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Phelps Health Home Health and Hospice

(573) 364-24251500 E State Highway 72, Rolla, MO 65401
CMS Certification Number 267555 · Non-Profit · Medicare-certified since 10/06/1998
38deficiencies since 2018
4serious
1inspections
2.5CMS quality stars
Data from CMS inspection reports (Form 2567), 2018-01-02 to 2026-10-15, downloaded 2026-10-21; CMS agency list file dated 2026-09-21. What the labels mean

Inspection 2018-09-12

· Recertification, Sample Validation · 38 deficiencies · CMS source report (PDF)
Serious Patient Rights

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information based on the new home health regulations effective 01/13/18. The agency failed to provide in writing, in advance of furnishing care, the…

Source: CMS Form 2567, inspection 2018-09-12, tag G0406 · view on CMS
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Serious Comprehensive Assessment Of Patients

The agency failed to ensure a timely initial assessment and a complete and accurate patient specific comprehensive assessment was completed for each patient.

Source: CMS Form 2567, inspection 2018-09-12, tag G0510 · view on CMS
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Serious Care Planning, Coordination, Quality Of Care

The agency met the condition of participation when the agency failed to ensure: - A complete plan of care (G574). - Services followed the plan of care as ordered by the physician (G580). - All verbal orders were timed (G584). - Physicians were informed regarding patient's health status that may…

Source: CMS Form 2567, inspection 2018-09-12, tag G0570 · view on CMS
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Serious Skilled Professional Services

The agency met the condition of participation when the agency failed to ensure: - Skilled professional services were delivered according to the HHA's policies and procedures (G702); - Ongoing interdisciplinary assessment of patients (G706); - Services were provided that are ordered by the physician…

Source: CMS Form 2567, inspection 2018-09-12, tag G0700 · view on CMS
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Moderate Exercise Of Rights

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0424 · view on CMS
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Moderate Accessibility

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0490 · view on CMS
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Moderate Infection Prevention

The agency failed to ensure skilled professional followed accepted standards of practice, including agency policy in two out of seven home visit observations (Patient/Record #3 and #5).

Source: CMS Form 2567, inspection 2018-09-12, tag G0682 · view on CMS
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Moderate Services By Skilled Professionals

The agency failed to ensure skilled professional services were delivered according to the HHA's policies and procedures in two out of seven home visit observations (Patient/Record #3 and #5).

Source: CMS Form 2567, inspection 2018-09-12, tag G0702 · view on CMS
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Moderate Supervise Skilled Professional Assistants

The agency failed to ensure supervision of skilled professional assistants in one of five records reviewed with skilled professional assistants (Patient/Record #13).

Source: CMS Form 2567, inspection 2018-09-12, tag G0724 · view on CMS
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Minor Written Notice Of Patient'S Rights

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0412 · view on CMS
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Minor Oasis Privacy Notice

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0416 · view on CMS
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Minor [Removed And Reserved]

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0420 · view on CMS
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Minor Written Notice Within 4 Business Days

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0422 · view on CMS
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Minor Participate In Care

The agency failed to ensure that the patients were adequately informed about the disciplines that will furnish the care and frequency of clinician visits.

Source: CMS Form 2567, inspection 2018-09-12, tag G0434 · view on CMS
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Minor Treatment Or Care

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0480 · view on CMS
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Minor Mistreatment, Neglect Or Abuse

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0482 · view on CMS
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Minor Immediate Reporting Of Abuse By All Staff

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients.

Source: CMS Form 2567, inspection 2018-09-12, tag G0488 · view on CMS
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Minor Rn Performs Assessment

The agency failed to ensure an initial assessment was conducted either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician ordered start of care date in two out of seventeen records sampled (Patient/Record #2 and #11).

Source: CMS Form 2567, inspection 2018-09-12, tag G0514 · view on CMS
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Minor Health, Psychosocial, Functional, Cognition

The agency failed to ensure patients current health, psychosocial, functional, and cognitive status were assessed in nine out of seventeen records reviewed (Patient/Record #2, #3, #7, #9, #11, #12, #13, #16 and #17).

Source: CMS Form 2567, inspection 2018-09-12, tag G0528 · view on CMS
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Minor A Review Of All Current Medications

The agency failed to ensure an accurate and ongoing drug regimen review.

Source: CMS Form 2567, inspection 2018-09-12, tag G0536 · view on CMS
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Minor Plan Of Care Must Include The Following

The agency failed to ensure a complete plan of care in eight out of seventeen records sampled (Patient/Record #3,#4, #7, #9, #10, #11, #13 and #16).

Source: CMS Form 2567, inspection 2018-09-12, tag G0574 · view on CMS
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Minor Only As Ordered By A Physician

The agency failed to ensure services followed the plan of care as ordered by the physician. in three out of seventeen records reviewed (Patient/Records #5, #8 and #13).

Source: CMS Form 2567, inspection 2018-09-12, tag G0580 · view on CMS
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Minor Verbal Orders

The agency failed to ensure all verbal orders were timed.

Source: CMS Form 2567, inspection 2018-09-12, tag G0584 · view on CMS
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Minor Reviewed, Revised By Physician Every 60 Days

The agency failed to ensure physicians were informed regarding patient's health status that may suggest a need to alter the plan of care in four out of seventeen records reviewed (Patient/Record #10, #11, #13, and #16).

Source: CMS Form 2567, inspection 2018-09-12, tag G0588 · view on CMS
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Minor Visit Schedule

The agency failed to ensure an accurate visit schedule, including ensuring documentation of the planned frequency of visits by agency personnel, was being maintained in the patient's home in six out of seven home visit observations (patient/Record #1, #2, #3, #4, #6 and #7).

Source: CMS Form 2567, inspection 2018-09-12, tag G0614 · view on CMS
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Minor Patient Medication Schedule/Instructions

The agency failed to ensure an accurate patient medication schedule/instructions, including: medication name, dosage and frequency was available in the patients' home in five out of seven home visit observations (patient/Record #1, #3, #4, #6, and #7).

Source: CMS Form 2567, inspection 2018-09-12, tag G0616 · view on CMS
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Minor Treatments And Therapy Services

The agency failed to ensure therapy treatments were provided to the patient in writing in one of seven home visit observations (Patient/Record #2).

Source: CMS Form 2567, inspection 2018-09-12, tag G0618 · view on CMS
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Minor Interdisciplinary Assessment Of The Patient

The agency failed to ensure ongoing interdisciplinary assessment of the patient in nine out of seventeen records sampled.

Source: CMS Form 2567, inspection 2018-09-12, tag G0706 · view on CMS
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Minor Provide Services In The Plan Of Care

The agency failed to ensure services were provided that are ordered by the physician as indicated in the plan of care in four out of seventeen sampled records (Patient/Record #1, #3, #13, and #17).

Source: CMS Form 2567, inspection 2018-09-12, tag G0710 · view on CMS
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Minor Patient, Caregiver, And Family Counseling

The agency failed to ensure effective teaching to patients in five out of seventeen sampled records.

Source: CMS Form 2567, inspection 2018-09-12, tag G0712 · view on CMS
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Minor Patient And Caregiver Education

The agency failed to ensure patient and caregiver education regarding discharge planning in one out of two records reviewed for discharge planning (Patient/Record #13).

Source: CMS Form 2567, inspection 2018-09-12, tag G0714 · view on CMS
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Minor A Qualified Hh Aide Successfully Completed:

The agency failed to ensure the registered nurse (RN) observed the home health aide perform all tasks required in one home health aide (Employee #5) of one applicable case.

Source: CMS Form 2567, inspection 2018-09-12, tag G0754 · view on CMS
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Minor Services Provided By Hh Aide

The agency failed to ensure the home health aide performed duties as assigned by the registered nurse in two out of two sampled home health aide records (Patient/Records #6 and #13).

Source: CMS Form 2567, inspection 2018-09-12, tag G0800 · view on CMS
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Minor Onsite Supervisory Visit Every 14 Days

The agency failed to ensure a registered nurse (RN) made an onsite visit to the patient's home no less frequently than every 14 days for supervision of the home health aide in one of two records sampled for aide services (Patient/Record #13).

Source: CMS Form 2567, inspection 2018-09-12, tag G0808 · view on CMS
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Minor Responsible For All Day-To-Day Operations

The agency administrator is effective in the day-to-day supervision of the agency.

Source: CMS Form 2567, inspection 2018-09-12, tag G0948 · view on CMS
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Minor Primary Hha Is Responsible For Patient Care

The agency failed to have contracts that specified how agency supervision of the contracted therapist would occur.

Source: CMS Form 2567, inspection 2018-09-12, tag G0980 · view on CMS
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Minor In Accordance With Current Clinical Practice

The agency failed to meet applicable Missouri state law, failed to ensure contracted therapy staff submitted a criminal disclosure statement as required in 192.2495.5, RSMo.

Source: CMS Form 2567, inspection 2018-09-12, tag G0984 · view on CMS
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Minor Discharge And Transfer Summaries

He/she stated that evidence/confirmation that a transfer and discharge was sent to the physician was not started as an agency practice until August 2018. PATIENT/RECORD #14: The clinical record showed a "discharge/Transfer Summary" with a discharge date of 05/23/18. Review of "HH Agency Discharge"…

Source: CMS Form 2567, inspection 2018-09-12, tag G1022 · view on CMS
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