Universal Healthcare

The agency failed to ensure the infection control program activities were included in QAPI program activities for 12 patients and employees.

The agency failed to ensure advance beneficiary notice prior to discharge from agency services were provided to one (Patient #11) of 12 patients.

The agency failed to: 1. Notify the physician the agency could no longer meet the patient’s need for nursing visits twice daily for one (Patient #11) of 12 patients.

The agency failed to ensure an initial assessment was conducted within 48 hours of receipt of referral for two (Patients #1 and #7) of 12 patients.

The agency failed to ensure a resumption of care assessment was completed after an inpatient facility stay for two (Patient #4 and #9) of 12 patients.

The agency failed to ensure care was coordinated between the agency and physician for one (Patient #11) of 12 patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for 12 patients and all employees.

The agency failed to ensure physical therapy assistant supervisory visits were completed for two (Patients #2 and #5) of 12 patients.

The agency failed to ensure a completed transfer or discharge summary was provided to the receiving service provider for four (Patients #4, 9, 10 and #12) of 12 patients.

The agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for all patients and employees.

The agency failed to ensure physician notification of BS levels greater than the ordered reporting parameter of 400 for one (Patient #4) of seven patients.

The agency failed to ensureutilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure: 1. The infection control program was included in QAPI program activities for all patients and employees and; 2. The infection control exposure plan was followed for one (Patient #2) of seven patients and three staff members.

The agency failed to ensure an initial assessment and comprehensive assessment (OASIS) was conducted within 48 hours of referral for two (Patient #5 and #6) of seven patients.

The agency failed to ensure a SOC comprehensive assessment (OASIS) was completed for one (Patients #5) of seven patients.

The agency failed to ensure the medication profile was reviewed and updated with ordered medications for two (Patient #4 and #6) of seven patients.

The agency failed to ensure the individualized patient POC included: Pain reporting parameters for three (Patients #2, 3 and #4) of seven patients and;Weight and edema monitoring reporting parameters for one (Patient #4) of seven patients.

The agency failed to ensure a completed discharge summary was provided for two (Patients #6 and #7) of seven patients.

The agency failed to ensure: 1) evaluation of PIPs 2) data documenting the need for PIPs.

The agency failed to ensure the comprehensive assessments included a review of all medications for drug reactions, interactions and duplicate drug therapy for seven (Pts #1, 2, 3, 4, 5, 6 and 7) of seven patients.

The agency failed to ensure the CHHA visit frequency was completed as ordered on the plan of care for two (Patient #3 and 5) of seven patients.