Cas Home Health Care

The agency failed to provide documentation that the emergency preparedness plan was reviewed and updated every two (2) years nor that a documented, facility-based and community-based risk assessment was completed.

The agency failed to demonstrate that the emergency preparedness communication plan included the Names and Contact Information for the following: Staff, Entities providing services under arrangement, Patients' physicians and Volunteers.

The agency failed to demonstrate that initial training in emergency preparedness policies and procedures was provided to newly hired employees.

The agency failed to provide evidence that the emergency preparedness plan was tested annually.

The agency failed to provide the patient and the patient's representative with information regarding the processes by which patient transfer and discharge can occur.

The agency failed to ensure that the CMS-485 Home Health Certification and Plan of Care (POC) was signed by the physician within 30 days, per agency policy, for four (4) of seven (7) CR's reviewed: CR#1, CR#2, CR#3, and CR#4. Findings Include: A review of the Physician Orders for Consumer Policy…

The agency failed to provide care according to the CMS-485 Home Health Certification and Plan of Care (POC) for six (6) of seven (7) CR reviewed: CR#1, CR#2, CR#4, CR#5, CR#6, and CR#7. Findings include: A review of the following policies was conducted on March 1, 2023 at approximately 2:30 PM…

The agency failed to follow its policy pertaining to infection control for one (1) of three (3) clinical home visits conducted: CR#4. Findings include: A review of the Care and Handling of Equipment Policy 5.90 conducted on March 1, 2023 at 10:00 AM reads in part, “Items that come in contact with…

The agency failed to provide Infection control education to staff at orientation, annually, and as needed to meet the staff's learning needs to provide adequate care; identify infection signs and symptoms; identify routes of infection transmission; appropriately disinfect/sanitize/transport…

The agency failed to show evidence of a Coronavirus (COVID-19) staff vaccination policy, and failed to provide documentation related to the vaccination or exemption status for individuals who provide care, treatment or other services to patients for four (4) of eight (8) personnel files reviewed…

The agency failed to provide the patient with the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center…

The agency did not demonstrate that a registered nurse conducted an initial assessment visit within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner-ordered start of care for three (3) of seven (7) records reviewed: CR#1, CR#2, and…

The agency failed to complete a comprehensive assessment within five (5) days of the end of the certification period for three (3) of seven (7) CR's reviewed: CR#3, CR#4, and CR#7. Findings include: A review of the following policies was conducted on March 1, 2023 starting at 12:00 PM: Consumer…

The agency failed to demonstrate the presence of the following: initial competency assessment for four (4) of eight (8) files reviewed: PF#1, PF#2, PF#3, and PF#6; annual competency assessment for one (1) of eight (8) files reviewed: PF#8; annual performance evaluation for one (1) of eight (8)…

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

The facility failed to ensure the emergency preparedness plan included the names and contact information for agency staff.

The agency failed to conduct an exercise to test the emergency plan at least annually.

Staff (EMP) the Agency failed to obtain a physician signature on the plan of care within 30 days and per agency policy for three (3) of eight (8) Clinical Records reviewed.

Agency failed to utilize quality indicator data, including measures derived from OASIS (The Outcome and Assessment Information Set), where applicable, and other relevant data, in the design of its program; failed to use the data to- (i) monitor the effectiveness and safety of services and quality…

A Registered Nurse did not follow standard precautions regarding infection control to prevent possible transmission of infection for one (1) of two (2) clinical visits conducted (CR # 7).

The agency failed to administer at least 12 hours of in-services to the Home Health Aides for four(4) of four (4) Home health Aides reviewed reviewed.

The agency failed to ensure a CLIA waiver was obtained prior to drawing blood glucose levels for diagnostic purposes.

The agency failed to conduct the initial visit in forty eight (48) hours of the referral for two (2) of six (6) Clinical Records (CR) reviewed.

The facility failed to ensure that the registered nurse checked all medications 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 and…

The agency failed to complete a comprehensive assessment within five (5) days of the end of the certification period for four (4) of eight (8) CR reviewed.

The agency failed to ensure that any changes to patient's treatments and/or services were documented in clinical record and that a verbal order was obtained for four (4) out of seven (7) clinical records (CR # 1, 3, 6 & 8) . Findings include: Review of policies occurred on 3/12/20 at approximately…

The agency failed to follow their policy and ensure home health aide training of at least 75 hours of classroom instruction for three (3) of four (3) Home Health Aides Personnel Files (PF) (PFs #1, 9 & 11) Findings include: Review of Home Health Aide Job description on 3/12/20 at approximately…

The agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control guidelines for four (4) of eleven (11) personnel files reviewed.