Allegiance Home Health of Southeast Louisiana

The agency failed to ensure the Outcome and Assessment Information Sets (OASIS) were successfully completed and transmitted within 30 days of completion for 5 (Patient #1, Patient #3, Patient #R9, Patient #R10, Patient #R11) of 13 OASIS Assessments reviewed for timely submission.

The agency failed to ensure occupational therapy services were provided per physician orders for 1(Patient #3) of 1 patient reviewed for occupational therapy services as ordered.

The agency failed to have a plan and policy in place related to integration of volunteers during activation of the agency’s Emergency Plan.

The agency failed to follow a patient’s plan of care by failing to initiate a Physical Therapy (PT) evaluation as ordered.

The agency failed to ensure the Registered Nurse (RN): 1. Changed her gloves and used hand hygiene between dirty and clean procedures; 2. Did not clean multiple wounds and intact skin with the same gauze; 3. Did not place a soiled dressing on the patient’s floor of the home; and 4. Properly cleaned…

The agency failed to ensure there was coordinated system for the collection of infection control data which included all infections for the Quality Assessment Performance Improvement (QAPI) committee to review.

The agency failed to ensure an accurate medication reconciliation was completed for 1 of 3 sampled patients (Patient #1) observed during home visits in a total sample of 7 patients.

The agency failed to coordinate with a patient’s physician regarding a referral for MSW (Medical Social Worker) services when the agency did not have MSW services available for 1 (Patient #4) of 2 patients sampled with MSW referral orders.

The Home Health Agency failed to meet the requirements of the Condition of Participation: Quality Assessment and Performance Improvement (QAPI) by failing to develop, implement, evaluate, and maintain an effective, ongoing, Home Health Agency-wide, data-driven QAPI program.

The agency failed to conform with physician orders by failing to ensure the following: 1. Skilled Nurse (SN) visits were provided as ordered for 2 (#1, #3) of 8 (#1-#8) sampled patients reviewed who had SN visits ordered; and 2. Therapy services were provided as ordered for 1 (#3) of 3 (#3, #5, #7)…

The agency failed to have documentation of a QAPI program capable of showing measurable improvement in indicators for which there was evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The home health agency failed to utilize OASIS and other relevant data in design of its QAPI program to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement.

The agency failed to have documentation of performance improvement activities to track adverse patient events, analyze their causes, and implement preventive actions.

The home health agency failed to have documentation of quality improvement projects and measurable progress to achieve those projects.

The agency failed to ensure the Home Health Agency's governing body: 1.) conducted ongoing monitoring of the agency's QAPI program for quality improvement and patient safety; 2.) implemented agency-wide quality assessments and performance improvement efforts to address priorities for improved…

The agency failed to ensure verbal orders were authenticated and dated by the physician in accordance with applicable state laws and regulations for 7 (#1, #2, #3, #4, #5, #7, #8) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) patients reviewed.

The agency failed to ensure any revision of the plan of care due to a change in patient health status was communicated to the physician for 1 (#7) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) patients reviewed.

The agency failed to coordinate care delivery to meet the patient's needs for 1 (#4) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) patients reviewed.

The agency failed to ensure a registered nurse, who was familiar with the patient and the patient's plan of care, made an onsite visit to the patient's home no less than every 14 days for aide supervisory visits for 1 (#1) of 4 (#1, #4, #5, and #7) sampled patient's with Home Health Aide Services…

The agency failed to ensure a registered nurse made an annual on-site visit to the location where a patient was receiving care in order to observe and assess 1 of 1 (S7CNA) aide, who had been employed with the agency for greater than 12 months, perform patient care.

The agency failed to ensure the patients' clinical record contained all clinical notes for 4 (#5, #6, #7, #8) of 8 (#1 #2, #3, #4, #5, #6, #7, #8) patients reviewed.

The agency's skilled professionals failed to deliver services and practice according to the HHA's policies and procedures for 1 (#1) of 5 (#1 - #5) sampled patients.

The agency failed to meet the patient's needs for home health aide services and ostomy supplies for 1 (#1) of 5 (#1 - #5) sampled patients.

The agency failed to ensure the individualized plan of care included all pertinent diagnoses and the services required for 1 (#1) of 5 (#1 - #5) sampled patients as evidenced by: (1) Patient #1 had a diagnosis of Colostomy and the patient's POC (Plan of Care) did not include an order for the…

The agency failed to coordinate care delivery to meet the patient's needs for 1 (#5) of 5 (#1 - #5) sampled patients as evidenced by failing to ensure the agency received wound care clinic orders and communicate with Patient #5's physician.

The agency failed to ensure each patient and his or her caregiver received education and training regarding the care and services identified in the plan of care for 1 (#1) of 5 (#1 - #5) sampled patients reviewed for care and services.

The agency failed to provide services that were ordered by the physician as indicated in the plan of care for 1 (#1) of 5 (#1 - #5) sampled patients.