The Whole Person, Inc.

The home health provider failed to ensure the patient had the right to have all efforts made and documented to resolve issues that resulted in an unsupported determination of homebound status and discharge from services in one of three patient records reviewed (Record/Patient #2).

The home health provider failed to ensure that the Outcome and Assessment Information Set (OASIS; a standardized data collection tool.

The provider failed to ensure: - An initial assessment visit was completed within 48 hours of the referral, or within 48 hours of the patient’s return home (G0514); - A comprehensive assessment that accurately reflected the patient’s current health status (G0528); and - An accurate medication…

The home health provider failed to: - Ensure an individualized plan of care (POC) included relevant physicians who were providing home health orders (G0574); - Ensure drugs, services, and treatments were administered only as ordered by a physician or allowed practitioner (G0580); - Promptly alert…

The home health provider failed to: - Ensure the quality assessment performance improvement (QAPI) program included quality indicator data, derived from the outcome and assessment information set (OASIS; a standardized data collection tool) reports (G0644); and - Provide evidence that the governing…

The home health provider failed to ensure: - The governing body assumed responsibility for the overall clinical and financial operations and the quality assessment performance improvement (QAPI) program (G0942); and - That the administrator and governing body authorized in writing a pre-designated…

The home health provider failed to ensure that the Outcome and Assessment Information Set (OASIS; a standardized data collection tool.

The home health provider failed to ensure the quality assessment performance improvement (QAPI) program included quality indicator data, derived from the outcome and assessment information set (OASIS; a standardized data collection tool) reports.

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

The home health provider failed to provide evidence the infection control program was included in the quality assessment performance improvement (QAPI) program.

The home health provider failed to maintain professional standards when wound measurements were not obtained/documented according to the provider's policy in, two of two records with wounds (Records/Patients #2 and #4).

Based on the results of this extended level survey, resulting in noncompliance with five Conditions of Participation: Reporting OASIS information, Patient rights, Care planning, coordination of services, and quality of care, Quality assessment and performance improvement (QAPI), and Organization…

The home health provider failed to ensure the governing body assumed responsibility for the overall clinical and financial operations and the quality assessment performance improvement (QAPI) program.

The home health provider failed to ensure all documented entries were accurate and complete, in two of five full records reviewed (Records/Patients #2 and #4).

The home health provider failed to ensure staff provided the patient and/or caregiver with contact information for the administrator, in order to receive complaints, in one of three home visit observations conducted (Record/Patient #2).

The home health provider failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in four (Patients/Records #1, #3, #4, and #5) of five records reviewed.

The home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status in, two of five full records reviewed (Records/Patients #2 and #4).

The home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in three of five full records reviewed (Records/Patients #1, #2, and #3).

The home health provider failed to develop a complete and individualized plan of care (POC) in, five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5).

The home health provider failed to ensure that treatments were provided only as ordered by the physician, in three of five full records reviewed (Records/Patients #1, #2 and #4).

The home health provider failed to promptly alert the physician when the patient had a change in condition, in four of five full records reviewed (Record/Patient #1, #2, #3, and #4).

The home health provider failed to ensure that each patient and his or her caregiver(s), received education regarding the physician order to instruct the patient on measures to detect and alleviate edema and instruct on a daily weight self-monitoring program, in one of five full records reviewed…

The home health provider failed to ensure each patient received complete/accurate written instructions related to their medication schedule/instruction in two of three home visit observations (Records/Patients #2 and #3).

The home health provider failed to ensure staff provided the patient and/or caregiver with the name contact information for the provider’s clinical manager in, one of three home visit observations conducted (Record/Patient #2).

The home health provider failed to ensure the registered nurse (RN) adequately supervised the licensed practical nurse (LPN) in two of five records of patients who received LPN visits (Records/Patients #2, and #4).

The home health provider failed to ensure that the administrator and governing body authorized in writing a pre-designated administrator for when the administrator is not available.

The agency failed to ensure staff were provided annual Emergency Preparedness (EP) training, in two (Employees #2 and #5) of five employee files reviewed.

The agency failed to ensure that accepted standards of practice to prevent the transmissions of infections and communicable diseases were followed in one (Record/Patient #3) of three home visits conducted.

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases specific to care and services provided, in two (Records/Patients #1 and #2) of five full records reviewed.

The agency failed to ensure clinical record documentation was complete and/or accurate in, two (Records/Patients #3 and #4) of five full records reviewed.

The agency failed to provide the patient with contact information for the HHA (home health agency) administrator, in one (Record/Patient #2) of three home visit observations.

The agency failed to ensure that the patients be advised, orally and in writing, of the extent to which payment for HHA (home health agency) services may be expected, in one (Record/Patient #2) of three home visit observations.

The agency failed to conduct the initial assessment visit to determine the immediate care and support needs of the patient within 48 (forty eight) hours of the referral, in three (Records/Patients #1, #2, and #4) of five full records reviewed.

The agency failed to ensure an accurate and complete review of all medications was completed upon admission/SOC (start of care) and/or update of the patient’s medications was completed, in two (Records #2 and #3) of five full records reviewed.

The agency failed to ensure a comprehensive assessment was completed within 48 (forty-eight) hours of the patient’s return home from a hospital admission, in one (Record/Patient # 1) of five full records reviewed.

The agency failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner, in two (Records/Patients #1 and #2) of five full records reviewed.

The agency failed to alert the physician to a change in the patient’s condition, in two (Records/Patients #1 and #2) of five full records reviewed.

The agency failed to ensure a revised plan of care accurately reflected information from the patient’s updated comprehensive assessment, in one (Record/Patient # 1) of five full records reviewed.

The agency failed to ensure ongoing interdisciplinary assessment of patient, in three (Records/Patients #1, #2, and #4) of five full records reviewed.

The agency failed to ensure that physical therapy assistant (PTA) services were provided under the supervision of the physical therapist (PT), in one (Record/Patient #2) of five full records reviewed.

The agency failed to: 1) Ensure all staff had the Employee Disqualification List (EDL) checked prior to hire (E1, E2, E3, and E4), and had the Family Care Safety Registry (FCSR) checked prior to patient contact (E1, E2, E3, and E4); and 2) Ensure services were provided in accordance with their…

The agency failed to complete or send a transfer summary to the receiving institution within two business days of becoming aware of becoming aware of an unplanned transfer in two (Records/Patients #2 and #5) of five full records reviewed; and the agency failed to send a discharge summary to the…

The agency failed to conduct an annual tabletop exercise test to test its emergency preparedness plan.

The agency failed to ensure staff followed physician orders in, but not limited to, one (Record/Patient #4) of six records reviewed.

The agency failed to ensure the patient's stated goals for care, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient were assessed/documented as part of the patient's comprehensive assessment in, but not limited to…

The agency failed to ensure an accurate medication reconciliation was completed in, but not limited to, two (Record/Patient #1 and #4) of six records reviewed.

The agency failed to ensure staff developed a complete plan of care in, but not limited to, two (Record/Patient #3 and #4) of six records reviewed.

The agency failed to ensure care was provided as ordered by the physician on the plan of care in, but not limited to, one (Record/Patient #1) of six records reviewed.

The agency failed to ensure patient/caregiver education was provided in, but not limited to, one (Record/Patient #4) of six records reviewed.

The agency failed to: - Request and obtain results of findings of the Employee Disqualification List (EDL) prior to hire in one employee (Employee #3) out of four employee files reviewed; - Request and obtain results of findings of the Family Care Safety Registry (FCSR) prior to first patient…