Access Care Home Health Agency Inc

The agency failed to ensure the comprehensive assessment was completed and signed by the visiting registered nurse (RN) within the required time frame for 1 of 2 sampled patients (Patient 2).

The agency failed to ensure it maintained condition level compliance with the emergency preparedness program.

The agency failed to maintain condition level compliance with reporting OASIS information.

The agency failed to ensure it maintained condition level compliance with comprehensive assessments of patients.

The agency failed to maintain condition level compliance with the quality and performance improvement program.

The agency failed to maintain condition level compliance with the organization and administration of services.

The agency failed to maintain compliance with conditions for participation for complete and accurate clinical records regarding visits, plans of care, and policy enforcement for securing patient information.

The agency failed to ensure it reviewed and updated its emergency preparedness plan at least every 2 years.

The agency failed to ensure it reviewed and updated its all-hazards risk assessment at least every 2 years.

The agency failed to ensure its emergency preparedness training and testing program was reviewed and updated, with employees receiving training on the updates at least every 2 years.

The agency failed to ensure its emergency preparedness training program was implemented at hire and then reutilized every 2 years for employee retraining.

The agency failed to ensure it conducted exercises to test its emergency plan at least every two years.

The agency failed to electronically transmit each completed OASIS assessment within 30 days of completing the assessment of the beneficiary for every quarter reviewed since its initial certification survey in March 2021. Findings include: According to the state's OASIS Education Coordinator in the…

The agency failed to ensure it measured, analyzed, and tracked quality indicators, including adverse patient events, and other aspects of performance, enabling the agency to assess processes of care, services, and operations.

The agency failed to ensure its quality program utilized quality indicator data in its design and the data collected to monitor quality of care effectiveness.

The agency failed to ensure it tracked adverse patient events, analyzed their causes, and implemented preventive actions.

The agency failed to ensure it conducted and documented any performance improvement projects.

The agency's Governing Body failed to ensure an ongoing program for quality and performance improvement.

The Governing Body failed to take responsibility for the agency's overall management and operation, provision of all home health services and its quality and performance improvement program.

The agency failed to ensure it appropriately authenticated, dated and timed its documentation for 5 of 12 patients (Patient #6, #7, #8, #10 and #12).

The agency failed to ensure it had policies and procedures to ensure the security of clinical records and the privacy of information contained within such records to prevent loss or unauthorized use in the patient's home, in transit, in the office setting, or any other location for all patients…

The agency failed to ensure it conducted and documented an OASIS Start of Care assessment within five days of the first visit where the agency provided hands on, direct care services for 1 of 12 patients (Patient #10).

The agency failed to ensure it conducted and documented OASIS Transfer/Discharge assessments within two days of a patient's discharge date for 2 of 12 patients (Patient #6 and #8).

The agency failed to ensure ordered skilled visits were conducted as ordered for 2 of 12 patients (Patient #1 and #5) and failed to ensure ordered services were delivered as ordered for 1 of 12 patients (Patient #9).

The agency failed to ensure it maintained an accurate medication profile for 2 of 12 patients (Patient #1 and #10).

The agency failed to ensure it took actions aimed at performance improvement, implemented those actions, measured its success and tracked performance to ensure improvements were sustained.

The agency failed to ensure clinical notes were prepared, documented and authenticated in a timely manner for 5 of 12 patients (Patient #6, #7, #8, 10 and #12).

The agency failed to ensure any skilled professional, regardless of whether the skilled professional was a direct employee or contractor of the agency, contributed to all phases of the QAPI program.

The agency's Administrator did not demonstrate responsibility for all day-to-day operations of the agency.

The agency failed to ensure patient clinical information was documented and authenticated in a timely manner for 6 of 12 patients (Patient #6, #7, #8, #10, #11 and #12).

The agency failed to ensure clinical record entries included ordered treatments, services and patient responses to interventions for 4 of 12 patients (Patient #7, #8, #10 and #12).

The agency failed to ensure goals, orders and treatments were included in a plan of care in a timely manner for 2 of 12 patients (Patient #11 and #12).

The agency failed to ensure it documented a discharge order and discharge summary within 2 days of discharge for 2 of 12 patients (Patient #6 and #12).