Act Home Health, Inc

The agency failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets.

The agency failed to ensure the standard precautions to prevent the transmission of infections and communicable diseases were implemented for two of sampled seven patients (Patients 6 and 7).

The agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and investigation of infections.

The agency failed to ensure the initial comprehensive assessment was completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for one of seven sampled patients (Patient 2).

The agency failed to ensure the review of medications included all of the patients' current medications to identify any potential adverse effects and drug reactions for two of seven sampled patients (Patients 6 and 7).

The agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for two of seven sampled patients (Patients 2 and 5 ).

The agency failed to ensure the POCs included specific information related to medications, nutritional requirement, DME, and supplies for four of seven sampled patients (Patients 1, 2, 4, and 6).

The agency failed to ensure the provided treatment was included in the POC for one of seven sampled patients (Patient 7).

The agency failed to ensure effective communication with the patient's physician for two of seven sampled patients (Patients 1 and 2).

The agency failed to ensure the patients received care and services as per the written plan of care for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7).

The agency failed to ensure the skilled professionals prepared accurate clinical notes for five of seven sampled patients (Patients 1, 2, 3, 5, and 6 ).

The agency failed to ensure the HHA’s RN provided supervision to the SN to ensure quality of care and services were provided for five of seven sampled patients (Patients 1, 3, 4, 5, and 6 ).

The agency’s Administrator failed to be responsible for the day-to-day operations related to ensuring LVN 1's pre-employment physical health examination was completed timely before the start of employment.

The agency failed to ensure the agency’s P&Ps were implemented as evidenced by: There was no address listed in the written complaint filings for nonsampled patients (Patients A and B) as per the agency’s P&P.

The agency failed to maintain accurate and complete clinical records for two of seven sampled patients (Patients 1 and 4).

The facility failed to ensure the OASIS data were transmitted for four of seven patients (Patients 2, 3, 6, and 7), creating the risk of not reporting and coordinating patient care assessments for patients receiving care and services from the HHA.

The agency failed to ensure the recertification assessments were completed within the last five days of the certification period for two of seven sampled patients (Patients 1 and 5), creating the risk of not providing the necessary care and services to these patients.

The agency failed to ensure the agency had revised the POC for one of seven sampled patients (Patient 4), creating the risk of a substandard healthcare outcome to this patient.

The agency failed to ensure infection control practices were implemented for two of seven sampled patients (Patients 6 and 7).

The agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and investigation of infections.

The facility failed to ensure the POCs included specific information related to medication administration for two of seven sampled patients (Patients 3 and 7), creating the risk of not addressing the care needs for these patients.

The agency failed to communicate with the physician regarding the patients' care needs for two of seven sampled patients (Patients 2 and 5).

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for six of seven sampled patients (Patients 1, 2, 3, 4, 5, and 7).

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes four of seven sampled patients (Patients 2, 3, 5, and 7).

The agency failed to ensure the agency’s RN provided supervisions to the SN to ensure quality of care and services provided for three of seven sampled patients (Patients 2, 4, and 7), creating the risk of substandard healthcare outcomes to these patients.

The agency's Administrator failed to be responsible for the day to day operations related the P&P implementation for one of seven patients (Patient 7).

The agency failed to ensure the emergency preparedness plan included the strategies for addressing the emergency events identified by the risk assessment.

The agency failed to ensure the emergency preparedness P&P included a system of medical documentation that preserved, protected and maintained patient information records in an emergency.

The agency failed to ensure the emergency preparedness P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The agency failed to develop and maintain the emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the…

The agency failed to ensure the patients received care and services as written in the POC for six of eight sampled patients (Patients 1, 3, 4, 5, 6, and 7), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to ensure the collected data was analyzed to assess the agency's processes of care, services, and operations, creating the risk for not addressing care problems.

The agency failed to ensure the QAPI projects included the reason for conducting the projects, creating the risk of persistent of poor practices and substandard health outcomes to the patients receiving services from the agency.

The agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and investigation of infections, creating the risk of spread of infections.

The agency failed to ensure the written assignment for CHHA was prepared by the RN for one of eight sampled patients (Patient 2), creating the risk of not providing the necessary care and services to this patient.

The agency failed to ensure the clinical records were complete for four of eight sampled patients (Patients 1, 2, 6, and 7), creating the risk of substandard care provided to these patients as their clinical information was not complete.

The agency failed to ensure the resolution of the complaints were provided in writing for two of eight sampled patients (Patients 3 and 5) and three nonsampled patients (Patients A, B, and C), creating the risk of violating the patient's rights and not addressing the grievances for the patients.

The agency failed to ensure the update comprehensive assessments were completed within the last five days of every 60 days for three of eight sampled patients (Patients 2, 5, and 7), creating the increased risk of not addressing the care needs for these patients.

The agency failed to ensure the comprehensive assessment was complete at discharge for one of eight sampled patients (Patient 7), creating the risk of not updating the patient's status for this patient.

The facility failed to ensure the POCs included specific information related to medication administration for three of eight sampled patients (Patients 2, 6, and 8 ), creating the risk of not addressing the care needs for these patients.

The agency failed to coordinate care related to low pulse rates and eye conditions for two of eight sampled patients (Patients 2 and 3), creating the risk of not providing the necessary care and services to these patients.

The agency failed to ensure the patients received care and services as written in the POC for six of eight sampled patients (Patients 1, 3, 4, 5, 6, and 7), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to ensure the SN had completed and accurately prepared the clinical notes for one of eight sampled patients (Patient 4), creating the increased risk of substandard healthcare outcomes to this patient.

The agency failed to ensure the RN provided supervision to the LVN to ensure quality of care and services provided for two of eight sampled patients (Patients 3 and 4), creating the risk for a substandard healthcare outcome to these patients.

The agency failed to ensure the completed discharge summary was sent to the primary care practitioner after discharge from the HHA within five business days of the discharge date for two of eight sampled patients (Patients 6 and 7), creating the risk of not providing the necessary care and services…