Care Solutions

The Agency failed to ensure a system for the completion and electronic submission of Outcome Assessment and Information Set (OASIS) date collected within the required timeframe's.

The Agency failed to ensure patient's or the patient's representatives were informed of their rights and responsibilities.

The Agency failed to ensure each patient received a patient specific comprehensive assessment.

The Agency failed to ensure the Plan of Care was individualized, identified care and services necessary to meet the patient's needs, was revised accordingly and care/services were coordinated between all caregivers.

The Agency failed to develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide Quality Assessment Performance Improvement (QAPI) program to analyze, measure and track measurable quality indicators to determine the effectiveness of the Agency's care and services.

For 1 of 1 (Home Health Aide- HHA#1) Aide, the Agency failed to ensure HHA services were provided and supervised, in accordance with the physician ordered Plan of Care, by individuals who have met the annual education requirements.

The Governing Body and Administrative staff failed to effectively organize, manage, and maintain Agency resources to maintain a functional Agency to ensure the provision of safe, effective, ongoing patient care provided in accordance with accurate physician ordered plans of care to promote positive…

The Agency failed to ensure information within the clinical record was accurate, adhered to documentation standards of practice, and were retrievable upon request.

For 5 of 5 (Pt #1, Pt #2, Pt #3, Pt #5, Pt #6) Medicare beneficiaries, the Agency failed to electronically submit the completed Outcome Assessment and Information Set (OASIS) data to the Centers for Medicare and Medicaid (CMS) system within 30 days of completing the assessment.

In 4 of 6 (Pt #1, Pt #3, Pt #5, Pt #6) patients records reviewed, the Agency failed to complete all requirements of the comprehensive assessment, which accurately reflects the patient's status.

The Governing Body failed to develop, implement, evaluate, and maintain an Agency-wide, ongoing Quality Assessment Performance Improvement (QAPI) program to analyze, measure and track measurable quality indicators to determine the effectiveness of the Agency's care and services.

The Agency failed to ensure the single patient use blood glucose monitoring device was not used for multiple patient use, in accordance with accepted practices and manufacturer guidelines.

For 6 of 6 (E#2, E#4, E#5, E#6, E#7, and Home Health Aide-HHA#1) staff, the Governing Body failed to ensure ongoing annual infection control training, in accordance with its policy.

For 1 of 1 (Home Health Aide- HHA#1) Home Health Aide, the Agency failed to ensure the completion of 12 hours of in-service training each 12 month period.

In 1 of 1 (Pt #2) patient record reviewed, who received Home Health Aide services, the Agency failed to ensure a Home Health Aide Care Plan was completed and appropriate.

The Governing Body failed to ensure overall management of the Agency was clearly defined in its organizational chart.

The Governing Body failed to designate a qualified person to provide oversight of patient care in the absence of the Agency Supervisor, in accordance with its' policy.

The Governing Body failed to ensure an annual preparation, review, and revision of an annual operating budget and capital expenditure plan.

For 6 of 6 (Pt #1, Pt #2, Pt #3, Pt #4, Pt #5, Pt #6) patients records reviewed, the Agency failed to ensure patient's records were completed, accurate, legible and appropriately authenticated, dated and timed.

The Governing Body failed to ensure the accuracy of Administrator contact information presented to patients during the admission process.

In 2 of 6 (Pt #4, Pt #6) patients records reviewed, the Agency failed to ensure the patient or patient's legal representative received a written OASIS (Outcomes and Assessments Information Set) privacy notice.

In 2 of 6 (Pt #4, Pt #6) patients records reviewed, the Agency failed to obtain the patient or patient's legal representative's signature confirming receipt of the notice of rights and responsibilities.

In 6 of 6 (Pt #1, Pt #2, Pt #3, Pt #4, Pt #5, Pt #6) patients records reviewed, the Agency failed to provide written notice of the Agency's transfer and discharge policies.

In 2 of 6 (Pt #4, Pt #6) patients records reviewed, the Agency failed to ensure the patient or patient's representative participated in and consented to the services to be provided by the Agency.

In 6 of 6 (Pt #1, Pt #2, Pt #3, Pt #4, Pt #5, Pt #6) patients records reviewed, the Agency failed to advice the patient or patient's representative of the expected payment for services covered by insurance or expected charges for non-covered services.

In 4 of 6 (Pt #1, Pt #2, Pt #4, Pt #6) patients records reviewed, the Agency failed to complete the Medication Profile of all medications the patient is currently using, in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side…

In 1 of 1 (Pt #6) patient record reviewed, who received services greater than 60 days, the Agency failed to ensure an updated comprehensive assessment was conducted within the last 5 days of certification period.

In 6 of 6 (Pt #1, Pt #2, Pt #3, Pt #4, Pt #5, Pt #6) patients records reviewed, the Agency failed to document the patient's risk for emergency department visits and/or hospital readmission.

In 1 of 1 (Pt #6) patient record reviewed, the Agency failed to ensure patient care orders were recorded in the plan of care.

In 5 of 6 (Pt #1, Pt #2, Pt #3, Pt #5, Pt #6) patients records reviewed, the Agency failed to ensure verbal orders were "read back" and authenticated and dated by the physician in a timely manner.

In 1 of 1 (Pt #6) patient record reviewed, who received services greater than 60 days, the Agency failed to ensure the Plan of Care was revised by the physician who is responsible for the home health plan of care within 60 days.

In 1 of 1 (Pt #1) patient record reviewed, who had a change in condition, the Agency failed to notify the physician for a change in condition.

In 2 of 2 (Pt #1, Pt #6) patients record reviewed with missed visits, the Agency failed to ensure care activities were communicated and coordinated with the care providers.

The Agency failed to ensure the accuracy of Agency Supervisor's contact information, presented to patients during the admission process.

In 1 of 1 (Pt #2) patient record reviewed, who received Home Health Aide services, the Agency failed to ensure the Home Health Aide (HHA) provided services per the Plan of Care.

In 1 of 1 (Pt #2) patient record reviewed, who received Home Health Aide (HHA) services greater than 14 days, the Agency failed to ensure HHA supervision was conducted at least every 14 days.

The Administrator failed to ensure an Agency Supervisor was available during all operating hours.

For 1 of 3 (E#7) therapy providers, who had provided therapy services within the last 2 years, the Administrator failed to ensure annual performance and competency evaluations were conducted, in accordance with its' policy.

The Agency Supervisor failed to ensure effective coordination of care and services between disciplines.

The Governing Body failed to ensure public information accurately reflected the service areas and office locations, approved by the State Agency, for the provision of services.

For 5 of 5 (Pt #2, Pt #3, Pt #4, Pt #5, Pt #6) patients records reviewed who were discharged, the Agency failed to complete discharge summaries.