document both the existence of the complaint and the resolution of the complaint for one (Patient # 3) of two clients who needed physical therapy services. The failure placed the patient at risk of harm due to a delay in receiving the needed therapy services. Findings include: Patient # 3: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 3 as 08/06/2024. Inactive Clinical Record-Patient # 3: Record review of the clinical record for Patient # 3 revealed a POC for the certification period of 08/01/2024 to 09/29/2024. Review of the POC revealed a start of care date of 08/01/2024 with a primary diagnosis of osteoarthritis of left shoulder (a chronic disease of the joints where bone and cartilage break down and causes pain and stiffness). The POC was dated 08/01/2024 and electronically signed by RN B. The POC contained an order for skilled nursing visits one time per week for one week, and PT visits one time per week for one week to evaluate and treat. Continued review of the POC revealed that RN B determined that Patient # 3 met homebound criteria to receive skilled home health services and was admitted to the agency. Continued review of Patient # 3’s record revealed a PT evaluation dated 08/06/2024. PT Sup. dated and signed the evaluation on 08/06/2024. Review of the evaluation determined that PT Sup. determined that Patient # 3 did not meet the homebound criteria and was not eligible to receive skilled physical therapy services from the agency. Further review of the record revealed a PT discharge OASIS dated 08/06/2024 and signed by PT Sup. During an interview on 02/21/2025 at 12:45 p.m. with Patient # 3, Patient # 3 stated that someone from the agency came to her home and conducted the initial assessment. Patient # 3 stated that she only remembered PT Sup. coming to do an assessment. Patient # 3 stated that she called the agency and spoke with the DON about one week after the assessment to ask why no one came back to provide therapy. Patient # 3 stated that the DON told her that she had been discharged because she was not homebound. Patient # 3 stated that she was not told prior to discharge that she was going to be discharged. Patient # 3 stated that PT Sup. never came back and did not provide other options. Patient # 3 stated that she asked the agency to mail her written information on why she was discharged. Patient # 3 stated that she never received any written information regarding her discharge from the agency. During an onsite complaint investigation (on 02/20/2025) the surveyor reviewed the agency’s complaint records. Review of the complaint records did not reveal any documentation of the existence of the complaint or resolution of the complaint. During an interview with the Admin and DON on 03/03/2025 at 11:07 a.m. the surveyor asked who was responsible for following up on complaints. The Admin replied, “I do and [the DON].” The Admin stated that the DON followed up on complaints first and then the Admin followed up on the agency’s complaints. The surveyor reviewed the grievances and complaints of Patient # 3 and asked why there was no documentation of the existence of the complaint or resolution of the complaint. The DON replied, “Just an oversight. It just did not get done at the time.” The DON stated that she understood that documentation of receipt of the complaint and resolution was part of the patient complaint and resolution process. Review of agency policy titled, “Resolution of Patient/Client Conflicts, Grievances or Complaints” dated 08/01/24 read in part: “Purpose I. To establish a procedure and ensure the rights of patients/clients, representatives (if any), caregivers, and/or families to file a report of a grievance or complaint and to make recommendations for resolutions of conflicts without fear of retaliation, coercion, discrimination, reprisal, or unreasonable interruption of care…Procedure… III. The Agency will document the receipt of the complaint/grievance and initiate an investigation within 10 calendar days. Management will be informed of the complaint…B. The Agency will take action to prevent further potential violations, including retaliation, while the complaint is being investigated. C. Documentation will include, but not be limited to, the name and address of the person filing the complaint, the nature of the complaint, and the remedy/relief the person is seeking. IV. The Agency will complete the investigation and documentation of the resolution within 30 days after the receipt of the complaint unless the Agency has and documents reasonable cause for the delay…””