Denbos Care Services, Inc

The agency failed to update their policies and procedures, ensure initial training and training every 2 years, and annually test their emergency plan.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 5 of 7 (MR# 1, 3, 5, 6, 7) records reviewed, resulting in a delay in determining the immediate care and support needs for these two patients.

The agency failed to ensure plans of care reflected the specific needs of the patients; that services were provided as ordered; physician orders were signed and dated; notify physician of changes in patient's condition; and provide contact information for the agency's Clinical Manager.

The Agency failed to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided (G642); failed to collect and monitor quality indicator data for the Quality Assessment and Performance…

The agency failed to ensure the home health aide received a minimum of 12 in-service hours, was following the orders in the plan of care, received on-site supervision as required, and was annually observed providing patient care in the home.

The agency failed to update their policies and procedures to reflect the alternate location of the incident command center in the event an emergency renders the agency office unusable as part of their emergency preparedness plan, resulting in staff being unprepared in the event of an actual…

The agency failed to ensure staff had initial training and training every 2 years regarding the agency's emergency preparedness policies and procedures, resulting in staff being unprepared in the event of an actual emergency.

The agency failed to conduct exercises to annually test their emergency plan, resulting in staff not being familiar with their roles and responsibilities during an emergency.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 5 of 7 (MR# 1, 3, 5, 6, 7) records reviewed, resulting in a delay in determining the immediate care and support needs for these five patients.

The agency failed to ensure that the comprehensive assessment was updated and revised in 1 of 1 record reviewed (MR#3) in which the patient visited the emergency room due to pain, resulting in the lack of information in determining the care and support needs for this one patient.

The agency failed to ensure services were provided as ordered by the physician for 3 of 7 (MR# 1, 2, 3) records reviewed, resulting in a delay of services and the potential for poor patient outcomes.

The Agency failed to measure, track and analyze its quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided to all 16 patients currently serviced by this agency or it's 64 patients admitted over the last year.

The agency failed to collect and monitor quality indicator data for the Quality Assessment and Performance Improvement program; and failed to ensure the governing body approved the program's frequency and detail of data collection, resulting in the potential for poor patient outcomes for the…

The agency failed to track and analyze adverse events in order to implement preventative actions, which had the potential to negatively affect all 64 patients serviced by the agency in the past 12 months, resulting in the potential for failing to prevent future adverse events.

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2017, 2018 and 2019, resulting in the Agency's inability to…

The Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, addressed priorities for improved quality of care and patient safety and was evaluated for…

The Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for increased…

The agency failed to ensure the home health aide received a minimum of 12 in-service hours in 2019 for 1 of 1 (Aide#1) home health aides employed by the agency for more than 12 months, resulting in a lack of educational opportunities pertinent to patient care for Aide#1. This deficient practice…

The agency failed to ensure 3 of 3 contracts (Contractor# 1, 2, 3) met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that received contracted services.

The agency failed to ensure that at least one qualifying service was provided directly by agency employees for 3 of 3 (Contract# 1, 2, 3) contracts reviewed, resulting in the potential for all services to be provided by contracted staff.

The Agency failed to include contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed concerns for all patients serviced by this agency.

The Agency failed to advise their patients of the names, addresses and telephone numbers of federally funded and state-funded entities that serve the area where the patient resides, resulting in the potential for unmet patient care needs.

The Agency failed to ensure the Registered Nurse conducted the initial assessment visit within 48 hours of referral to determine the immediate care and support needs of the patent including homebound status and eligibility for the Medicare home health benefit for 1 (MR# 4) of 7 records in which…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 4 records (MR's #2, 4, 5, 6) from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all 16…

The agency failed to ensure the comprehensive assessment accurately reflected the primary caregivers willingness, ability, and availability to provide care for 1 of 2 patients (MR#1) assessed as needing assistance with activities of daily living, resulting in the potential for poor hygiene…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 1 (MR #5) record of a patient with a diagnosis of Heart Failure, from a total of 7 sampled records reviewed…

The agency failed to ensure Physician's orders were complete, signed, authenticated and dated by the Physician for 1 (MR# 4) of 1 patient who was resumed for care post hospitalization and re-certified for additional services, from a total of 7 records reviewed, resulting in the provision of…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 of 1 record reviewed (MR#3) in which the patient requested something for pain, resulting in a poor patient outcome for this patient.

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure occupational therapists, speech therapists, and medical social workers assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 3 of 7 (MR# 1, 2, 3) records reviewed, resulting in the potential for decline in…

The Agency failed to ensure Occupational Therapy and Physical Therapy services were provided for 1 (MR #4) of 4 records with Occupational Therapy and Physical Therapy services ordered; and failed to ensure the Registered Nurse followed the plan of care during a home visit for 1 (MR #6) of 7 patient…

The Agency failed to ensure the clinical record was completed and included detailed Skilled Nursing notes for 2 (MR #5, 6) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient…

The agency failed to ensure the home health aide provided care in accordance with the plan of care for 1 of 1 (MR#3) patients in which aide services were provided, resulting in no monitoring of vital signs and unmet care needs for this one patient.

The agency failed to ensure on-site supervisory visits to the patient's home were made at least every 14-days in order to supervise the care provided by the home health aide for 1 of 1 (MR#3) record reviewed in which aide services were provided for a period of time greater than 2 weeks, resulting…

The agency failed to ensure the skilled professional made an annual onsite joint visit at the patient's residence to observe the care being provided by the home health aide, for 1 of 1 (Aide#1) aides employed by the agency for more than one year, resulting in a lack of oversight and the potential…

The agency failed to ensure the contract for services under arrangement specified the home health agency must maintain overall responsibility for the services provided under arrangement for 1 of 3 (Contract #3) contracts reviewed, resulting in a lack of agency responsibility for the care provided.

The agency failed to ensure that home health aide visit notes were completed and included in the clinical record for 1 of 1 (MR#3) records reviewed in which aide services were provided, resulting in the physician not having a clear and concise clinical picture of the patient's health status and…

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 2 of 2 (MR#3, 7) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status at…