Cass Co Public Health Services

The agency failed to encode and electronically transmit completed Outcome and Assessment Information Set (OASIS) assessments to the Center of Medicare and Medicaid (CMS) system within 30 days of completing the assessment for 4 of 4 (P1, P5, P6, P8) patients reviewed.

The agency failed to update the comprehensive assessment every 60 days for 1 of 4 patients (P1) reviewed for recertification assessments.

The agency failed to ensure a registered nurse completed an initial assessment visit within 48 hours of a referral for home care services for 1 of 7 patients (P5) reviewed.

The agency failed to ensure a comprehensive review of all medications a patient was taking was completed for 1 of 3 patients (P2) whose medications were reviewed during home visits.

The agency failed to complete an updated comprehensive assessment for home care recertification, which included completion of Outcome and Assessment Information Set (OASIS) assessment every 60 days for 1 of 4 patients (P1) reviewed for recertification assessments.

The agency failed to ensure patient's plan of care included all required components in the patient's individualized care plans for 5 of 7 patients (P1, P3, P4, P5, P7) whose care plans were reviewed.

The agency failed to ensure medication changes as ordered were recorded in the patient's plan of care for 1 of 4 patients (P5) whose orders were reviewed.

The agency failed to ensure all services were provided as ordered by patient physician and/or ensure the physician was notified when services were not provided as ordered for 3 of 7 patients (P2, P3, P5) reviewed for home health aide services (HHA).

The agency failed to ensure onsite home health aide (HHA) supervision was completed every fourteen days as required for 1 of 1 patient (P1) reviewed who received HHA services.

The agency failed to ensure discharge summaries contained all required medical information for 2 of 2 patients (P6, P7) reviewed for discharge records.

The agency failed to ensure a comprehensive medication review was completed for 1of 3 patient's (P3) in the sample whose drug regimen was reviewed.

The agency failed to ensure visits were conducted in accordance with physician orders for 5 of 7 patients (P2, P3, P4, P5, and P6) and failed to notify the physician when the visits were not conducted according to the plan of care (POC).

The agency failed to ensure 1 of 7 patients (P6) was informed or consented to services or care being provided including any ongoing changes in services.

The agency failed to ensure 1 of 7 patients (P7) was informed in writing, of the extent of payment from Medicare/Medicaid or the expected out-of-pocket cost to the patient for the services.

The agency failed to develop an abuse prevention policy which included a policy and procedure to ensure immediate (without delay) notification to Minnesota Adult Abuse Reporting Center (MAARC) of suspected and/or potential abuse.

The agency failed to ensure that a comprehensive assessment was updated and revised, including the Outcome and Assessment Information Set (OASIS) data within 48 hours of return from a hospital for 1 of 1 skilled patients (P6) in the sample, who had been hospitalized.

The agency failed to ensure the plan of care (POC) included a description of the risk for emergency department visits and hospital re-admission for 1 of 7 patients (P2).

The agency failed to ensure supervisory visits of home health aides (HHA) were completed every 14 days by a registered nurse (RN) for 1 of 7 patients (P5) reviewed who received skilled services.

The agency failed to ensure direct supervision of the home health aide (HHA) was completed every 60 days for 1 of 1 non-skilled patients (P3) reviewed.

The agency failed to ensure home health aide supervisory note included the core elements as required to be observed and or assessed during a supervisory visit for 2 of 7 patients (P3 and P5) reviewed who received home health aide services.