Peacehealth Southwest Home Health

The agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0104 and M0102 for 9 of 19 patients (Patient #104, #108, #109, #603, #610, #612, #616, #618 and #619).

The agency failed to update its policies and procedures and conduct personnel Tuberculosis (TB) testing to comply with agency-wide and state licensing requirements for TB infection control program for 12 of 12 personnel files reviewed (Staff #608, #609, #610, #611, #612, #613, #614, #615, #616…

The agency failed to update and operationalize its policies and procedures consistent with state licensing requirements through failure to conduct reference checks for 2 of 12 clinicians (Staff #610 and #617) (Item #1); failure to update its policies and procedures on Mandatory Reporting based on…

The agency failed to conduct the initial assessment visit within the 48 hours of completing the referral and failed to notify the patients’ physician of the delayed services for 6 of 19 patients (Patient #102, #104, #603, #612, #614, and #616) Failure to meet this requirement places patients at…

The agency failed to provide evidence that Aide Supervisory visits occurred no less frequently than every 14 days for 1 of 2 patients receiving Home Health Aide (HHA) services (Patient #101).

The agency failed to develop and operationalize infection control policies and procedures that included an annual Tuberculosis (TB) risk assessment screening of Home Health staff consistent with State regulations for 4 of 7 Staff ( Staff #301, #302, #303 and #304).

The agency failed to ensure patients received a copy of their Patient Rights prior to receiving services for 2 of 17 patient records (Patient #612, and #615).

The agency failed to ensure patients received an initial assessment within 48 hours from the referral date for 4 of 17 patient records (Patient #301, #314, #611, and #615).