Acme Health Service Inc

The agency failed to ensure an Emergency Preparedness program was in place for 1 of 1 home health agency.

The agency failed to ensure they accepted patients needing therapy on the reasonable expectation that they were able to meet the patient’s therapy needs (See G570); the agency failed to ensure services were provided per the plan of care and failed to ensure each patient received an individualized…

The agency failed to ensure they implemented, documented, and maintained an effective, ongoing data-driven Quality Assessment and Performance Improvement (QAPI) program, involved all agency services, utilized quality indicators data, included data from OASIS data, failed to focus on high risk, high…

The agency failed to ensure the Administrator was managing the day to day operations of the agency (see G948); failed to ensure the Clinical Manager had a signed job description and was aware of their position as Alternate Administrator (see G954); failed to ensure care was coordinated with other…

The agency failed to submit OASIS (Outcome and Assessment Information Set) within 30 days of assessment completion for 2 of 2 qualified active skilled records reviewed where OASIS information was collected and transmitted.

The agency failed to ensure services were provided per the plan of care and failed to ensure each patient received an individualized plan of care, identified patient-specific measurable outcomes and goals for 5 of 6 active records reviewed (Patients: #1, 3, 4, 5, and 6) and 2 of 6 focused records…

The Case Manager failed to ensure the home health aide care plan was completed, individualized, and patient-specific for 1 of 3 active patient records reviewed.

The agency failed to ensure the comprehensive assessments were complete and accurately reflected the patient's status, including health, psychosocial, and cognitive status in 4 of 6 active records reviewed (Patients: #1, 3, 4, and 5) and 5 of 6 and focused records reviewed.

The agency failed to ensure all patients received a comprehensive assessment reflecting their current strengths, patient-specific and measurable goals, and care preferences for 5 of 6 active clinical records reviewed (Patients #1, 3, 4, 5, and 6) and 5 of 6 active focused records reviewed (Patients…

The agency failed to ensure a complete and accurate assessment of the patient’s medical nursing, rehabilitative, social, and discharge planning needs in 5 of 6 active records reviewed (Patients: #1, 3, 4, 5, and 6) and 5 of 6 focused records reviewed.

The agency failed to ensure the patient’s caregivers along with their frequency and willingness to assist in care were included in the comprehensive assessment for 3 of 6 (Patients: #1, 2, and 5) active clinical records reviewed and 1 of 6 (Patients: #10) active focused records reviewed.

The agency failed to ensure the Registered Nurse (RN) completed a comprehensive discharge assessment on 1 of 2 discharge records reviewed.

The agency failed to ensure the individualized plan of care included all diagnoses, all supplies and equipment, frequency and duration of visits made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety…

The skilled nurse failed to promptly notify the physician of changes in the patient’s condition in 1 of 1 patients with a change in condition.

The agency failed to ensure the patients' overall health and goals were discussed in the multidisciplinary team for 5 of 6 active clinical records reviewed (Patients #1, 2, 3, 4, and 5) and 4 of 6 focused audit clinical records reviewed.

The agency failed to ensure that the patient’s clinical records included information about the services the patient received from other health providers and failed to ensure they coordinated care delivery to meet the patient’s needs for 3 of 6 active patient records reviewed.

The agency failed to ensure the patient or the patient’s caregiver were provided with a medication schedule/instructions, including medication name, dosage, and frequency in plain language in 3 of 3 home visit patients.

The Administrator failed to ensure they were responsible for day-to-day operations, had a data-driven Quality Assessment and Performance Improvement (QAPI) program, a current Emergency Preparedness plan reviewed, and a tabletop exercise at least annually, ensured public information was accurate…

The agency failed to ensure the Alternate Administrator, was aware of their role as the Alternate Administrator and had a signed job description for the position of 1 of 1 Alternate Administrator.

The Clinical Manager failed to ensure the coordination of care with other providers in the patient's home for 1 of 1 home health agency.

The Clinical Manager failed to ensure needs were continuously assessed for 6 of 6 active clinical records (Patients: #1, 2, 3, 4, 5, and 6) and 6 of 6 focused clinical records reviewed (Patients: #9, 10, 11, 12, 13, and 14) and 2 of 2 closed records reviewed.

The agency failed to ensure a discharge and transfer summary was written and sent to the primary care provider who is responsible for the patient’s care after discharge within 72 hours of discharge (Patient: #7) and within 48 hours of transfer to another facility (Patient: #8) for 2 of 2 discharged…