Community Homecare

The agency did not complete a "Transfer OASIS [Outcome and Assessment Information Set]" or a "Resumption of Care OASIS" for one of seven patient (Patient (P) 5) records reviewed.

The agency failed to maintain an effective infection control program.

The agency's Quality Assessment Performance Improvement program (QAPI) did not measure, analyze, or tack adverse patient events or demonstrate surveillance and investigation of infectious and communicable disease.

The agency failed to ensure a Home Health Aide (HHA) performed appropriate hand hygiene when providing care in the home to one of one patient (Patient (P) 2).

The agency failed to develop and maintain a systematic program for the surveillance of infection data or include this information as a part of its Quality Assessment Performance Improvement (QAPI) program in order to identify trends and possible causative factors.

The agency failed to ensure the agency's Corona Virus Disease (COVID) -19 vaccination policy contained all the required content identified in the Center for Medicare and Medicaid Services (CMS) memo QSO-23-02-ALL "Revised Guidance for Staff Vaccination Requirements" dated 10/26/22. The failure to…

The agency did not provide to patients the correct state toll free home health telephone hot line number and hours of operation for complaints or questions about local HHAs.

The agency failed to ensure the Registered Nurse (RN) completed the initial assessment of patient needs within 48 hours of the referral date for four of seven patients (Patients (P) 3, 4, 5, and P6).

The agency failed to ensure two of seven patients (Patients (P2 and P4) and caregivers/representative of these patients were provided with a copy of written information to include visit schedules, and written information of frequency of visits the Home Health agency personnel would be providing.

The agency failed to ensure the frequency of skilled services were being done as per physician orders in the plan of care for two of seven patients (Patients (P) 1 and P6).

The facility failed to update and revise the plan of care for 3 (P# 2,3,4) of 7 patient records reviewed.

The facility failed to have a functional method of coordinating care between the disciplines of service for 7 (P#1-7) of 7 patient records reviewed.

The agency facility failed to have a written quality program that tracks, evaluates, trends or develop improvement projects from quality indicators.

The facility failed to provide their patients with up to date, individualized plans of care (POCs) in a manner consistent with professional standards for 3 (P# 2,3,4) of 7 (P#1-7) patient records reviewed.

The facility failed to integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patients for 2 (P#4 and P#5) of 7 (P#1 through P#7) patients sampled.