Fame Health Care Services Inc
Inspection 2019-02-15
· Recertification · 27 deficiencies · CMS source report (PDF)The agency failed to electronically report all Outcome and Assessment Information Set (OASIS) data collected in accordance with §484.55 - Condition of Participation, Comprehensive Assessment of Patients - each patient must receive and an agency must provide a specific comprehensive assessment as…
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G514 - RN Performs Assessment - The agency failed patient initial assessment visits were held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician- ordered start of care date.
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G572 - Standard: Plan of Care - The agency failed to ensure each patient received home health services in accordance with a written plan of care established and periodically reviewed by a physician.
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The agency failed to implement a quality assessment and performance improvement (QAPI) which evaluated all agency services and complied with the requirements and standards set forth in CFR 484.65. The failure created the potential for the agency to overlook trends which affected the quality of…
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G706 - Standard: Interdisciplinary Assessment Of The Patient - The agency failed to ensure ongoing interdisciplinary assessment occurred by the Registered Nurse (RN) who failed to re-evaluate the nursing needs for 5 of 5 patients reviewed receiving wound care (Patient #1, #3, #6, #9, and #11).
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The agency failed to provide physician ordered CNA services by qualified staff.
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Who also functioned as the Director of Nursing (DON) failed to organize, manage, and administer the agency's resources in order to attain and maintain the highest practicable functional capacity of the agency, including providing optimal care to achieve the goals and outcomes identified in the…
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The agency failed to ensure each patient's clinical record contained past and current information for every patient accepted by the HHA and receiving home health services.
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The agency failed to provide services by qualified staff.
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The agency failed to ensure the comprehensive assessment accurately reflected the status of 5 of 11 patients (Patients #1, #3, #6, #9 and #11).
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The agency failed to ensure comprehensive assessments were updated/revised as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status for 11 of 11 patient reviewed with an improvement (Patients #1, 2, #3, #4, #5, #6, #7, #8, #9, #10 and…
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The agency failed to ensure each patient received home health services in accordance with a written plan of care established and periodically reviewed by a physician.
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The agency failed to ensure conformance with physician's orders including skilled nurse (SN) and certified nurse aide (CNA) services and treatments including insulin administration and wound care.
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The agency failed to ensure patient-specific written care instructions for the Home Health Aide (referred hereafter as certified nurse aide (CNA) were prepared by the registered nurse (RN) for 7 of 8 patients reviewed who received CNA services (Patients #1, #2, #3, #4, #5, #8, and #10) reviewed…
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The agency failed to ensure supervision of home health aides (referred to throughout as certified nurse aides, CNA).
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The agency failed to assign certified nurse aides who were currently listed in good standing on the state nurse aide registry.
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The agency failed to ensure services provided to Patient #4 requiring monitoring, assessment and medications administered based of an assessment, was completed by a licensed nurse practicing within their scope of practice.
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The agency failed to ensure a registered nurse conducted an initial assessment visit to determine the immediate care and support needs for 5 of 11 patients selected for review.
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The agency failed to ensure a complete comprehensive assessment was updated and revised, including the administration of the Outcome and Assessment Information Set (OASIS) within 48 hours of the patient's return home from a hospital admission of 24 hours or more, for 3 of 3 patients reviewed who…
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The agency failed to ensure the comprehensive assessment was updated and revised at the time of patient discharge for 2 of 4 patients that had been discharged (Patients #1 and #6).
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The agency failed to record all patient care orders in the plans of care in 5 of 11 active patient records reviewed (Patients #1, #3, #4, #9 and #10.) Findings include: AGENCY POLICY According to the policy titled, "Plan of Care-CMS #485 and Physician Orders" The total plan of care will be reviewed…
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The agency failed to ensure each patient's total Plan of Care was reviewed by the physician at least every 60 days.
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The agency failed to ensure nursing staff promptly alerted the physician of symptoms and changes in the patient's condition that suggested a need to alter the plan of care for 5 of 11 patients whose record was reviewed (Patient #1, #2, #3, #8 and #9).
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The agency failed to ensure ongoing interdisciplinary assessment occurred by the Registered Nurse (RN) to re-evaluate the nursing needs for 5 of 5 patients reviewed receiving wound care (Patients #1, #3, #6, #9, and #11).
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The agency failed to ensure nursing professional services communicated with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current Plan of Care for 4 of 11 patient records reviewed (Patient #1, #2, #3 and #9).
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The agency failed to ensure a certified nurse aide (CNA #13) provided care for a patient with complex nursing needs in accordance with his/her scope of certification practice and; Failed to provide care for patients with staff (#3, #4, #5 and #14) who were qualified through formal training, testing…
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The agency failed to ensure certified nursing aides (CNAs) provided patient specific services that were ordered by the physician and included in the plan of care; permitted to be performed under state law and consistent with CNA training for 3 of 6 (Staff #3, #4 and #13).
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