Cosmopolitan Healthcare Inc

The home health agency (HHA) failed to ensure the emergency preparedness plan/drill for field and office staffs were completed in an annual basis.

The agency staff failed to ensure care followed the written plan of care for one of seven sampled patients (Patient 4) with an open wound at left lower leg.

Based an interview, and record review, the home health agency failed to ensure an ongoing quarterly Quality Assessment and Performance Improvement( QAPI) projects.

The hospice agency failed to follow the accepted standards of practice including the use of standard precautions to prevent spread of COVID-19 infection (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) for one of seven patients…

The agency staff failed to review all medications the patient is currently using for three of seven patients (Patients 1, 2 and 4 ).

The home health agency (HHA) failed to follow the written plan of care (POC) for one of seven patients (Patient 4).

This Condition of Participation is not met as evidenced by: Based on record review, observation and interview, the Home Health agency failed to: G514: Conduct a full comprehensive assessment within the required timeframe.

This Condition of Participation is not met as evidenced by: Based on observation, interview, and record review, the Home Health agency failed to: G572: Develop a plan of care.

This Condition of Participation is not met as evidenced by: Based on record review and interview, the Home Health agency failed to: G642: Develop, implement, evaluate, and maintain an ongoing agency-wide data-driven Quality Assessment/Performance Improvement (QAPI) program that measures, analyzes…

This Condition of Participation is not met as evidenced by: Based on record review, observation, and interview, the Home Health agency failed to: G682: Ensure staff followed the infection control and prevention principles and procedures when providing care to patients.

This Condition of Participation is not met as evidenced by: Based on record review, observation, and interview, the Home Health agency failed to: G958: Ensure the Director of Patient Care Services provided oversight of patient care services, clinical operations, and agency personnel.

The Agency failed to develop a plan of care (POC) for one of seven sampled patients (Patient 4).

The Home Health Agency (HHA) failed to: obtain: 1. Obtain a physician prescribed order for culture and sensitivity test ( C/S-test to identify presence of microorganisms (bacteria or fungus) in the wound that can cause an infection and antibiotics/medications the microorganism is sentivity to) and…

The Home Health agency (HHA) failed to develop, implement, evaluate, and maintain an ongoing, agency-wide, data-driven Quality Assessment/Performance Improvement (QAPI) program that measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance.

The Home Health agency (HHA) failed to ensure staff followed the infection control and prevention principles and procedures when providing care to three of three observed sampled patients (Patients 1, 2, and 3).

The facility failed to develop, implement, and maintain an ongoing agency-wide Infection Control program and failed to integrate such program into the Quality Assessment and Performance Improvement (QAPI) program.

The Home Health agency (HHA) failed provide Infection Control and Prevention education to staff.

The Home Health agency (HHA) failed to ensure the Director of Patient Care Services (Adm 6) provided oversight of patient care services for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7), clinical operations, and agency personnel.

Authentication

The home health agency (HHA) failed to ensure seven of seven sample patient's clinical records (Patient 1, 2, 3, 4, 5, 6 and 7), and any additional patients records housed in the agency were protected from illegal access or use.

The agency failed to ensure a complete initial assessment was conducted within 48 hours of the referral date, or within 48 hours or on the physician-ordered start of care date, for one of seven sampled patients (Patient 4) . The failure had the potential for a delay in the delivery Patient 4's…

The Home Health Agency (HHA) failed to ensure a comprehensive assessment (Recertification OASIS) for one of seven sampled patients (Patient 2) was complete to reflect the full status or condition of the patient.

The facility failed to review and identify all medications currently taken by two of three observed sampled patients (Patients 1 and 2).

The home health agency (HHA) failed to ensure a discharge summary was completed to include an assessment of the patient and coordinated with the responsible health care providers within five business days for one of two sampled discharged patients (Patient 7).

The Home Health agency (HHA) failed to ensure a plan of care (POC) for one of seven sampled patients (Patient 3) contained the required patient education and training.

The Home Health agency (HHA) failed to ensure the plans of care (POCs) for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7) contained the current physicians' orders.

The Home Health agency (HHA) failed to: 1. Ensure a physician's order was followed during provision of wound care treatment to one of seven sampled patients (Patient 1).

The Home Health agency (HHA) failed to update the plan of care (POC) with accurate and complete physician's orders received during the Resumption of Care (ROC - upon return to HHA services after hospitalization) for one of seven sampled patients (Patient 1).

The Home Health Agency (HHA) failed to provide the current written medication regimen instructions to three of three observed sampled patients (Patients 1, 2, and 3).

The Home Health agency (HHA) failed to ensure skilled professionals provided care and services in accordance with the plan of care (POC) for five of seven sampled patients (Patients 1, 2, 3, 6, and 7).

The Home Health agency (HHA) failed to ensure patients and care givers were provided education on : 1.Blood sugar testing (the concentration of glucose in the blood) and newly placed gastrostomy tube management (G-tube - inserted through the abdomen that delivers nutrition directly to the stomach)…

The HHA failed to coordinate in a timely manner a social worker referral for professional services for one of seven patients receiving therapy services (Patient 5).

The agency failed to ensure that the records were maintained with complete and accurate information for one of seven sampled patients (Patient 6).

The home health agency (HHA) failed to ensure a discharge summary was complete to include an assessment of the patient and sent to the responsible health care providers within five business days for one of two sampled discharged patients (Patient 7).