Advisacare

The agency failed to ensure the patient received the services outlined in the plan of care in 3 (P-5, 6, and 10) of 10 records reviewed, resulting in the potential for unmet care needs ( see G572), failed to ensure the plan of care included individualized, patient-specific, interventions, and…

The agency failed to ensure the patient received the services outlined in the plan of care in 3 (P-5, 6, and 10) of 10 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure the registered nurse supervised the care of the licensed practical nurse for 1 (P-5) of 10 records reviewed, resulting in a lack of oversight regarding the services provided by the licensed practical nurse.

The agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the start of care in 3 (P-4, 5, 6) of 10 records reviewed, resulting in a delay in determining the immediate care and support needs for these patients.

The agency failed to ensure the comprehensive assessment contained an accurate, complete picture of the patient’s current health, psychosocial, functional, and cognitive status in 2 (P-8, 10) of 10 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure the comprehensive assessment contained goals identified by the patient with measurable outcomes in 3 (P-7, 8, 9) of 10 records reviewed, resulting in the potential for a lack of individualized care and unmet care needs.

The agency failed to ensure the comprehensive assessment included a review of all medications prescribed to the patient, and include those medications in the patient's medication profile in its entirety for possible adverse effects or drug interactions in 1 (P-2) of 10 records reviewed and failed…

The agency failed to ensure the plan of care included individualized, patient-specific, interventions and measurable outcomes and goals in 8 (P-1, 4, 5, 6, 7, 8, 9 and 10) of 10 sampled records reviewed potentially resulting in insufficient information to adequately assess patient progress.

The agency failed to ensure the registered nurse promptly alerted the physician to changes in the patient's condition for 1 (P-5) of 10 records reviewed, resulting in increased pain, and burning with urination, resulting in a six-day hospitalization requiring intravenous antibiotics.

The agency failed to ensure care was coordinated between disciplines to assure identification of patient needs, safety and treatment effectiveness in 2 (P-7, 9) of 10 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs.

The agency failed to ensure the skilled professionals provided services as ordered by the physician in the plan of care for 1 (P-5) of 10 records reviewed, resulting in the potential for physical decline and unmet care needs for this patient.

The agency failed to ensure home health aides reported changes in the patient’s condition to a registered nurse or other appropriate skilled professional in 2 (P-6 and 9) of 4 records reviewed with home health aide services, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure a completed transfer summary was sent to the physician within 2 business days of becoming aware of an unplanned transfer in 2 (P-4, and 9) of 3 records reviewed with a transfer, resulting in the potential for unmet patient care needs.

The agency failed to ensure the comprehensive assessment included baseline information detailing the patient's current health at the time of admission for 6 of 10 (MR# 5, 6, 7, 8, 9 and 10) records reviewed (See G528); failed to ensure the patient's Activity of Daily Living needs were adequately…

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 4 of 5 records reviewed (MR#s 5, 6, 8 and 9) with skilled nursing ordered out of a total of 10 records reviewed, resulting in a potential for failure to measure progress toward achievement of…

The Agency failed to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided (G642); failed to develop Performance Improvement activities, as part of the Agency's QAPI (Quality…

The agency failed to ensure the clinical record was complete and included clinical notes, transfer summaries and comprehensive assessments for 2 (MR#'s 2, 9) of 10 records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient's health status and…

The agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 3 of 10 records reviewed (MR #8, 9 and 10) for Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for negative patient outcomes in the…

The Agency failed to ensure that the comprehensive assessment was updated and revised in 1 (MR #2) of 2 records in which the patient was transferred and admitted to an inpatient facility related to unknown causes, resulting in the lack of information in determining the care and support needs of the…

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 4 of 5 records reviewed (MR#s 5, 6, 8 and 9) with skilled nursing ordered out of a total of 10 records reviewed, resulting in a potential for failure to measure progress toward achievement of…

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all 79 patients currently…

The Agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the annually quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2018, 2019 and 2020 calendar years, resulting in the…

Based record review and interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness…

The Agency (HHA) failed to provide documented evidence that infection control education was provided to any of the 37 employees of the agency including those granted clinical privileges, resulting in the potential for the development and spread of infection.

The Registered Nurse (RN) failed to prepare clearly written patient care instructions and include safety precautions on the aide's care plan, in 2 of 4 records in which Home Health Aide (HHa) services were provided (MR# 1, 5) from a total sample of 10 records reviewed.

The Agency failed to ensure that 1 of 1 Physical Therapy Assistants, who was granted clinical privileges, maintained an active and current license when providing care, resulting in the potential for the provision of unsafe care and unmet care needs.

The agency failed to inform the patient in advance of the disciplines that will furnish care in 1 of 10 records reviewed (MR#8) from a total sample of 10 records reviewed, resulting in the patient not having knowledge of the plan for treatment.

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments, outcomes, baseline information and history of events leading to current home…

The Agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 1 (MR #2) of 3 patients assessed as needing assistance with ADLs; and failed to ensure 1 (MR #2) of 1 patient's Medical Social Work needs were met, resulting in the potential for…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required, failed to have a registered nurse review the medications, and failed to ensure the physician…

The agency failed to ensure the plan of care included safety measures, and pain parameters in 3 of 7 records (MR# 5, 6 and 7) from a total of 10 records reviewed, resulting in the potential for injury and unmet care needs.

The Agency failed to ensure that all drugs, care and services were provided only in accordance with Physician's orders for 1 (MR #1) of 3 discharged records, from a total of 10 records reviewed, resulting in the potential for the provision of unsafe, unauthorized care and unmet care needs.

The Agency failed to ensure the Physician was promptly notified, as ordered in the plan of care, of vital signs outside the reportable parameters, for 1 (MR #2) of 1 patient with elevated blood pressure readings, from a total of 10 sample records reviewed, resulting in the potential for…

The agency failed to ensure the Clinical Manager coordinated patient care in 1 of 4 (MR#'s 7) home visits where State surveyors were scheduled, from a total sample of 10 records reviewed.

The agency failed to ensure the clinical record was complete and included clinical notes, transfer summaries and comprehensive assessments for 2 (MR#'s 2, 9) of 10 records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient's health status and…

The agency failed to ensure that discharge and transfer summaries were complete, provided the patient's current health status at the time of discharge and transfer, documented progress toward goals, and were sent to the physician in 4 of 4 records (MR# 1, 2, 5 and 8) who were discharged/transferred…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 1 (MR #1) record of a patient with a diagnosis of Pressure Ulcers, from a total of 4 sampled records reviewed (G574)…

The Agency failed to ensure the Licensed Practical Nurse followed accepted standards of practice in assuming responsibility for the care of 1 (MR #1) of 1 patient who required wound care management, from a total of 4 sampled patient records reviewed, resulting in interruption in needed care and…

The agency failed to ensure the Clinical Manager maintained a record of referral and acceptance/non-acceptance of patients for services that were ordered for 4 of 4 (MR# 5, 6, 7, and 8) records reviewed (SEE G964).

The agency failed to ensure clinical record was complete and included clinical notes, assessments, and documentation that accurately captured the status of the patient and responses to treatment during the specified episode of care, for 1 (MR #1) record, from a total of 4 sampled records reviewed…

The Agency failed to ensure the Licensed Practical Nurse followed accepted standards of practice in assuming responsibility for the care of 1 (MR #1) of 1 patient who required wound care management, from a total of 4 sampled patient records reviewed, resulting in interruption in needed care and…

The Agency failed to ensure all treatments and services were administered only as ordered by the physician, and failed to ensure the plan of care was reviewed by the physician for 1 (MR #1) of 4 records reviewed of patient's who required wound care, from a total of 4 sampled records reviewed…

The Agency failed to ensure all treatments and services were administered only as ordered by the physician, and failed to ensure the plan of care was reviewed by the physician for 1 (MR #1) of 4 records reviewed of patient's who required wound care, from a total of 4 sampled records reviewed…

The agency failed to ensure Physician's orders were complete, signed, authenticated and dated by the Physician for 1 (MR# 1) of 1 patient who was required wound care for a diagnosis of Pressure Sores to bilateral buttocks, from a total of 4 records reviewed, resulting in the provision of…

The agency failed to ensure the Physician was promptly notified that skilled nursing and wound care services had been discontinued for 1 (MR #1) patient with a diagnosis of Pressure Sores bilateral buttocks, from a total of 4 sampled records reviewed, resulting in the potential for worsening of…

The agency failed to ensure the registered nurse performed re-assessments of the patient's health status and needs in 1 (MR #1) record of a patient with a diagnosis of congestive heart failure, and pressure ulcers, from a total of 4 sampled records reviewed, resulting in the potential for…

The agency failed to maintain a record of referral and acceptance of patients for services that were ordered for 4 of 4 (MR# 5, 6, 7, and 8) records reviewed, resulting in unmet record maintenance and availability.

The Agency failed to ensure the clinical record was complete and included clinical notes, assessments, and documentation that accurately captured the status of the patient and responses to treatment during the specified episode of care, for 1 (MR #1) record, from a total of 4 sampled records…

The agency failed to ensure that a transfer summary was completed and sent to the receiving facility for 1 (MR #1) patient who was transferred to an inpatient facility, from a total of 4 records reviewed, resulting in lack of continuity of care and the potential for unmet care needs.

The Agency failed to provide documented evidence that Covid-19 infection control education was provided to all 27 staff employed by the agency and contracted staff who were granted clinical privileges, resulting in the potential for the development and spread of infection.

The agency failed to ensure the plan of care covered all pertinent interventions, patient teaching and measurable goals specific to the needs of 3 (MR's #2, 3, 4) records of a patients with a diagnoses of Covid-19, from a total of 4 sampled records reviewed, resulting in the potential for negative…

The agency failed to maintain compliance with this condition of participation.

The agency failed to maintain compliance with this condition of participation.

The agency failed to maintain compliance with this condition of participation.

The agency failed to maintain compliance with this condition of participation.

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section.

The agency failed to provide documentation of participation in a community-based and tabletop drill.

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments to determine progress towards goals, and ascertained the…

The agency failed to ensure the plan of care included individualized measurable goals and outcomes in 5 of 7 records reviewed (MR#s 1, 2, 3, and 6); and failed to ensure the skilled nurse provided nursing care at the frequency ordered in the plan of care in 1 of 7 records reviewed (MR# 7) in which…

The agency (HHA) failed to ensure that 1 of 1 Home Health Aides (HHa #5) whose personnel file was reviewed and whom was employed by the agency for at least 12 months, received the required 12 hours of annual in-service training, resulting in a lack of educational opportunities pertinent to patient…

The agency failed to ensure the registered nurse (RN) prepared written patient care instructions for the home health aide (HHa) for 1 of 4 records reviewed in which HHa services were ordered (MR#7), and failed to ensure the RN included safety precautions in 1 of 4 aide care plans reviewed (MR#1)…

The agency failed to ensure the patient/caregiver were able to participate in the scheduling of physical therapy visits in 1 of 3 joint survey home visit observations (MR#4), from a total sample of 3 home visits, resulting in a potential delay in the attainment of the patient's physical therapy…

The Agency failed to ensure the initial comprehensive assessment visit was made within 48 hours of the date the order was received for 2 records, from a total of 7 records reviewed (MR#s 2 and 3), resulting in the delay of needed services and the potential for decline in health status.

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine major drug interactions, document the findings of the drug regime review, and failed to ensure the physician was notified of potential drug interactions in 1 record from a total of 7…

The Agency (HHA) failed to ensure that the comprehensive assessment (Discharge Oasis) was updated/completed at the time of discharge from the agency in 1 of 2 discharged records, from a total of 7 sampled records reviewed (MR#1), resulting in an incomplete assessment of the patient's health status…

The agency failed to ensure the Plan of Care included functional limitations, safety precautions, specific frequency of visits, durable medical equipment, patient specific individualized interventions that relate to the diagnoses in 3 of 7 sampled records reviewed (MR#s 1, 2, 3) out of a total of 7…

The agency failed to ensure a physician's order for the resumption of care was recorded in the plan of care for 1 of 1 patients in which care was resumed after a hospital admission (MR#7) from a total sample of 7 records reviewed, resulting in a lack of physician oversight and input regarding the…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 of 1 record reviewed (MR#7) in which the patient had increased pain, from a total sample of 7 records reviewed, resulting in a poor patient outcome.

The agency failed to ensure the skilled nurse performed complete assessments and re-assessments of the patient's health status including, actual weights for congestive heart failure patients, edema monitoring in 1 of 7 records reviewed in which nursing services were provided (MR#s 1) out of a total…

The Agency failed to ensure the Physical Therapist (PT) and Occupational Therapist (OT) assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 3 of 7 records in which PT and OT services were ordered (MR#s 1, 3, 7), from a total sample of 7…

The Agency failed to ensure that Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services were administered in accordance with the physician's orders and the plan of care in 2 of 7 records with SN, PT, and OT services ordered (MR#s 3 and 5) from a total of 7 sample records…

The agency failed to ensure the RN (registered nurse) supervised the care provided by the LPN (licensed practical nurse) in 1 of 3 records reviewed in which LPN services were provided (MR#5), from a total sample of 7 records reviewed, resulting in a lack of clinical supervision and oversight and…

The agency (HHA) failed to maintain documentation of competency evaluations in 1 of 1 Home Health Aides (HHa #5) whose personnel file was reviewed, resulting in the potential for the rendering of substandard care and unmet care needs.

The agency failed to ensure that a qualified home health aide (HHa) furnished home health aide services to patients in 1 of 4 records (MR#1) in which HHa services were provided from a total 7 records reviewed.

The agency failed to ensure the home health aide (HHa) provided services as ordered in the plan of care for 3 of 4 patients in which HHa services were provided (MR#s 1, 4, 5), from a total sample of 7 records reviewed, resulting in the patient not receiving services as ordered and unmet care needs.

The agency failed to ensure the registered nurse completed an on-site supervisory visit to the patient's home at least every 2 weeks to supervise the services that were provided by the home health aide for 1 of 4 records reviewed (MR#4) in which aide services had been documented for a period of…

The agency failed to ensure the registered nurse (RN) identified that the home health aide (HHa) did not follow the patient's plan of care during an on-site supervisory visit for 1 of 4 records reviewed in which home health aide services were provided (MR#5), from a total sample of 7 records…