Healthcare Stat Home Care (Hcsh)

The agency failed to base the emergency preparedness plan on and to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

The facility failed to ensure the emergency preparedness plan included the contact information for agency staff.

The agency failed to provide evidence that the emergency preparedness plan was tested annually.

The agency failed to follow its policy regarding transmitting OASIS (outcome and assessment information set) for three (3) of seven (7) clinical records reviewed.

The registered Nurse did not complete a recertification assessment for one (1) of seven (7) clinical records reviewed (CR #6).

An interview with the administrator and director of nursing the agency failed to ensure a skilled nurse perform wound management including assessment and treatment for two (2) of seven (7) clinical records reviewed (CR#1 & 4) and the agency failed to ensure a skilled nurse monitored patients…

The agency failed to ensure appointment of a qualified, pre-designated person, who is authorized in writing by the agency's Governing Body and who will assume the same responsibilities and obligations as the administrator for one (1) of seven (7) personnel files (PF #2).

The agency failed to ensure length of service provided was listed on the Plan of Care for seven (7) of seven (7) clinical records reviewed (CR# 1, 2, 3, 4, 5, 6 &; 7).

An interview with the administrator and director of nursing the agency failed to ensure physician orders were followed for five (5) of seven (7) clinical records reviewed (CR #1, 3, 4, 6 & 7).

The agency did not maintain current Cardiopulmonary resuscitation (CPR) certification for clinical staff for one (1) of seven (7) (PF # 6) and personnel files did not contain a current signed job description for two (2) of seven (7) personnel files reviewed (PFs # 6 and 7).

Agency failed to provide documentation that a discharge summary was sent to the physician within five (5) days of discharge for two (2) of two (2) discharge records reviewed (CR #6 & 7).

Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the beneficiary for twenty-four (24) of twenty-four (24) CRs reviewed (CR#3, CR#9-#31).

Agency failed to document the development, implementation, and evaluation of performance improvement projects for 2017 and 2018 for one (1) of one (1) observations (Observation #1).

The agency did not maintain a coordinated agency-wide program for the surveillance of communicable disease by failing to ensure all staff is screened and triaged for COVID-19 for three (3) of three (3) interviews (Interview #1-#3).

The agency failed to ensure the patient was advised of the state toll free home health telephone hot line (1-800-254-5164) contact information for eight (8) of eight (8) CRs reviewed, (CR#1- CR#8).

The agency failed to complete the initial assessment within 48 hours of referral, or within 48 hours of the patients return home, or on the physician- ordered start of care date for two (2) of eight (8) clinical records (CR#4, CR#8).

The agency failed to ensure a review of all medications the patient is currently using for four (4) of eight (8) CRs reviewed, (CR#1, CR#4, CR#7, CR#8).

Agency failed to have the total plan of care reviewed by the attending physician at least once every 60 days for three (3) out of eight (8) clinical records with recertifications (CR#1, CR#5-6).