Elara Caring Xviii

The agency failed to ensure advance beneficiary notice and/or HHCOC notice was provided to a patient prior to discharge from agency services for one (Patient #13) of 13 patients.

The agency failed to ensure a medication profile was reviewed and updated with ordered medications for two (Patients #5 and #7) of 13 patients.

The agency failed to ensure physician ordered placement of compression stockings for one (Patient #4) of 13 patients.

The agency failed to ensure: SN notified the physician for weight readings outside of reporting parameters as ordered on the POC for one (Patient #1) of 13 patients.

The agency failed to ensure a completed discharge summary was provided for two (Patients #12 and #13) of 13 patients.

The agency failed to ensure the Infection Control Program was included in QAPI activities for all patients and staff.

The agency failed to ensure clinical records were complete timely for one (Patient #6) of 10 patients.

The agency failed to ensure a medication profile was reviewed and updated with dose instruction for an ordered medication for one (Patient #5) of 10 patients.

The agency failed to ensure a discharge oasis assessment was completed for two (Patients #1 and #2) of 10 patients.

The agency failed to ensure a completed discharge summary was provided for two (Patients #1 and #2) of 10 patients.

The agency failed to ensure annual review and update of a facility-based community-based risk assessment.

The agency failed to document emergency drills from January 1, 2018 - December 31, 2018 for 6 current patients and all current employees.

The agency failed to ensure patients were provided discharge information/notification or communication for one (Pt #7) of seven patients.

The agency failed to ensure physician notification of vital signs, blood glucose and pain outside of ordered parameters for three (Pt #2, 5 and 6) of seven patients.

The agency failed to ensure: 1) One PIP documented what the project was to improve; 2) Documentation of the evaluation and measurable improvement of PIPs for all home health employees and six current patients.

The agency failed to ensure an ongoing, comprehensive QAPI program was approved by the governing body.

The agency failed to ensure governing body oversight of the agency's operation, services, budget and QAPI Program potentially effecting the health and safety of all home health employees and 6 current patients.