Direct Care Home Health Services LLC

The agency's clinical staff failed to electronically report all OASIS [(Outcome & Assessment Information Set) data collected for five (5) of five (5) beneficiaries receiving skilled nursing services, (Patients # 1, 2, 3, 4 and 5).

The Home Health Agency failed to ensure the registered nurse conducted an effective initial assessment visit (G514); failed to provide comprehensive assessments that were complete; failed to document complete comprehensive assessment consistent with the patient's immediate needs, no later than five…

The Home Health Agency failed to ensure that each individualized plan of care included all required elements (G574), failed to follow the physician’s orders for frequency and duration of skilled nursing services in accordance with the plan of care (G580); and failed to coordinate care delivery to…

The agency's staff consistently failed to electronically transmit completed OASIS assessments directly to the CMS system, within the timely guidelines of 30 days of completing each beneficiary’s assessments, for four (4) of four (4) submitted assessment records, for the time periods of 01/21/2023…

The agency's clinical staff failed to encode OASIS (Outcome and Assessment Information Set) data that accurately reflect the patient's status at the time of assessment for one (1) of ten (10) clinical records, (Patient #1).

The Home Health Agency failed to maintain complete and accurate records reflecting the specific skilled nursing services provided as evidenced by failure to ensure the LPN (Licensed Practical Nurse) recorded clinical notes for one (1) of five (5) clinical records for patients receiving skilled…

The Home Health Agency failed to provide the patient’s caregiver the following information during the initial evaluation visit, in advance of furnishing care for one (1) of one (1) patient, (Patient #1).

The Home Health Agency failed to ensure the registered nurse conducted an effective initial assessment visit to determine the immediate care and support needs of the patient for one (1) of five (5) clinical records for patients receiving skilled services, (Patient #1).

The Home Health Agency failed to document a complete comprehensive assessment consistent with the patient's immediate needs, no later than five (5) calendar days after the start of care for one (1) of five (5) clinical records, (Patient #1).

The Home Health Agency failed to provide a complete comprehensive assessment that accurately reflected the patient's status for one (1) of five (5) clinical records, for patients receiving skilled services, (Patient #1).

The Home Health Agency failed to review of all medications the patient was using 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 for…

The agency's staff failed to ensure that the patient's Plan of Care was individualized and included all required elements, for one (1) of five (5) clinical records for patients receiving skilled services, (Patient #1).

The Home Health Agency failed to follow the physician’s for frequency and duration of skilled nursing services in accordance with the plan of care for one (1) patient, (Patient #1).

The Home Health Agency failed to coordinate care delivery to meet the patient’s needs for one (1) of five (5) clinical records, for patients receiving skilled services, (Patient #1).

Agency staff failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice in one (1) of 10 clinical records (Patient # 8).

The Home Health Agency failed to update comprehensive assessments at discharge for one (1) of three (3) clinical records for discharged patients, (Patient #10).

The agency's clinical staff failed to conduct a patient-specific comprehensive assessment in one (1) of 10 clinical records (Patient #4).

The agency's staff failed to ensure that patients' Plans of Care were individualized and included all required elements in four (4) of 10 clinical records (Patients #1, 4, 7, and 8).

Agency staff failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice in two (2) of 10 clinical records (Patient #1 and 4).

The agency's clinician failed to document complete discharge summaries in three (3) of four (4) closed clinical records for patients discharged from the agency (Patients #2, 6, and 10).

The Home Health Agency failed to electronically report all OASIS [(Outcome & Assessment Information Set) data collected for six (6) of 11 Medicaid beneficiaries receiving skilled services (Patients # 1, 2, 4, 6, 9, and 10).

1. Based on review of the CMS (Centers for Medicare and Medicaid Services) Submission Report, OASIS (Outcome & Assessment Information Set) Agency Final Validation Report, submitted to CMS on 05/03/19 at 2:35 PM, [Processing Completion Date/ Time: 05/03/19 at 2:45 PM], and a copy received by the…

The Home Health Agency staff failed to complete timely, patient-specific, comprehensive assessment that accurately reflected the patient's current health status, and consistent with the patient's immediate needs in one (1) of 11 clinical records (Patient # 5).

The Home Health Agency failed to conduct performance improvement projects.

The Agency failed to ensure that its governing body that has full legal authority, and responsibility for the agency's overall management and operation, the provision of all home health services, including its quality assessment and performance improvement (QAPI) program, participated in the…

The Home Health Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the Home Health Agency's quality assessment and performance improvement (QAPI)…

The agency's staff failed to ensure that all entries were appropriately authenticated, dated, and timed in one (1) of 11 clinical records (Patient #4).

The Home Health Agency failed to transmit OASIS (Outcome & Assessment Information Set) data for all applicable patients in an electronic format that meets CMS [Center for Medicaid and Medicare Services] specifications for six (6) of 11 Medicaid beneficiaries receiving skilled services (Patients #…

The agency's clinician failed to document complete, updated and revised comprehensive assessments at discharge to include summaries of the patient's progress in meeting care plan goals in one (1) of two (2) closed clinical records for discharged patients (Patient #4).

The agency's staff failed to ensure that patients' Plans of Care were individualized, and included all required elements in two (2) of 11 clinical records (Patients # 4 and 5) Findings included... The CMS [Center for Medicare and Medicaid] Provider Manual: Appendix 5, Reporting and Assessment…