Life Fountain Health Care, Inc.

The home health provider failed to ensure the accuracy of the Outcome and Assessment Information Set (OASIS- Outcome and Assessment Information Set; a standardized data collection tool) data in one of five full records reviewed (Record/Patient #1).

The home health provider failed to maintain professional standards when wound measurements were not obtained/documented according to the clinical practice guidelines and interview, in one of two records with wounds (Record/Patient #3).

The home health provider failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one of five full records reviewed (Record/Patient #1).

The home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status in one of five full records reviewed (Record/Patient #1).

The home health provider failed to provide skilled nursing services as ordered by the physician on the plan of care (POC) in one of five full records reviewed (Record/Patient #3).

The home health provider failed to provide a clinical record that was accurate and included completed nursing visits in one of five full records reviewed (Record/Patient #3).

The home health provider failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the home health provider/services within five business days…

The agency failed to provide training in emergency preparedness policies and procedures to new and existing staff and to individuals providing services under arrangement upon orientation and at least every two years in, but not limited to, three (Employees #1, #2, and #3) of three employee files…

The agency failed to ensure the accuracy of the Outcome and Assessment Information Set (OASIS) data in, but not limited to, one (Record/Patient #1) of five full records reviewed.

The agency failed to ensure that each patient received the home health services that are written in the individualized plan of care in, but not limited to, three (Records/Patients #1, #2 and #6) of five full records reviewed.

The agency failed to provide infection control education to staff on orientation and annually, thereafter in, but not limited to, three (Employees #1, #2, and #3) of three employee records reviewed.

The agency failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 in, but not limited to, five (Employees #3, #4, #5, #6, and #7) of 16 employee vaccination records reviewed.

The agency failed to ensure that entries into the clinical records are legible, clear, complete, and appropriately authenticated, dated, and timed in two (Records/Patients #3 and #6) of five full records reviewed.

The agency failed to provide written notice of patient rights regarding their right to have a copy of the patient’s rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit.

The agency failed to provide written notice of the correct state toll free home health hotline number and its hours of operation.

The agency failed to complete the initial assessment of the patient within 48 hours of the referral to home health care or within 48 hours of the physician ordered start of care in, but not limited to, two (Records/Patient’s #1 and #2) of five full records reviewed.

The agency failed to ensure the registered nurse performed an accurate review/update of all medications the patient was currently using in, but not limited to, two (Records/Patients #1 and #6) of five full records reviewed.

The agency failed to promptly alert the physician of changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered in two (Records/Patients #1 and #6) of five full records reviewed.

The agency failed to ensure ongoing interdisciplinary assessment of patient, in one (Record/Patient #2) of five full records reviewed.

The agency failed to provide services that are ordered by the physician or allowed practitioner as indicated in the plan of care in, but not limited to, two (Records/Patients #3 and #4) of five full records reviewed.

The agency failed to: - Ensure that personnel received the required Alzheimer’s disease and related dementias training on orientation and annually in three (Employees #1, #2, and #3) of three employee files reviewed; and - Ensure that the employee disqualification list (EDL) was checked prior to…

The agency failed to send a discharge summary to the primary care practitioner or other healthcare professional within five business days of the discharge in one (Record/Patient #4) of six applicable records reviewed.

The agency failed to include the types of services the agency would be able to provide in an emergency and the agency's plans to continue operations during an emergency.

The agency failed to develop an emergency preparedness procedure regarding how the agency will follow up with on-duty contract staff and patients to determine services that are needed and the process for informing State and local officials of any on-duty staff or patients that the agency is unable…

The agency failed to develop an emergency preparedness policy/procedure regarding the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integrating State and Federally designated health care professionals to address surge needs during an…

The agency failed to update and annually review the communication plan to comply with Federal, State and local laws.

The agency failed to develop an emergency preparedness communication plan that includes the names and contact information for staff, any entities providing services under arrangement, patient's physicians, and volunteers.

The agency failed to develop an emergency preparedness communication plan that includes primary and alternate means of communicating with agency staff, and Federal, State, tribal, regional, and local emergency management agencies.

The agency failed to develop an emergency preparedness training and testing program.

The agency failed to develop an emergency preparedness plan training program that included initial training in emergency preparedness policies and procedures to all new and existing staff, maintained documentation of all emergency preparedness training, and demonstrated staff knowledge of emergency…

The agency failed to conduct exercises to test the emergency preparedness plan.

The agency failed to provide written notice regarding the patient's financial obligation in two (Records/Patients #1 and #2) of five records reviewed for this standard.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of the state hotline hours (7:00 AM to midnight).

The agency failed to ensure the patients were provided the names, addresses, and telephone numbers of federal and state-funded entities that serve the area where the patient resides.

The agency failed to ensure the plan of care (POC) included all of the required elements in, but not limited to, three (Records/Patients #1, #2 and #5) of five records reviewed.

Patient home folder review and interview the agency failed to provide the patient and/or caregiver a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel in, three of three home visit observations (Records/Patients #1, #2 and #3).

The agency failed to provide the patient/caregiver with a copy of written instructions outlining the patient's medication schedule/ instruction, including the medication's name, dosage, and frequency in one (Record/Patient #2) of three home visit observations.

The agency failed to provide in writing the name and contact information of the clinical manager in three (Records/Patients #1, # 2 and #3) of three home visit observations.

The agency failed to ensure that all nursing clinicians performed and documented ongoing interdisciplinary assessment in but not limited to one (Record/Patient #2) of five records reviewed.

The agency failed to provide services as ordered by the physician on the plan of care in, but not limited to, two (Records/Patients #2 and #5) of five records reviewed.

The agency failed to ensure that patient and caregiver education was provided in, but not limited to, one (Record/Patient #2) if five records reviewed.

The agency failed to: 1. - Document orientation/inservice training for contract staff; 2. - Obtain a copy of an Advanced Directive (a written statement of an individual's rights to make decisions concerning acceptance of medical care, refusal of medical care, surgical treatment or other lifesaving…

The agency failed to ensure the clinical record contained accurate assessment of the patient in, but not limited to, one (Record/Patient #2) of five patients reviewed.

The agency failed to provide/send a completed transfer summary to the responsible physician within two business days of the patient's transfer in one (Record/Patient #3) of one applicable record reviewed.