Majestic Home Health LLC

The home health agency failed to ensure the EP Plan included strategies for addressing emergency events identified by the risk assessment (See E0006); failed to ensure the EP Plan addressed patient population, including, but not limited to, the type of services the home health agency has the…

The home health agency failed to provide the Patient with a copy of the OASIS privacy notice (See G416); failed to obtain power of attorney paperwork (See G418); failed to ensure the Patient was informed about the delay in the initial OT evaluation assessment (See G434); failed to ensure the…

The home health agency failed to ensure the POC was established with the physician or allowed practitioner (See G572); failed to ensure all required information was included in the POC and failed to ensure all information included in the POC was correct (See G574); failed to ensure physician or…

The home health agency failed to show measurable improvement in indicators which will improve health outcomes, patient safety, and quality of care (See G642); failed to ensure the governing body approved the frequency and data of QAPI (See (G644); and failed to document performance improvement…

The home health agency failed to ensure the Alternate Administrator was authorized in writing (See G954); failed to ensure the Clinical Manager was involved in daily activities of the agency (See G958); failed to ensure the Clinical Manager coordinated patient and personnel assignments (See G960)…

The home health agency failed to ensure the EP Plan included strategies for addressing emergency events identified by the risk assessment for 1 of 1 EP Plan.

The home health agency failed to ensure the EP Plan addressed patient population, including, but not limited to, the type of services the home health agency has the ability to provide in an emergency for 1 of 1 EP Plan.

The home health agency failed to ensure the EP Plan included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation for 1 of 1 EP Plan.

The home health agency failed to ensure each patient had an individualized EP plan for 1 of 6 patient records reviewed (Patient #6) and failed to ensure the individualized EP plans were complete and accurate for 4 of 5 patient records reviewed who had an individualized EP plan (Patient #1, 2, 3…

The home health agency failed to ensure policies or procedures were implemented to address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs…

The home health agency failed to ensure the EP Plan included names and contact information of agency staff for 1 of 1 EP Plan.

The home health agency failed to ensure the EP Plan included contact information for local EP staff for all counties the agency served for 1 of 1 EP Plan.

The home health agency failed to ensure the EP Plan included both primary and alternate means of contacting Federal, State, regional, and local emergency staff for 1 of 1 EP Plan.

The home health agency failed to ensure the EP Plan included a means of providing information about the home health agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee for 1 of 1 EP Plan.

The home health agency failed to ensure all staff received training upon hire and at least every two years for 4 of 13 active staff (Communication Liaison, RN 2, RN 3, and PT 1).

The agency failed to submit OASIS assessments within 30 days for 1 of 1 agency surveyed.

The home health agency failed to ensure patients received a copy of the agency’s discharge and transfer policies at SOC for 1 of 1 agency.

The home health agency failed to ensure the POC was established with the physician or allowed practitioner for 6 of 6 patient records reviewed (Patient #1, 2, 3, 4, 5, and 6).

The home health agency failed to show measurable improvement in indicators which will improve health outcomes, patient safety, and quality of care for 1 of 1 agency.

The home health agency failed to ensure the governing body approved the frequency and data of QAPI for 1 of 1 agency.

The home health agency failed to document performance improvement projects for 1 of 1 agency.

The home health agency failed to ensure the Clinical Manager was involved in daily activities of the agency for 1 of 1 home health agency surveyed.

The home health agency failed to ensure all clinical record entries were appropriately authenticated, dated and timed for 1 of 1 discharge record reviewed (Patient #4).

The home health agency failed to provide patients with accurate information on their right to receive a copy of their clinical record for 1 of 1 agency.

The home health agency failed to provide the Patient with a copy of the OASIS privacy notice for 1 of 1 agency.

The home health agency failed to obtain POA paperwork for 1 of 1 patient record reviewed with POA signed admission consents (Patient #4).

The home health agency failed to ensure the Patient was informed about the delay in the initial ST or OT evaluation assessment for 4 of 6 patient records reviewed with ST or OT services ordered on the referral (Patient #1, 4, 5 and 6) and failed to ensure the patient was notified of discharge prior…

The home health agency failed to ensure the patient received the ST evaluation as ordered on the POC for 1 of 1 discharged record reviewed with ST ordered (Patient #6).

The home health agency failed to ensure patients were notified of the State hotline hours of operation for 1 of 1 agency.

The home health agency failed to ensure collaboration with the physician prior to discharge for 1 of 1 discharged record reviewed for goals met (Patient #4).

The home health agency failed to conduct an initial assessment to determine the patient's immediate care and support needs within 48 hours of referral for 2 of 6 patient records reviewed (Patient #1 and 5).

The home health agency failed to conduct a comprehensive assessment which included an evaluation for all referred services within five days of the SOC for 3 of 3 discharged records reviewed with therapy services (Patient #4, 5 and 6).

The home health agency failed to ensure all required information was included in the POC and/or failed to ensure all information included in the POC was correct for 6 of 6 patient records reviewed (Patient #1, 2, 3, 4, 5, and 6).

The home health agency failed to ensure physician or allowed practitioner orders were received prior to services and treatments being provided for 5 of 6 patient records reviewed (Patient #1, 2, 3, 4, and 6).

The home health agency failed to ensure the POC was reviewed by the physician or allowed practitioner at least every 60 days for 1 of 1 patient record reviewed where the patient had been on service with the agency for more than 60 days (Patient #1).

The home health agency failed to notify the physician regarding the need to alter/change the POC for 1 of 1 patient record reviewed with SN interventions to administer insulin (Patient #4).

The home health agency failed to ensure collaboration with outside entities also providing care for the patient for 4 of 4 patient records reviewed in which the patient was also receiving services from an outside entity (Patient #2, 3, 4, and 5).

The home health agency failed to ensure the caregiver was provided wound care education for 1 of 1 discharged record with wounds (Patient #4).

The home health agency failed to provide the current CM’s name and contact information to patients for 1 of 1 agency.

The SN failed to measure wounds at least weekly for 1 of 1 discharged record reviewed with wounds (Patient #4).

The home health agency failed to ensure all SN visit note documentation was completed the day of service for 1 of 1 discharge record reviewed with wounds (Patient #4).

The Governing Body failed to ensure the Alternate Administrator was authorized in writing for 1 of 1 agency.

The home health agency failed to ensure the Clinical Manager coordinated patient and personnel assignments for 1 of 1 home health agency surveyed.

The home health agency failed to ensure the Clinical Manager coordinated patient care for 1 of 1 home health agency surveyed.

The home health agency failed to ensure the Clinical Manager was involved in coordinating referrals for 1 of 1 home health agency surveyed.

The home health agency failed to submit a transfer summary within two days for 2 of 3 discharge records reviewed (Patient #5 and 6).