Shas Inc.

The agency failed to ensure a COVID – 19 request for a medical exemption met the criteria from the Center for Medicare and Medicaid Services (CMS) and / or the Centers for Disease Control and Prevention (CDC) in 1 of 1 medical exemption reviewed.

The home health agency failed to ensure all employees followed agency infection control policies and procedures and standard precautions for 3 of 4 home visit observations (#1, 2, 4).

The home health agency failed to ensure an agency-wide infection control program was maintained for the surveillance, identification, prevention, control, and investigation of patient and staff infections for 1 of 8 active patient infection reports (#31), 3 of 5 discharged patient infection reports…

The home health agency failed to ensure all staff received infection control education in relation to daily self-monitoring for COVID-19 for 4 of 4 employees interviewed regarding self-monitoring for COVID-19 symptoms (F, G, L, LL), which had the potential to impact all employees and patients of…

The home health agency failed to ensure home health aides (HHA) were oriented and competency checked on the proper use of Hoyer lifts for 4 of 6 HHAs interviewed (Employees L, LL, P, MM) and were trained on patient-specific Hoyer lifts via manufacturer's instructions for use in 10 of 10 active…

The home health agency failed to ensure all patient complaints were thoroughly investigated for 20 of 36 complaints reviewed, which involved 16 patients (#4, 5, 12, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30).

The home health agency failed to ensure the comprehensive assessment contained a complete and thorough health status for 5 of 5 active records reviewed (#1, 2, 3, 4, 5), in a total sample of 17 records.

The home health agency failed to ensure the comprehensive assessment included the patient's progress towards goals and care preferences for 5 of 5 active records reviewed (#1, 2, 3, 4, 5), in a total sample of 17 records.

The home health agency failed to ensure the comprehensive assessment included individualized patient nursing and discharge planning needs for 5 of 5 active records reviewed (#1, 2, 3, 4, 5), in a total sample of 17 records.

The registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications which maintained the medication list accurately for 4 of 5 active records reviewed (#2, 3, 4, 5), in a total sample of 17 records.

The home health agency failed to ensure the comprehensive assessment included the primary caregiver's willingness and ability to provide care, availability, and schedules for 1 of 1 active records of patients with primary caregivers reviewed (#2), in a total sample of 17 records.

The home health agency failed to ensure the plan of care (POC) included all pertinent diagnoses, the patient's nutritional requirements, a complete list of the patient's medications, patient and caregiver education, training to facilitate timely discharge, and patient-specific and measurable goals…

The home health agency failed to ensure the skilled nurse did not provide services absent a physician order for 2 of 4 home visit observations (Patients #1, 4).

The home health agency failed to notify the patient's medical provider for a change in the patient's condition for 1 of 2 active records with a noted change in patient condition, in a total sample of 17 records.

The home health agency failed to ensure the revised plan of care (POC) contained the patient's progress towards their goals for 5 of 5 active records reviewed (#1, 2, 3, 4, 5), in a total sample of 17 records.

The home health agency failed to ensure the administrator reported to the governing body.

The home health agency failed to ensure written agreements were in place which delineated the services each agency was to provide for 2 of 2 active records reviewed (#2, 5), in a total sample of 24 patients who received care from another agency and 17 records reviewed.

The home health agency failed to ensure a shared patient agreement which indicated the primary home health agency was created for 2 of 2 active records reviewed (#2, 5), in a total sample of 24 patients who received care from another agency and 17 records reviewed.