Advisacare Solutions of Kalamazoo

The Agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the start of care in 1 (P-10) of 17 records reviewed (see G520); failed to ensure the comprehensive assessment accurately reflected the patient's health status and included diagnoses in 1 (P-8) of 1…

The Agency failed to ensure that each patient receive home health services that are written in an individualized plan of care per agency policy in 2 (P-5 and P-8) of 17 sample records reviewed (See G572); failed to ensure the Plan of Care (POC) included measurable outcomes and goals for skilled…

The agency failed to follow accepted standards of practice for infection control in 4 (P-2, P-6, P-7, and P-11) of 7 records reviewed with home visits (See G682); failed to analyze data collected used to monitor infection control measures among patients identified within its Quality Assessment and…

The agency failed to ensure physical therapy (PT) responsibly assessed, performed pertinent interventions and communicated urgent patient needs in 1 (P-13) of 11 records reviewed with therapy services, from a total sample of 17 records reviewed, resulting in a poor clinical outcome (see G 704)…

The agency failed to ensure that 1 of 8 Certified Occupational Therapy Assistant (COTA), who was granted clinical privileges, maintained an active and current license to provide care, resulting in the potential for unsafe care and unmet care needs for the 18 patients serviced by this employee.

The Agency failed to provide documentation that it had participated in the community based full-scale exercise required every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency.

The agency failed to ensure that each patient receive home health services that are written in an individualized plan of care per agency policy in 2 (P-5 and P-8) of 17 sample records reviewed resulting in a delay in identifying patient specific measurable outcome and goals and progress toward them.

The Agency failed to analyze data collected to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the Quality Assessment and Performance Improvement (QAPI) program, resulting in a potential to negatively affect all 1079 patients serviced…

The agency failed to follow accepted standards of practice for infection control in 4 (P-2, P-6, P-7, and P-11) of 7 records reviewed with home visits, resulting in the potential for transmission of infections and communicable disease.

The Agency failed to analyze data collected used to monitor infection control measures among patients identified within its Quality Assessment and Performance Improvement (QAPI) program and failed to incorporate a means to track and trend staff acquired infections, resulting in the potential spread…

The agency failed to provide documented evidence of infection control education for 7 of 12 sampled staff members including those employed through an arranged contract which has the potential to negatively impact the safety and well-being of all 1079 patients serviced by the agency in the past 12…

The Agency failed to ensure physical therapy (PT) responsibly assessed, performed pertinent interventions and communicated urgent patient needs in 1 (P-13) of 11 records reviewed with therapy services, from a total sample of 17 records reviewed, resulting in a poor clinical outcome.

The agency failed to ensure that clinical records were safeguarded against unauthorized use, resulting in the potential compromise of protected health information for all patients served by this agency.

The agency failed to ensure that 1 of 8 Certified Occupational Therapy Assistants (COTA), who was granted clinical privileges, maintained an active and current license to provide care, resulting in the potential for unsafe care and unmet care needs for the 18 patients serviced by this employee.

The Agency failed to ensure the patient/caregiver were able to participate in the choice of accepting all health care disciplines ordered on the referral for home care in 1 (P-14) of 1 record reviewed with ordered social work services, failed to offer home health aide services when ordered in 3…

The agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the start of care in 1 (P-10) of 17 records reviewed, resulting in a delay in determining the immediate care and support needs for this patient.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's health status and included diagnoses in 1 (P-8) of 1 sample records reviewed for which therapy was the only service ordered by the physician; and failed to ensure the comprehensive assessment incorporated…

The Agency failed to ensure clinicians included a review of all medications during the comprehensive assessment in order to identify any potential adverse effects and drug reactions in 5 (P-8, P-9, P-10, P-11, and P-12) of 17 sample records reviewed, and failed to perform a medication…

The agency failed to ensure the comprehensive assessment was updated after hospital discharge and return to the same home health agency for 1 (P-10) of 3 records reviewed in which the patient was transferred, resulting in the potential for unmet care needs and an inaccurate reflection of the…

The Agency failed to ensure the Plan of Care (POC) included measurable outcomes and goals for skilled nursing, and reportable parameters in 15 (P-1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 15, 16, 17) of 16 total records reviewed with skilled nursing services, and failed to ensure therapy services…

The agency failed to ensure treatment was provided only as ordered by the physician in 1 (P-6) of 17 sample records resulting in the potential to negatively affect the health and well-being of this patient.

The Agency failed to ensure the physician was notified of changes in the patient's condition in 2 (P-3, 13) of 11 records reviewed with therapy services, resulting in a poor clinical outcome, and weight gain in 1 (P-3) of 6 patients with congestive heart failure, from a total sample of 17 records…

The agency failed to ensure the clinical record was complete and included detailed notes for 3 (P-1, 3, 11) of 17 records reviewed, resulting in lack of continuity of care and undocumented health concerns.

The agency failed to ensure skilled nursing communicated assessment findings with the physician for 1 (P-9) of 17 records reviewed, resulting in the potential for poor patient outcomes.

The agency failed to secure Clinical Laboratory Improvement Amendments (CLIA) waivers for referral specimen laboratory testing as required while engaging in offsite testing.

The agency failed to ensure clinical manager oversight of coordinating patient care services and personnel for 1 (P-10) of 17 records reviewed, resulting in the potential for inappropriate care and unmet care needs.

The agency failed to ensure the Clinical Manager coordinated services that were ordered on the referral form in 1 (P-5) of 17 sample records reviewed resulting in omission of care by therapy services and potential decline in function of this patient.

The agency failed to ensure the clinical record contained completed assessments and visit notes for 5 (P-1, 2, 3, 4, 10) of 17 records reviewed, resulting in a lack of information for the physician and all agency staff caring for the patient.

The agency failed to ensure a discharge summary was complete, provided the patient's health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 4 (P-1, 3, 6, 9) of 5 closed records; and failed to ensure the transfer summary was…

The agency failed to ensure visit frequencies were provided only as ordered by the physician for 2 (P-2 and 3) of 10 records reviewed, resulting in the potential for the provision of inappropriate care and services.

The Agency failed to ensure a discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals in 1 (P-1) of 1 closed record, from a total of 10 records reviewed, resulting in the potential for unidentified continuing health care concerns…

The Agency failed to provide care and services, in accordance with the visit frequency, for one (P-1) of one patient who experienced high risk pregnancy with uncontrolled vomiting and dehydration, from a total of two sampled patients reviewed, resulting in the patient not receiving care based on…

The Agency failed to ensure the Registered Nurse was competent to perform ordered tasks for one (P-1) of 1 patient who required Infusion Therapy, from a total of two sampled records reviewed, resulting in the potential for ineffective medication administration and decline in physiological…

The agency failed to ensure the Plan of Care included physician orders to provide wound care by skilled nursing, and failed to include pertinent interventions with reportable parameters concerning diabetes management in 1 (MR#1) record, from a total of 3 sampled records reviewed (See G 574); and…

The Agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 1 (MR #1) record, from a total of 3 sampled records reviewed, resulting in incomplete clinical information and the potential for a poor clinical outcome.

The agency failed to ensure the Plan of Care (POC) included physician orders which approved wound care provided by skilled nursing and failed to include pertinent interventions with reportable parameters concerning diabetes management in 1 (MR#1) record, from a total of 3 sampled records reviewed…

The agency failed to ensure the physician was promptly notified of a significant change in condition concerning the following: development of a pressure ulcer, excessive weight gain with congestive heart failure, and elevated blood sugar readings with no reportable parameters for 1 (MR#1) record…

The agency failed to inform the patient in advance of the disciplines that will furnish care in 3 records reviewed (MR# 14, 15, 16) from a total sample of 17 records reviewed, resulting in the patient not having knowledge of the plan for treatment and potential unmet care needs.

The agency failed to inform the patient/caregiver before care was initiated of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient in 14 of 17 records reviewed (MR#s 1…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 16…

The agency failed to ensure the medical record contained documentation of a complete drug regime review and the findings of such review in 5 of 17 records reviewed of a total sample of 17 records reviewed (MR # 6, 7, 8, 9, 16).

It was noted that the agency failed to include safety precautions for this patient's diagnosis of diabetes.

The agency failed to ensure services were provided only as ordered by the physician in 3 of 17 (MR #12, 14, 17) records reviewed, resulting in the potential for the provision of inappropriate care and services.

The skilled nurse failed to document the patient's weight each visit as ordered.

The agency failed to have an accurate address on the Plan of Care to determine the actual address that home care services are provided for 2 of 7 patients (MR#s 4 and 6) with planned home visits.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 4 of 5 (MR#s 1, 2, 10, 12) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health…

The agency failed to ensure the emergency plan was based on both a facility-based and community based hazards risk assessment affecting 42 of 42 patients served by the agency in the past 12 months, resulting in the potential for being unprepared to respond in the event of an emergency.

The agency failed to ensure all staff received training on the emergency preparedness plan, the risk assessment, policies and procedures, and the communication plan affecting 42 of 42 patients served by the agency in the past 12 months, resulting in the potential for staff being unprepared to…

The agency failed to perform testing of their emergency preparedness program as required affecting 42 of 42 patients served by the agency in the past 12 months, resulting in the potential for being unprepared to respond in the event of an actual emergency.

The agency failed to ensure the Quality Assessment Performance Improvement (QAPI) program demonstrated measurable improvement in quality of care indicators by measuring, analyzing and tracking quality indicators for patient care which had the potential to affect 5 of 5 active patients out of a…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status and included the events leading to current home care needs in 5 of 7 records reviewed (MR# 1, 2, 3, 4 and 5), from a total sample of 7 records reviewed, resulting in incomplete clinical…

The agency failed to ensure the plan of care included patient specific interventions related to identified needs in 5 of 7 records reviewed (MR #1, 2, 3, 4 and 5) out of a total sample of 7 records reviewed, which resulted in the potential for unmet patient needs.

The agency failed to ensure coordination of care occurred to ensure patient needs were identified and communicated to the appropriate professional and the physician in 1 of 7 records reviewed out of a total sample of 7 records reviewed (MR #3), resulting in potential for decline in the patient's…

The agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status including, pain management activities, wound care procedures and blood pressure in 3 of 7 records reviewed in which nursing services were provided out of a total sample…

The agency failed to ensure services were provided as ordered in the plan of care in 2 of 7 records reviewed out of a total sample of 7 records reviewed (MR #1 and 4), resulting in the potential for negative patient outcomes for patients with diabetes or open wounds.