Omnia Health Care LLC

The agency failed to ensure patient rights were maintained; failed to ensure a patient's were free from neglect (see G0430), and failed to ensure services were provided as ordered in the POC (see G0436) for 1 of 1 patient death's reported.

The agency failed to include all elements required in the Plans of Care (see G0574), and failed to ensure MD was notified with changes in patient's condition (see G0590).

The agency failed to ensure the Governing Body approved the frequency and detail of the data collection(see G644) the agency failed to ensure clear expectations for patient safety were established and implemented (see G0660).

The agency failed to ensure the Governing Body approved the frequency and detail of the data collection for 1 of 1 Agency.

The Governing Body failed to ensure a program for quality monitors and patient safety were established and implemented with 1 of 1 agency.

The agency failed to ensure a patient's right to remain free from neglect, harm, and death, in 1 of 2 bedbound patients reviewed.

The agency failed to provide services as ordered in the Plan of Care for Patient #1 a bedbound patient with quadriplegia (paralysis that affects all a person’s limbs and body from the neck down), for 1 of 2 bedbound patients' clinical records reviewed.

The agency failed to ensure the POC had correct certification periods, duration of services, all services the agency provided, prognosis, hospitalization risk, and rehabilitation potential for 4 of 5 active records reviewed (Patients #3, #4, #5, and #6), and 1 of 2 closed records reviewed (Patient…

The agency failed to ensure providers were promptly notified with patients' changes in condition, in 1 of 2 bedbound patients reviewed.

The agency failed to ensure home health aides completed competency testing upon hire with 3 of 3 home health aides.

The agency failed to ensure the HHAs practiced within their scope by transporting and running errands for patients for 2 of 5 active clinical records reviewed.

The agency failed to ensure Home Health Aides were supervised no less often than every 14 days, for 2 of 3 active clinical records reviewed with SN and HHA services (Patients #4 and #6) , and for 1 of 2 closed clinical records reviewed.

The Administrator failed to execute all of their responsibilities for the day-to-day operations of the home health agency, for 1 of 1 Agency.

The DON failed to ensure services was continuously available for a 24 hour, 7 days a week case 1 of 1 - 24 hour care patient.

The agency failed to ensure an effective discharge planning process, to include coordination of care and assistance to patients and their caregivers in the procurement of another provider's service appropriate for the patient, for 1 of 4 closed records reviewed.

The agency failed to ensure a complete and accurate discharge summary was provided to the receiving facility or health care practitioner that included all necessary medical information and post-discharge goals of care for 3 of 4 closed records reviewed.

The agency failed to implement their policy that required a series of actions were taken prior to discharging a patient for cause, for 1 of 1 policies reviewed, which affected 1 (Patient #3) of 4 patients whose closed clinical record was reviewed.

The agency failed to ensure the patient's ordering provider was notified of the Home Health Agency's intention to discharge a patient for cause in 1 (patient 3) of 4 closed clinical records reviewed.

The agency failed to implement their policy to ensure the patient's caregiver was provided with the phone numbers and names of other Home Health agencies when the agency determined to discharge a patient for cause in 1 (patient 3) of 4 closed clinical records reviewed.

The agency failed to ensure discharge plans were communicated with the responsible physician and/or patient representative (if any) for 3 of 4 closed records reviewed.

The agency failed to ensure coordination of care included the patient, the patient's representative (if any), and the patient's caregivers, as appropriate in 4 of 8 records reviewed.

The agency failed to ensure clinical notes documented pertinent communication with patients, their families/caregivers, physicians, personal service agencies, and other applicable persons/entities as part of the clinical record for 1 of 1 active records reviewed (patient #1) and 2 of 4 closed…

The agency failed to ensure continuing communication with all physicians and/or other health care practitioners involved with the patient’s plan of care for 2 of 4 active records reviewed (patients #1, 5) and 2 of 4 closed records reviewed.

The agency failed to ensure a completed discharge or transfer summary was written and sent to the primary care physician or other health care professional who was responsible for the patient's care after discharge within 5 business days of the patient's discharge or within 2 business days of a…

The agency failed to ensure Outcome Assessment Information Set (OASIS) data was reported / transmitted to the state agency at least every 30 days after the assessment was completed for 2 of 2 active clinical records reviewed of adult patients that received skilled services and required…

The agency failed to ensure the quality assurance program was capable of showing measurable improvement and measured, analyzed and tracked quality assurance indicators, including adverse patient events, and other aspects of performance that enable the agency to assess processes of care, HHA…

The home health agency failed to ensure standard infection control practices related to handwashing and glove use were followed during patient care (See G682) and failed to have an active infection control program to maintain a coordinated agency-wide program for the surveillance, identification…

The skilled nurse failed to give a client's prescribed medication, Levothyroxine/ Synthroid, timely as ordered by the physician and to ensure the prescribed cranberry pills were given as ordered by the physician for 1 of 2 home skilled visits conducted with a gastrostomy tube (G-tube) (Patient 1)…

The agency failed to provide the patient and caregiver with a copy of the current plan of care for 1 of 2 home observations.[3] Findings include: A home observation was completed on 8/6/2019 at 8:25 AM at the residence of Patient 3. At such time, Patient documentation was reviewed to show that the…

The agency failed to ensure standard infection control practices related to handwashing and glove use were followed during patient care for 1 of 2 home visits observed of skilled nurse care.

The agency failed to have an active infection control program to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases and incorporated the information into the agencies QAPI (quality assurance…

The agency failed to ensure the documentation in the clinical records were complete and accurate for 1 of 6 active clinical records reviewed (patient #1) and failed to ensure that clinical records were authenticated for 1 of 2 active records reviewed with orders for only home health aide services…

The agency failed to provide updated written notice of the patient's rights and responsibilities for 5 of 5 records reviewed wth start of care was before 01/13/2018. [1, 2, 3, 4, and 6] Findings Include: 1. Clinical record 3, pediatric patient with start of care [SOC] of 5/22/17 and current…

The agency failed to provide education on the risks and potential adverse outcomes, and failed to provide physician notification for refusal of treatment for 1 of 2 active records reviewed of pediatric patient received skilled nursing care and services.

The agency failed to ensure they documented the investigation(s) and resolutions of all complaints for 1 of 1 agency.

The agency failed to ensure there were no discrepancies between patients medication profile and the medications listed on the plan of care for 3 of 4 active patient records reviewed.

The agency failed to complete the recertification within the 5-day window before the end of the 60-day recertification period for 2 of 4 active records reviewed with skilled services [# 2 and 4] and 1 of 2 closed records reviewed with home health only services [#8]. Findings Include: 1. Record…

The agency failed to ensure to individualize a client's plan of care related to the time and route of a medication, the amount of fluid for G-tube flushes, and included potential long term goals and/ or discharge plans for 2 of 2 skilled patient records reviewed receiving skilled nursing services…

The agency failed to administer services as ordered by the physician for 1 of 4 active records reviewed with orders for skilled nurse services.[4] Findings Include: Review of clinical record #4, included a plan of care established by the physician for the certification period 5/17/2019 through…

The agency failed to provide physician notification for refusal of treatment for 1 of 2 active pediatric records reviewed with orders for skilled nurse services.[4] Findings Include: Clinical record review for patient #4 included Skilled Nursing Visit Notes dated 7/13/2019, 7/12/2019, 6/18/2019…

The agency failed to ensure patient identified needs that affect patient safety were coordinated for 1 of 2 active records reviewed with orders for home health aide services only.[6] Findings include: Record review for patient #6 of most current plan of care for certification period 7/24/2019…

The agency failed to provide current written information for medication instructions for 1 of 2 home observations of skilled nurse care. [3] Findings include: A home observation was conducted on 8/6/2019 at 8:25 AM at the residence of Patient 3. During the observation, the home folder was found…

The agency failed to ensure the LPN's performance was evaluated during a supervisory visit for 1 of 1 record reviewed receiving skilled nurse services from a LPN (Licensed Practical Nurse).

The agency failed to ensure the home health aides were not assigned to administer medications for 1 of 2 closed records reviewed that received only aide services.

The agency failed to ensure the registered nurse made a supervisory visit at least every 60 days, to observe and assess each aide during the provision of care for 1 of 2 closed records reviewed who received only home health aide services.

The Administrator failed to ensure Surveys were provided unrestrictive access to electronic patient records persuant to the State Operations Manual Appendix B for 1 of 1 agency.

The facility failed to assess patient's behavior, which were identified during 2 case conferences, with modifications and/or interventions to address a patient's response of noise verbalization instead of the use of words for 1 of 2 skilled home visits conducted.

The agency failed to ensure a gastrostomy tube (G-tube) feeding was administered in a manner to prevent complications with a G-tube for 1 of 2 skilled home visits with observation of a G-tube feeding (patient 1) and failed to ensure that skilled nurse medication administration was provided in…

The agency failed to ensure that the clinical record included physician orders for 1 of 2 active pediatric records reviewed with orders for skilled nurse services.

The agency failed to ensure a discharge summary was submitted to the primary care physician at discharge for 1 of 2 closed records reviewed, who received only aide services.