Caresense Home Health

The agency failed to ensure the transmittal of OASIS data for two (2) of two (2) CR reviewed for patients eighteen (18) years of age with skilled services.

The agency failed to submit timely documentation of skilled nursing visits, and/or document physician notification and obtain a verbal order to amend frequencies for missed visits for three (3) of seven (7) CR reviewed.

The agency failed to ensure that physician orders were signed within the required timeframe for six (6) of seven (7) CR reviewed.

Agency Manager the agency failed to ensure the services were provided as ordered by the physician for three (3) of seven (7) records reviewed.

Personnel records (PR) and interview with Agency Manager the agency failed to maintain a Childline verification for staff having direct contact with children for one (1) of four (4) records reviewed.

The agency failed to maintain documentation for review/update of the emergency preparedness plan with all required elements annually.

The agency failed to ensure documentation of the facility's efforts to contact local, regional, State, and Federal emergency preparedness officials for 2018-2019. Findings include: Emergency Preparedness Documentation for 2018-2019 was reviewed on October 3, 2019, at approximately 9:00 A.M.

The agency failed to develop an emergency preparedness communication plan.

The agency failed to develop and maintain an emergency preparedness plan training and testing program that was reviewed and updated annually.

The agency failed to ensure that the registered nurse documented that all medications were reviewed at least every 60 days per agency policy for seven (7) of seven (7) CR's reviewed.

The agency failed to maintain documentation data collection.

The agency failed to maintain documentation to demonstrate performance improvement projects conducted annually at the agency.

The agency failed to ensure the "Home Health Certification and Plan of Care (POC) included detailed orders for all care to be provided for four (4) of seven (7) CR reviewed.

The agency failed to ensure the registered nurse (RN) and/or licensed practical nurse (LPN) perform and/or document care provided in accordance with the plan of care for seven (7) of seven (7) clinical records (CR) reviewed.

The agency failed to ensure personnel policies pertaining to staff competency program were documentated for four (4) of eight (8) PF reviewed.