Capitol Care Inc

The agency's clinical staff failed to electronically report all OASIS [(Outcome & Assessment Information Set) data collected for five (5) of five (5) beneficiaries receiving skilled nursing services, (Patients # 14, 15, 16, 17, and 18).

The Home Health Agency failed to ensure that Registered Nurses document complete comprehensive assessment consistent with the patient's immediate needs, within five (5) calendar days after the start of care(G520); failed to document complete comprehensive assessment that reflects the patient’s…

The Home Health Agency failed to ensure that each individualized plan of care included all required elements (G574); failed to include all physician orders in the Plan of Care (576); and failed to coordinate care delivery to meet the patient’s needs (G608).

The Home Health Agency failed to provide skilled professional services directly or under arrangement for ten (10) of 10 patients received wound care, Patients #1, 2, 3, 4, 7, 8, 9, 10, 11, and 12).

The Home Health Agency’s Quality Assessment Performance Improvement (QAPI) program failed to analyze and audit high-risk and high-volume quality data, including OASIS (Outcome & Assessment Information Set)).

The Registered Nurse failed to review and revise the written patient care instructions for home health aides according to the changes in the patient's care needs for one (1) patient, (Patient #1).

The Home Health Agency failed to document a complete comprehensive assessment consistent with the patient's immediate needs, within five (5) calendar days for one (1) of five (5) clinical records, (Patient #1).

The Home Health Agency failed to document complete comprehensive assessment that reflects the patient’s health, psychosocial, functional, cognition for one (1) of five (5) clinical records, for patients receiving non-skilled services, (Patient #1).

The Home Health Agency failed to review of all medications the patient was using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for…

The agency's staff failed to ensure that the patient's Plan of Care was individualized and included all required elements, for one (1) of five (5) clinical records for patients receiving skilled services, (Patients #1 and 12).

The Home Health Agency staff failed to ensure that all patient care orders, including verbal orders, were recorded in the Plan of Care for one (1) of five (5) active clinical records (Patient # 12).

The Home Health Agency failed to coordinate care delivery to meet the patient’s needs for nine (9) of 9 patients who received wound care provided by outside entities, Patients #1, 2, 3, 4, 7, 9,10, 11, and 12).

The Personal Care Aide failed to report changes in the patient’s condition to a Registered Nurse and complete appropriate records timely, in accordance with the agency’s policy for one (1) of one clinical record, (Patient #1).

The Registered Nurse failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice for 11 of 11 patients with wounds, Patients #1, 2, 3, 4, 7, 8, 9, 10, 11, 12, and 13).

The agency's clinician failed to document complete discharge summaries in two (2) of (2) closed clinical records for patients discharged from the agency, (Patients # 5 and 6).