Utah Home Health

“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 interview and record review, it was determined the home health agency failed to meet the Condition of Participation for Organization and administration of services. Specifically, the agency was operating two branches that were not approved by Medicare or the State Agency. The parent home health agency failed to report all branch locations of the HHA to the state survey agency at the time of the home health agency’s request for initial certification, at each survey, and/or at the time the parent proposed to add or delete a branch. (Refer to Tag G0972)”

“Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA’s request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This Element is not met as evidenced by: Based on interview and record review, it was determined the home health agency did not ensure all branch locations of the home health agency were reported to the state survey agency at the time of the HHA’s request for initial certification, at each survey, and/or at the time the parent proposed to add or delete a branch. Patient identifiers 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. Findings include: During the off-site preparation for the recertification survey at Utah Home Health, the State Agency had an address of 350 West Center Street, Orem, UT and an agency phone number of 801-373-1400. An entrance interview was conducted with the Regional Clinical Director (RCD) on 12/26/2023 at approximately 8:57 AM, the RCD was asked if the agency had any branches. The RCD did not state if there were branches and said that she “got in trouble” when she previously stated the agency had branches. The RCD stated she was the agency Director of Nursing (DON). A review of the agency web site was conducted on 12/26/2023. The web site documented there was Home Health Care in Utah, Salt Lake, Davis and Weber Counties. On 12/26/2023 at 12:40 PM, an e-mail was sent to the RCD. The RCD was asked why the HOME “HEALTH CERTIFICATION AND PLAN OF CARE” (HHC/POC) was completed by a registered nurse (RN) who was not documented as a DON. The RCD responded on 12/26/2023 at 1:06 PM with, “HR (human resources) should have them listed as ADON’s (assistant director of nursing) technically. Likely an oversite? I can look into it...” Further information was not received by 12/28/2023. On 12/26/2023 at 2:43 PM, copies of the HHC/POC was requested for all sample patients. The agency name listed on the Home Health Certification and Plan of Care for all patients was Utah Home Health and Hospice. The HHA’s (Home Health Agency’s) Medicare number was for Utah Home Health. Additionally, the agency name in the Medicare system was listed as Utah Home Health with no DBA (doing business as) or a legal name noted as Utah Home Health and Hospice. On 12/27/2023 at 9:40 AM, an e-mail was sent to the RCD asking why the HHC/POC had the agency name of Utah Home Health and Hospice. On 12/27/2023 at 12:53 PM, an e-mail was received from the RCD stating, “Per our owner [name redacted]- ‘The reason our 485’s (HHC/POC) have Hospice listed is because that’s what our LLC is listed as a legal entity. And again, [RNs from Salt Lake office and Layton office] should have been listed as ADON in the signature line. That was an oversight by HR.’” The HHC/POC for patients 1, 4, 7 and 10 had the agency name as Utah Home Health & Hospice - Provo. The HHC/POC for patients 2, 3, 6 and 9, had the agency name as Utah Home Health & Hospice - Salt Lake. The address documented was 5242 South College Drive, Suite 205 in Murray, Utah. The phone number was 801-335-6455. The HHC/POC for patient’s 5 and 8, had the agency name as Utah Home Health and Hospice -Ogden. The address documented was 910 West Heritage Park Boulevard, Suite 120 in Layton, Utah. The phone number was 385-787-5850. Review of the State Agency records for Utah Home Health were reviewed. There was no documentation that Utah Home Health had notified the State Agency that there were branches in Salt Lake City or Layton. The review of records shows no evidence of Medicare certification approval for these locations.”