Elara Caring

The agency failed to ensure Outcome and assessment information set (OASIS) was submitted within 30 days of completing the assessment (See Tag G372), and failed to ensure OASIS data accurately reflected the patient's status at the time of the assessment (See Tag G374).

The agency failed to provide patients with the administrator's name in order to receive complaints (See Tag G414), failed to ensure patients were free from neglect (See Tag G430), and failed to investigate and document complaints appropriately (See Tag G478).

The registered nurse (RN); failed to complete the initial assessment (See Tag G514); failed to ensure the comprehensive assessment was; completed within 5 days of start of care (See Tag G520); contained the patient's current health status (See Tag G528); contained individual patient strengths and…

The agency failed to ensure the needs of the patients were met for 5 of 17 records reviewed (#3, 11, 15, 16, 17), failed to ensure the plan of care was followed and that it contained all required information and all orders, that physicians orders were obtained, that the nurse who obtained verbal…

The agency failed to ensure all staff followed infection control policies and standard precautions (See Tag G682); and failed to ensure all patient infections were logged into the infection control program (See Tag G684).

The agency failed to ensure administrative functions were not delegated to another agency for education, failed to ensure protected health information (PHI) was safeguarded due to the lack of contracts and patient information being reviewed for quality assurance (QA) reviews, coding, and Outcome…

The agency failed to ensure that OASIS (outcome and assessment information set) submissions were completed within 30 days of completing the assessment.

The agency failed to ensure outcome and assessment information set (OASIS) data accurately reflected the patient's status at the time of the assessment for 5 out of 17 OASIS records reviewed, in a total sample of 32 (Patient #1, 3, 9, 13, 17).

The agency failed to ensure the Registered Nurse provided wound treatment per the plan of care for 1 of 1 patient's with wounds (#1) failed to ensure the plan of care contained individualized vital sign parameters for 2 out of 17 records reviewed (#6, 17), and failed to ensure the plan of care was…

The Registered Nurse failed to ensure infection control precautions were maintained during wound treatments for 3 of 3 patients observed with wounds (#1, 3, 7), and that the home health aide/certified nursing assistant (CNA) completed appropriate hand hygiene at correct intervals and changed gloves…

The agency failed to ensure patient infections were logged into the infection control program for 2 of 17 records reviewed (#4, 5), in a sample of 32. Findings include: 1. An agency policy dated 4/8/19 and titled "Infection prevention/control," Policy # B-403 stated "POLICY: GLC [great lakes…

The registered nurse failed to assign aides to a specific patient, and failed to prepare clear, concise instructions on the aide care plan for the aide to follow, including equipment or supplies needed to complete the task if applicable for 2 of 2 home health aide home visit observations completed…

Governing Body minutes failed to evidence information regarding policy review, updates, and approvals, fiscal operation approvals, budget approvals, operational plans and approvals, and quality assessment performance improvement (QAPI) approvals specific to the surveyed provider number.

The agency failed to ensure physician orders were signed and dated in a timely manner for 1 out of 17 records reviewed (#1), and all entries were accurately authenticated for 4 of 17 records reviewed (#2,4, 7, 8), in a total sample of 32. Findings include: 1. An agency policy dated 4/8/19 and…

The agency failed to provide patients with the administrator's name in order to receive complaints, for 5 out of 6 home folders observed (#1, 2, 3, 5, 7), in a sample of 7 home visits.

The agency failed to ensure patients were free from neglect for 8 of 19 records reviewed (#1, 3, 8, 11,12, 15, 16, 17), in a sample of 32. Findings included: 1. An agency policy dated 4/8/19, titled "pain assessment/management," Policy # C-148, stated "...Policy: All clients admitted to GLC [great…

The agency failed to investigate and document complaints for 2 of 2 patient complaints reviewed (#8, 12), in a sample of 32. Findings include: 1. An agency policy dated 4/8/19 and titled "Patient/family complaint/grievance policy," Policy # C-381 stated "...The home health agency must investigate…

The registered nurse failed to conduct the initial assessment visit to determine the immediate care and support needs of the patient for 1 of 17 initial assessments reviewed, in a sample of 32 (#2).

The agency failed to ensure the comprehensive assessment was completed within 5 days of start of care for 2 of 15 records with start of care episodes reviewed, in a sample of 32 (#11, 17).

The comprehensive assessment failed to contain all information about the current health status for 15 of 16 comprehensive assessments completed by a registered nurse (RN), in a total sample of 32 (#1, 2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17).

The agency failed to ensure comprehensive assessment contained strengths and care preferences identified by the patient for 13 of 17 records reviewed (#2, 3, 4, 5, 7, 8, 9, 10, 11, 13, 14, 15, 16), in a sample of 32. Findings include: 1. The clinical record of patient #2 was reviewed on 8/18/20 and…

The registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications the patient was taking and medication lists were accurately maintained for 7 of 17 records reviewed (#1, 2, 4, 6, 7, 10, 17), in a sample of 32. Findings include: 1. An agency policy…

The agency failed to ensure comprehensive assessments contained the patient's primary caregivers willingness and ability to provide care for 10 of 17 records reviewed (#2, 3, 4, 5, 7, 11, 13, 14, 15, 16), in a sample of 32. Findings include: 1. The clinical record of patient #2 was reviewed on…

The plan of care failed to include allergies, all durable medical equipment (DME)/supplies, appropriate diagnoses, treatment/ interventions (including timeframe's), medications, and measurable patient specific goals, appropriate agency phone number, all supplies, education to facilitate timely…

The agency failed to ensure that all home health staff were working from a current plan of care by failing to include all interim orders received during the certification period into the plan of care for 2 out of 17 records reviewed (#1, 6,).

The agency failed to ensure all physician orders were sent to the physician for signature for 2 of 17 records reviewed (#2, 8), in a sample of 32. Findings include: 1. An agency policy dated 4/8/19, titled "physician orders," Policy # C-635, stated "...All medications, treatments and services…

The agency failed to ensure the nurse obtaining verbal orders, put those orders in writing along with their signature and date for 1 out of 17 records reviewed.

The skilled nurse failed to notify the physician of; the need to discontinue current treatment to the patient's coccyx due to the patient's wound not meeting goal of improved wound healing due to current long standing treatment of dakins solution and need for treatment to the left and right…

The agency failed to ensure the plan of care was revised to be reflective of patients current status for 2 of 17 records reviewed (Patient #1, 6), in a sample of 32. Findings include: 1. The clinical record of patient #1 , SOC (start of care) 04/23/2019, was reviewed on 8/12/2020. The record…

The agency failed to ensure communication took place with all physicians involved in the plan of care for 1 of 17 records reviewed (#2), in a sample of 32. Findings include: An agency policy dated 4/8/19, titled "Coordination of client services," Policy # C-360, stated "...Purpose: To ensure…

The interdisciplinary team failed to communicate amongst each other in order to meet the patient's needs in regards to pain control for 2 out of 17 records reviewed (#2, 17), in a sample of 32. Findings include: 1. An agency policy dated 4/8/19, titled "Coordination of client services," Policy #…

The Registered Nurse failed to ensure the patient and their caregiver were provided and educated on the COVID-19 pandemic and failed to be educated per the plan of care for 3 of 4 skilled nurse observations conducted (Patient #1, 3, 7) and failed to ensure caregivers conduct a return demonstration…

The agency failed to ensure all patients were provided with a copy of written instructions outlining visit schedule, including frequency of visits by the home health personnel for 5 out of 6 home folders observed (#1, 2, 3, 5, 7), in a sample of 7 home visits.

The agency failed to ensure a medication list was provided to the patient for for 5 out of 6 home folders observed (#1, 2, 3, 5, 7), in a sample of 7 home visits.

The agency failed to provide a written instructions outlining treatments and therapy that would be administered by agency staff to the patient for 5 out of 6 home folders observed (#1, 2, 3, 5, 7), in a sample of 7 home visits.

The agency failed to provide the patient with a written aide care plan which outlined the services to be provided from the home health aide (HHA) for 1 of 1 patients receiving HHA services in which the home folder was observed, in a sample of 7 home visit observations.

The agency failed to ensure all patients are provided with a copy of written instructions outlining name and contact information of the home health clinical manager/ director of nursing for 1 out of 2 patient interviews conducted.

Skilled nurses failed to ensure wounds were appropriately identified and measured consistently for 9 out of 10 records of patients with wounds (Patient #1,3, 4, 7, 8, 13, 14, 15, 17), failed to ensure pain assessments included pain ratings for 2 out of 17 records reviewed (Patient #2, 17), failed…

The Skilled Nurse failed to provide education to patients and/or their caregivers as ordered per the plan of care for 3 out of 4 skilled nursing observation visits (Patient #1, 3, 7) and failed to ensure return demonstration of wound care provided by caregivers for 1 out of 1 new admission records…

The skilled nurse failed to appropriately document the treatment being provided to each wound location for 1 of 10 wound care patients (Patient #1) and inaccurately documented the patient as taking insulin for diabetes and hydrocodone for pain for 1 of 17 records reviewed (Patient #17), in a sample…

The home health aide failed to follow the aide care plan for 2 of 2 aide home visits observed (#2, 4).

The home health aide failed to report changes in the patient's condition to the registered nurse for 1 of 1 patient observed with pain during a home visit (#2).

The administrator failed to report to the governing body.

The administrator failed to be responsible for the day to day functions of the agency.

The clinical manager (CM) failed to ensure the home health agency employed qualified nurses with knowledge and training about assessing, staging, and completing wound care for 5 of 5 nurse documentation (H, U, V, X, W) for 2 of 2 patient records (#1, 17).

The clinical manager (CM) failed to make patient and personnel assignments.

The clinical manager (CM) failed to coordinate patient care for the agency.

This medication was not listed on the medication profile.

The clinical manager (CM) failed to assure patient plans of care were implemented, and updated for 2 of 17 patients whose plan of cares were not updated (#1, 6), in a sample of 32. Findings include: 1. An agency policy dated 4/8/19 and titled "Clinical manager," Policy # A-138 stated…

The parent home health agency failed to provide oversight and administrative control over branch locations.

The agency failed to ensure that written agreements were in place (and signed by both parties) that delineated the services each agency was to provide for all patients with shared agencies.

The agency failed to ensure all patients had one primary home health agency, and all services provided to the patient occurred either directly or under arrangements for all patients with shared agencies for 16 of 16 patients with other agency's who provided care in the home (#16, 18, 19, 20, 21…

The agency failed to ensure the skilled nurse (SN) performed a urinalysis of a patient with an indwelling catheter per professional standards for 1 of 1 records with documented urinalysis collection (#2), in a sample of 19. Findings include: An agency policy dated 4/8/19 and titled "Standards of…