247 Allstaff West LLC

The Home Health Agency (HHA) failed to implement a safe and coordinated discharge planning process to effectively transition patients upon discharge from home health services (G 0562).

The Home Health Agency (HHA) failed to implement a safe and coordinated discharge from home health services for two sampled patients (Patient 1 and Patient 2), when Patient 1 and Patient 2 had unplanned discharges from home health services with less than 24 hour notice and no follow up care…

The Home Health Agency (HHA) failed to ensure the Comprehensive Assessments reflected the patients' representative for 3 of 10 sampled patients (Patient 8, Patient 9, Patient 10).

The home health agency (HHA) failed to comply with all applicable Federal, State and local emergency preparedness requirements referenced in Appendix Z of the State Operation Manual.

The Home Health Agency (HHA) failed to ensure the patient and representative, have the right to be informed of the patient's rights in a language and manner the individual understands (G406); failed to provide the patient and the patient’s legal representative (if any), the following information in…

The Home Health Agency (HHA) failed to conduct the initial assessment visit within 48 hours of referral (G514); failed complete the comprehensive assessment within 5 calendar days after the start of care (G520); failed to accurately reflect the patient's health status in the comprehensive…

The Home Health Agency (HHA) failed to ensure patients were accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence (G570); failed to ensure the plan of care was updated every 60 days…

The Home Health Agency (HHA) failed to have a program that showed measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care (G642); failed to take actions aimed at performance improvement…

The agency failed to maintain and document the infection control program which had as its goal the prevention and control of infections as evidenced by: The agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and…

The Home Health Agency (HHA) failed to ensure skilled professional services are delivered and supervised only by health care professionals (G702); failed to ensure the plan of care was developed and evaluated in partnership with the patient, representative or caregiver(s) (G708); failed to provide…

The agency and its staff failed to operate and furnish services in compliance with all applicable federal regulations related to the health and safety of patients.

The Home Health Agency (HHA) failed to have a governing body (or designated persons so functioning) who assumed 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…

The agency failed to ensure that clinical records included all interventions, including medication administration, treatments, and services, and responses to those interventions (G1014); failed to ensure there were goals in the patient's plans of care and the patient's progress toward achieving…

The Home Health Agency (HHA) failed to have a qualified Administrator (G1053) and failed to ensure Licensed Vocational Nurses who furnished services were under the supervision of a qualified registered nurse (G1060).

The agency failed to have official documentation of any adjudication by a court that indicates that a patient lacks the legal capacity to make his or her own health care decisions and the name of any person identified by the court who may exercise the patient's rights for three of seven sampled…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included the right to be informed of the HHA's (home health agency) policies for transfer and discharge for three of seven sampled patients (Patient 1, 2 and 3).

The agency failed to ensure each patient received home health services that were written in an individualized plan of care (POC) that identifies patient-specific measurable outcomes and goals, that was established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry…

The home health agency (HHA) failed to provide the patient and caregiver with a copy of written plan of care (POC) for one out of seven sampled patients (Patient 2).

Failed to present their Quality Assessment and Performance Improvement (QAPI) program was at least capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The Home Health Agency’s (HHA) governing body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained.

The agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections to 7 sampled patients.

The Home Health Agency (HHA) failed to promote an infection control surveillance program to prevent possible transmission of infections for 7 sampled patients.

The Home Health Agency (HHA) failed to provide Infection control education to staff at periodic intervals consistent with accepted standards of practice for 7 sampled patients.

The agency failed to ensure skilled professional services were delivered and supervised only by health care professionals who met the appropriate qualifications and according to the HHA's (home health agency) policies and procedures for four out of seven sampled patients (Patient 1, 2, 4, and 6).

The Home Health Agency (HHA) failed to obtain a Clinical Laboratory Improvement Amendment (CLIA) Certificate of Waiver when employees conducted blood glucose meter testing (test to measure amount of sugar in the blood) for two out of seven sampled patients (Patient 2 and Patient 4).

The agency failed to have a governing body (or designated persons so functioning) who assumed 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…

The agency failed to provide skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) which are made available on a visiting basis, in a place of residence used…

The agency's governing body failed to prepare an overall plan and a budget that included an annual operating budget and capital expenditure plan and failed to ensure the overall plan and budget was reviewed and updated at least annually under the direction of the governing body of the HHA (Home…

The home health agency (HHA) failed to ensure clinical records were completed timely for one out of seven sampled patients (Patient 4).

The agency failed to have a qualified Administrator for a census of 19. This failure negatively impacted the day-to-day operations of the agency and resulted in the agency' s inability to remain in compliance with Federal Regulations.

The agency failed to ensure Licensed Vocational Nurses (LVN) who furnished services was under the supervision of a qualified registered nurse for four out of seven sampled patients (Patient 1, 6, 2, and 4).

The agency failed to provide the patient and the patient’s legal representative (if any), the following information in the Patient Rights during the initial evaluation visit, in advance of furnishing care to the patient for three of seven sampled patients (Patient 1, 2 and 3).

The agency failed to ensure the patient and/or their representative received written notice of the patient’s rights and responsibilities, the HHA’s (home health agency) transfer and discharge policies and be accessible to individuals with disabilities for three of seven sampled patients (Patient 1…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included contact information for the HHA (home health agency) administrator, including the administrator's name, business address, and business phone number in…

The agency failed to obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for three of seven sampled patients (Patient 1, 2, and 3).

The agency failed to provide written notice of the patient's rights and responsibilities and the home health agency's (HHA) transfer and discharge policies to a patient-selected representative within four business days of the initial evaluation visit for three of seven sampled patients (Patient 1…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included the right to have his or her property and person treated with respect for three of seven sampled patients (Patient 1, 2, and 3).

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included make complaints to the Home Health Agency (HHA) regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities, which included the right to consent or refuse care in advance of and during treatment for four of seven sampled patients (Patient 1, 2, 3, and 4).

The Home Health Agency (HHA) failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included the right to receive all services outlined in the plan of care for three out of seven sampled patients (Patient 1, 2 and 3).

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included the right to have a confidential clinical record and access to or release of patient information and clinical records for three of seven sampled…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included being advised, orally and in writing, of the extent to which payment for HHA (home health agency) services may be expected from Medicare, Medicaid, or…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included proper written notice, in advance of a specific service being furnished, if the HHA (home health agency) believes that the service may be non-covered…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included being advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included being advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included the right to be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA (home health agency) or…

The agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included the right to be informed of the right to access auxiliary aids and language service, and how to access these services for three of seven sampled…

The home health agency (HHA) failed conduct the initial assessment visit within 48 hours of referral for two out of seven sampled patients (Patient 2 and Patient 4).

The home health agency (HHA) failed to complete the comprehensive assessment for two out of seven sampled patients (Patient 2 and Patient 7) within five calendar days after the start of care.

The home health agency (HHA) failed to accurately reflect two of seven sampled patients' (Patient 2 and Patient 7) health status in its comprehensive assessment.

The home health agency (HHA) failed to include patient's goals for three out of seven sampled patients (Patient 2, 3 and 4) in their comprehensive assessment.

The home health agency (HHA) failed to include assessment of patient's continuing need for home care for two out of seven sampled patients (Patient 2 and Patient 4) in their comprehensive assessments.

The home health agency (HHA) failed to include patient's discharge plan for three out of seven sampled patients (Patient 2, Patient 3, and Patient 4) in their comprehensive assessments.

The home health agency (HHA) failed to include a review of all medications the patient is currently using for two out of seven sampled patients (Patient 2 and Patient 7) in their comprehensive assessment.

The home health agency (HHA) failed to include an assessment on the willingness and ability to provide care, and availability of the patient’s primary caregiver(s), if any, and other available supports for two out of seven sampled patients (Patient 2 and Patient 7) in the comprehensive assessment.

The agency failed to ensure the individualized plan of care included all pertinent patient diagnoses and all patient medications for four out of seven sampled patients (Patient 2, Patient 4, Patient 6 and Patient 7).

The agency failed to ensure the individualized plan of care included all patient care orders, including verbal orders, for one out of seven sampled patients (Patient 2).

The agency failed to ensure drugs, services, and treatments were administered only as ordered by a physician or allowed practitioner for seven out of seven sampled patients (Patient 1, 2, 3, 4, 5, 6, and 7).

The Home Health Agency (HHA) failed to ensure all verbal order(s) were authenticated and dated by the physician or allowed practitioner in accordance with applicable state laws and regulations and the HHA’s internal policies for one out of seven sampled patients (Patient 2).

The agency failed to ensure the individualized plan of care (POC) was reviewed and revised by the physician or allowed practitioner who is responsible for the home health POC and the HHA (home health agency) as frequently as the patient's condition or needs required, but no less frequently than…

The agency failed to ensure communication with all physicians or allowed practitioners involved in the plan of care for five out of seven sampled patients (Patient 1, 5, 6, 2, and 4).

The agency failed to ensure integration of orders from all physicians or allowed practitioners involved in the plan of care for one out of seven sampled patients (Patient 2).

The agency failed to ensure patient care was coordinated when there was no documented evidence in patients' clinical records that care coordination occurred for five of seven sampled patients (Patient 1, 2, 4, 5, and 6).

The agency failed to ensure that each patient, and his or her caregiver(s), received ongoing education and training provided by the HHA (Home Health Agency) regarding the care and services by not providing an admission packet, upon admission, for two of seven sampled patients (Patient 2, and…

The home health agency (HHA) failed to provide the patient and caregiver with a copy of written instructions outlining frequency of visits by HHA personnel and personnel acting on behalf of the HHA for two out of seven sampled patients (Patient 2 and Patient 3).

The agency failed to provide the patient and caregiver with a copy of written instructions outlining patient medication schedule/instructions and which medications will be administered by home health agency (HHA) personnel and personnel acting on behalf of the HHA, and ensure medication profiles…

The home health agency (HHA) failed to provide the patient and caregiver with a copy of written instructions outlining treatments to be administered by HHA personnel and personnel acting on behalf of the HHA for one out of seven sampled patients (Patient 2).

The agency failed to ensure the plan of care (POC) was developed and evaluated in partnership with the patient, representative or caregiver(s) for five out of seven sampled patients (Patient 1, 2, 4. 5, and 6).

The agency failed to provide services that are ordered by the physician or allowed practitioner as indicated in the plan of care and follow the planned frequency of visits for five out of seven sampled patients (Patient 1, 2, 4, 5, and 6).

The agency failed to communicate with all physicians involved in the plan of care and other health care practitioners related to the current plan of care for seven out of seven sampled patients (Patient 1, 2, 3, 4, 5, 6, and 7).

The agency failed to ensure nursing services were provided under the supervision of a registered nurse for five out of seven sampled patients (Patient 1, 2, 4, and 6).

The agency failed to provide documentation that the Administrator was appointed by and reported to the governing body for a census of 19. This failure negatively impacted the day-to-day operations of the agency and resulted in the agency' s inability to remain in compliance with Federal Regulations.

The agency failed to ensure the Administrator was responsible for all day-to-day operations of the agency for a census of 19. This failure negatively impacted the day-to-day operations of the agency and resulted in the agency's inability to remain in compliance with Federal Regulations.

The agency failed to have documentation 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 for a census of 19. This failure…

The agency failed to ensure the clinical record included all interventions, including medication administration, treatments, and services, and responses to those interventions for one of seven sampled patients (Patient 5).

The agency failed to ensure there were goals in the patient's plans of care and the patient's progress toward achieving them for four out of seven sampled patients (Patient 3, 2, 4, and 6).

The agency failed to ensure the clinical record contained the contact information for the patient's representative and/or patient's primary caregiver for three out of seven sampled patients (Patient 1, 2, and 7).

The agency failed to have a completed discharge summary that was sent to the primary care practitioner or other health care professional who are responsible for providing care and services to the patient after discharge from the HHA (Home Health Agency) within 5 business days of the patient's…

The Home Health Agency (HHA) failed to complete recertification assessments for 5 of 7 (Patient 1, Patient 2, Patient 4, Patient 5, Patient 7) sampled patients within the last 5 days of every 60 days of the Plan of Care (POC) certification period.

The Home Health Agency (HHA) failed to provide an accurate Plan of Care (POC) for patients when; 1. 5 of 7 sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, Patient 7) had POCs with certification periods greater than 60 days and; 2. 7 of 7 sampled patients (Patient 1, Patient 2, Patient…

The Home Health Agency (HHA) failed to ensure complete nursing notes were in the clinical record for 4 of 7 sampled patients (Patient 1, Patient 3, Patient 6, Patient 7).

The Home Health Agency (HHA) failed to notify the patients' physicians of missed visits for 3 of 7 (Patient 1, Patient 5, Patient 7) sampled patients.

The Home Health Agency (HHA) failed to ensure the plan of care was updated every 60 days (G572), the staff followed the physician ordered services (G578), the staff notified the physician when the services ordered were not provided (G590).

The Home Health Agency (HHA) Governing Body failed to designate a person to act in the absence of the administrator and oversee the overall daily operations of the agency (G954), ensure the Director of Patient Care Services (DPCS) was available for sufficient hours to oversee, supervise and train…

The home health agency (HHA) failed to update the Plan of Care (document that includes HH needs, services and the frequency of these services according to a physician's order) to reflect current physician orders every 60 days for 3 of 7 sampled Patients (Patient 4, Patient 5, Patient 6).

The agency failed to follow the physician orders when visits were not completed as ordered for 3 of 7 sampled patients (Patient 1, Patient 5 and Patient 7).

The agency failed to ensure records were readily retrievable for 18 active patients and for discharged patients.

The home health agency (HHA) failed to complete comprehensive assessments within the last 5 days of every 60 days for 2 of 7 sampled Patients (Patient 4 and Patient 5).

The home health agency (HHA) failed to ensure a discharge assessment and discharge summary was completed for 2 of 7 sampled patients (Patient 6 and Patient 7).

The agency failed to ensure patient care was coordinated as per facility policy "Care Coordination," for 7 of 7 sampled patients (Patient 1, 2, 3, 4, 5, 6, and 7) when there was no documented evidence in patients' clinical records that care coordination occurred.

The home health agency (HHA) failed to follow the Plan of Care for scheduled visits for 2 of 7 sampled patients (Patient 1 and Patient 5).

The home health agency (HHA) failed to ensure medication profiles were accurate and medications in the home were current for 2 of 7 sampled patients (Patient 1 and Patient 3) when: 1. Patient 1's medication profile in her clinical record did not match the medication profile in the home, the…

The home health agency (HHA) failed to complete clinical visit notes within 48 hours of the visit per agency policy for 3 of 7 sampled patients (Patient 1, Patient 4, and Patient 5).

The agency failed to ensure the Director of Patient Care Services (DPCS) was available to oversee, supervise and train the nursing staff when she worked 15 hours per week for a census of 18 patients.

The agency Administrator failed to designate a person to act in his absence as per their policy for a census of 18 patients.

The agency failed to ensure care was coordinated as per policy for 7 of 7 sampled patients (Patient 1, 2, 3, 4, 5, 6, and 7) when there was no documented evidence in the patients' clinical record it occurred.

The home health agency (HHA) failed to complete comprehensive assessments within the last five days of every 60 days for 2 of 7 sampled Patients (Patient 4 and Patient 5).

The home health agency (HHA) failed to update the Plan of Care every 60 days for three of seven sampled Patients (Patient 4, Patient 5, Patient 6).

The home health agency (HHA) failed to include in the clinical record complete clinical visit notes for 3 of 7 sampled patients (Patient 1, Patient 4, and Patient 5).

The home health agency (HHA) failed to ensure a discharge assessment and discharge summary was completed and retained in the clinical record for 2 of 7 sampled patients (Patient 6 and Patient 7).

The agency failed to ensure patient care and services were provided under direct supervision of a Registered Nurse (RN) as per the regulations for a census of 15. This failure had the risk potential for patients not to receive quality of care and services.

The agency failed to ensure the Plan of Care (POC) for 3 of 10 sampled patients (Patient 4, Patient 7, and Patient 10) were approved by the physician when they were not signed by the physician within 30 days as per the agency's policy.

The agency failed to ensure 1 of 10 sampled patients (Patient 3) physician's orders were followed when Skilled Nursing services were not provided for over 4 weeks.

The agency failed to ensure infection control practices were followed for 1 of 10 sampled patients (Patient 4) when reusable equipment was not sanitized after use and when used sharps were not disposed of properly.

The agency failed to ensure the contents of the clinical records were properly organized for a census of 19. This failure resulted in extensive time usage to locate patients' records, which were stored as documents and images, some defaced and illegible.

The agency failed to ensure the clinical records for the patients under their care were secure when staff were transmitting care notes using their personal computers, fax machines and cell phones for a census of 19 active patients.

Staff failed to maintain patient information in a confidential manner when patient health care information was transmitted via staffs' personal cell phones for a census of 19. This failure had the potential for unauthorized use and access of patient health information.

The Agency failed to ensure that the comprehensive assessment for 1 of 10 sampled patients (Patient 2), was updated and revised during the last 5 days of the 62 day certification period, for the assessment period beginning 6/15/19. Review of the clinical record for Patient 2 indicated she had a…

The agency failed to ensure the individualized Plan of Care (POC) for one of 19 patients (Patient 5) included the frequency and duration of visits to be made by Skilled Nursing (SN).

The agency failed to ensure the individualized Plan of Care (POC) was reviewed and revised for 1 of 10 sampled patients (Patient 7).

The agency staff failed to ensure their clinicians prepared and submitted their visit notes in a timely manner for 1 of 10 sampled patients (Patient 7).

The agency failed to ensure there were sufficient hours dedicated to the Clinical Supervisor to be able to meet the responsibility for staff training, competency testing, staff supervision and, to implement clinical policies and procedures.

The agency's Administrator failed to ensure the policies and procedures (P & Ps) were reviewed and contained accurate information and, failed to ensure information given to patients/families was updated for a census of 19. This failure had the potential to result in out-dated care practices when…

The agency failed to ensure there was sufficient hours dedicated to the Clinical Supervisor to be able to meet the responsibility for staff training and competency testing, staff supervision and, to implement clinical policies and procedures.

The agency failed to ensure the clinical records were complete and included all nursing notes for four of 10 sampled patients (Patients 2, 4, 9, and 7) when, 1. Patient 2 had multiple missing nursing notes; 2. Patient 4 had multiple missing nursing notes; 3. Patient 9 had multiple missing nursing…