Ralls County Health Department and Home Health Agency

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information.

The agency failed to ensure that a complete and accurate patient specific comprehensive assessment was completed for each patient.

The agency failed to: - Provide the required information in the patient's individualized plan of care (574); - Provide a visit schedule, including frequency of visits to the patient (G614); - Provide an accurate medication schedule/instructions to the patient (G616); - Provide a copy of written…

The agency failed to: - Ensure there was evidence that the agency is measuring, analyzing, and tracking quality indicators (G642); - Ensure the agency used data collected to monitor the effectiveness and safety of the services and quality of care and identifying opportunities for improvement…

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative…

The agency failed to ensure staff were provided emergency preparedness training annually for two (Employee #1 and #3) and emergency preparedness training at orientation for one (Employee #2) of three agency employee files reviewed.

The agency failed to ensure the patient's comprehensive assessment was up to date and revised to include change in patient's health status in one (Patient/Record #1) of three records reviewed.

The agency failed to provide evidence that the agency was measuring, analyzing, and tracking quality indicators.

The agency failed to provide evidence that collection of quality data was on-going to: - Monitor the effectiveness and safety of the services and quality of care; and - Identify opportunities for improvement.

The agency failed to provide evidence that the performance improvement activities were focused on high risk, high volume, or problems-prone areas This deficient practice has the potential to affect the quality of care and safety of all agency patients.

The agency's Quality Assessment and Performance Improvement (QAPI) activities failed to show the agency conducted at least one performance improvement project to reflect the scope, complexity, and past performance of the agency's services/operations with measurable progress achieved.

The agency failed to provide evidence that the governing body was responsible for ensuring the agency had an ongoing program for quality improvement and patient safety.

The facility failed to continue implementing their program for screening visitors/non-employees for COVID-19 (pandemic infection) who entered the home health agency office.

The home health agency failed to ensure that the clinical manager was available to provide oversight of all patient care services and personnel, assuring the patient needs are continually assessed, and assuring the development, implementations, and updates of the individualized plan of care on one…

The agency failed to provide at least one other service in addition to skilled nursing services, in but not limited to, one (Record/Patient #1) of one home visit observations.

The agency failed to provide the patient and representative correct contact information for the current home health agency administrator, to receive complaints in, but not limited to, one (Records/Patients #1) of one home visit conducted.

The agency failed to provide written information regarding the patient's right to participate in, be informed about, and consent or refuse care, with respect to completion of all assessments, care to be furnished based on the comprehensive assessment, establishing and revising the plan of care, the…

The agency failed to ensure the patient was advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program and the charges of services that may not be covered in, but not limited to, one (Record/Patient…

The agency failed to update the written notice of patient rights to include that the patient has the right to be advised of the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides.

The agency failed to ensure the patient's current health status was assessed and documented in one (Patient/Record #1) of three records reviewed.

The agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in, but not limited to, one (Record/Patient #1) of one home visit observations and one (Record/Patient #3) of three full record reviews.

The agency failed to ensure the plan of care (POC) included diagnosis, complete wound care orders, oxygen settings, and durable medical equipment for two (Record/Patient #1 and #3) of three records reviewed.

The agency failed to ensure each patient received written information related to visit schedule/instructions in one (Record/Patient #1) of one home visit made.

The agency failed to ensure each patient received updated/current written instructions related to the patient's medication schedule in one (Record/Patient #1) of one home visit observation.

The agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in one (Record/Patient #1) of one home visit made.

The agency failed to provide in writing the name and contact information of the clinical manager in one (Record/Patient #1) of one home visit made.

The agency failed to provide evidence of any performance improvement activities that were focused on high risk, high volume, or problems-prone areas.

Based on the results of this extended level survey, resulting in noncompliance with five Conditions of Participation: Patient rights, Comprehensive Assessment of Patients, Care Planning, Coordination of Services and Quality of Care, Quality Assessment and Performance Improvement (QAPI), and…

The agency failed to ensure the clinical manager supervised effective assessment of agency patients in one (Record/Patient #1) of one home visit made.

The agency failed to assure the development, implementation, and updates to the individualized plan of care on one (Records/Patients #1) of three patient records reviewed.

The agency failed to ensure the clinical records contained the contact information for the patient's primary caregiver in, but not limited to, one (Record/Patient #1) of three records reviewed.

The agency failed to ensure a complete, comprehensive transfer summary containing relevant information was sent to the other health care facility the patient was receiving care at within two business days of the agency becoming aware of the patient's transfer for two (Record/Patient #2 and #3) of…

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information based on the new home health regulations effective 01/13/18. The agency failed to provide in writing, in advance of furnishing care, the…

The agency failed to meet the requirements for the Condition of Participation: Quality Assessment and Performance Improvement (QAPI), when the agency failed to: - Ensure there was evidence that the agency is measuring, analyzing, and tracking quality indicators (G642); - Ensure the agency used data…

The agency failed to provide care using effective infection prevention and control methods, when: - Accepted standards of practice to prevent the transmission of infections were not identified by agency-specific procedure/policies (G682); - The agency failed to maintain a coordinated agency-wide…

The agency failed to meet the requirements for the Condition of Participation: Organization and Administration of Services, when the agency failed to ensure: - The governing body assumed full legal authority and responsibility for the agency management, operation, and the provision of all home…

The agency failed to ensure each patient had an individualized emergency plan documented as part of the patient's comprehensive assessment in, but not limited to, two (Records/Patients #2 and #4) of five cases reviewed.

The agency failed to ensure encoded OASIS data accurately reflected the patient's status in two (Records/Patients #3 and #4) of five applicable cases.

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 notice that if the state court has not adjudged a patient to lack legal capacity to make health care decisions as defined by state…

The agency failed to update/provide the written notice of patient rights that included the patient's right to be informed of the agency's policies for transfer and discharge.

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 that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities…

The agency failed to provide evidence that the agency was measuring, analyzing, and tracking quality indicators.

The agency failed to provide evidence that the frequency and detail of the quality data collection was approved by the agency's governing body, and collection of quality data was on-going to: - Monitor the effectiveness and safety of the services and quality of care; and - Identify opportunities…

The agency failed to provide evidence that performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventive actions.

The agency failed to provide evidence that the governing body was responsible for ensuring an ongoing program for quality improvement and patient safety.

The agency failed to show documented evidence of agency-specific procedures or policies regarding the use of standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases when providing care to patients.

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is a part of the agency's quality assessment and performance improvement (QAPI) program that included: - A method for…

The agency failed to provide infection control education to staff in three (Employees: E1, E2, and E3) of three employee files reviewed.

The governing body meeting notes held one to two times a month from January 2015 through May 2018 failed to show: - A specific discussion/review of the home health agency quality assurance performance improvement program (QAPI) information occurred; - A review of performance improvement activities…

The administrator, who is also a member of the governing body, has effectively assumed responsibility for the overall administration, supervisory functions and overall operations of the home health agency.

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: - Transfer and discharge policies; - Rights and responsibilities that are understandable to persons who have limited English…

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 verbal notice of the patient's rights and responsibilities in the individual's language, free of charge, no later than the completion of…

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 written notice to the patient about their right to have a copy of the patient's rights and responsibilities provided to a…

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 free from verbal, mental, sexual and physical abuse, including injuries of unknown source, neglect and…

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 make complaints to the home health agency regarding treatment or care that is (or fails to be) furnished…

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 participate in, be informed about, and consent or refuse care, with respect to completion of all…

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 receive all services outlined in the plan of care The deficient practice has the potential to affect the…

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: - Financial liability changes as soon as possible, in advance of the next home health visit…

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 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 names, addresses, and telephone numbers of federal and state-funded entities that serve…

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 informed of the right to access auxiliary aids and language services and how to access these services.

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 that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

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 that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

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 and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician…

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 that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

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 that the agency policy for discharge for cause: - Determines that the patient's or other persons in the home, behavior is disruptive…

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 that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for…

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 that if the patient is being considered for discharge for cause, the agency must make efforts to resolve the problem.

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 that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact…

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 that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause.

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 that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the…

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 and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency…

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 that if the patient, the patient's representative (if any), or the patient's caregiver or family made a complaint, the agency must…

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 that if the patient, the patient's representative (if any), or the patient's caregiver or family made a complaint regarding treatment or…

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 that the agency must investigate mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown…

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 that the patient had a right to be informed that the agency must investigate and document both the existence and resolution of…

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 that the agency must take action to prevent further potential violations while investigating a complaint.

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 that any agency staff in the normal course of providing services to patients, who identifies, notices, or recognizes incidences of…

The agency failed to ensure the registered nurse (RN) performed an accurate and complete review/update of all medications the patient was currently using in, but not limited to, three (Records/Patients #1, #2, and #3) of five cases reviewed.

The agency failed to ensure a complete plan of care (POC) was developed in, but not limited to, three (Records/Patients #3, #4, and #5) of five cases.

The agency failed to provide evidence that the performance improvement activities were focused on high risk, high volume, or problem-prone areas.

The agency failed to provide evidence that the performance improvement activities considered the incidence, prevalence, and severity of problems in high risk, high volume, or problem-prone areas.

The agency failed to provide evidence that the performance improvement activities lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of the patients.

The agency failed to provide evidence that actions aimed at performance improvement occurred, and that the agency measured its success and tracked performance to ensure that improvements are sustained.

The agency failed to ensure staff received the required home health agency sponsored in-service training in, but not limited to, one (Employee: E3) of three employee files reviewed.

The agency failed to ensure the administrator provided responsible oversight for the day-to-day operations of the home health agency, when the administrator failed to: - Develop/implement a Quality Assessment and Performance Improvement (QAPI) program; - Provide/document information to the…

The administrator failed to ensure the agency developed personnel policies and provided adequate in-service training to staff.

The agency failed to ensure the discharge summary was sent to the physician within five business days of discharge in one (Records/Patient #5) of one applicable case reviewed where a discharge occurred after 1/13/18 when the new federal regulations became effective.