Amber Home Health Care, Inc

The Agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 10 (MR#'s 1, 2, 5, 6, 7, 8, 9, 10, 11, and 13) of 17 records reviewed, resulting in the potential for unmet care needs and a poor outcome (See G528); failed to ensure a registered…

The agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes in 4 of a total of 17 sampled records reviewed (MR#s 6, 7, 8, and 10), resulting in difficulty determining the patient's progress toward the achievement of goals (See G572); failed to…

The agency (HHA) failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care (G-682), and failed to provide documented evidence that infection control education was provided to all staff (G-686), in 3 of 8 employee files (MSW #1, LPN #2 and RN #2)…

The Agency failed to ensure the Skilled Nurse performed baseline assessments and reassessments, including monitoring patient's weight and measurable assessments of edema for 2 (MR #2, 4) of 5 patients with diagnoses that included Congestive Heart Failure, from a total of 17 sampled records reviewed.

The agency (HHA), failed to provide initial training in Emergency Preparedness (EP) policies and procedures to all contracted employees, and failed to maintain documentation of training, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the…

The Agency failed to ensure the transfer summaries were complete, detailed, and provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 1 (MR#'s 11 and 15) of 2 records in which the patient…

The agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes in 4 of a total of 17 sampled records reviewed (MR#s: 6, 7, 8, and 10), resulting in difficulty determining the patient's progress toward the achievement of goals.

The agency failed to ensure home health aide services were provided as ordered by the physician for 1 (MR#15) of 7 records reviewed with home health aide services ordered, resulting in a lack of services and the potential for unmet patient needs; and failed to ensure the skilled nurse followed the…

The Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for…

The Agency failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care and services for 2 (MR's 1,4) of 2 patients observed during home visits from a total of 17 sampled records reviewed, resulting in the potential for the development and spread of…

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

The agency failed to ensure the registered nurse supervised the care of the licensed practical nurse for 1 of 17 (MR #17) records reviewed, resulting in a lack of oversight regarding the services provided by the licensed practical nurse.

The Agency failed to ensure the Registered Nurse (RN) prepared clear written patient care instructions for the Home Health Aide regarding safety precautions and client needs, prior to providing care in 3 (MR's #1, 2, 4) of 7 records in which Home Health Aide services were provided, from a total of…

The agency failed to ensure that 2 (MR's #1, 4 ) of 2 patient's observed during home visits, from a total of 17 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, the…

The Agency failed to provide documented evidence of the existence of complaints received, details of the investigation and the resolution of the complaints, as per this requirement, resulting in the potential for unaddressed patient/family concerns, inability to exercise one's rights and unmet care…

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 and outcomes, measurable data to use as a baseline for future assessments…

The Agency 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, and failed to ensure the physician was notified of potential severe drug interactions and…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters and measurable goals for 9 (MR's #1, 2, 4, 6, 9, 11, 12, 16, and 17) records, from a total of 17 sampled records reviewed, resulting in patients not receiving care specific to their…

The agency failed to ensure the physician was notified of significant changes in the patient's condition in 1 (MR #11) of 5 records reviewed with congestive heart failure, 1 (MR #1) of 1 record of a patient with elevated blood pressure readings, 1 (MR #2) of 1 record of a patient with a newly…

The Agency failed to coordinate the delivery care concerning skilled nursing (SN), physical therapy (PT), and physician in 1 (MR#11) of 16 records reviewed in which more than one discipline was ordered to provide care out of a total of 17 records reviewed, resulting in unmet clinical care needs and…

The agency failed to provide 2 (MR#'s 1, 4) of 2 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, from a total of 17 sampled records reviewed, resulting in lack of direction…

The Agency failed to ensure the Skilled Nurse performed baseline assessments and reassessments, including monitoring patient's weight and measurable assessments of edema for 2 (MR #2, 4) of 5 patients with diagnoses that included Congestive Heart Failure, from a total of 17 sampled records reviewed.

The Agency failed to ensure the clinical record was complete and included detailed Skilled Nursing and Occupational Therapy notes for 1 (MR #2) of 1 record where the ordered disciplines communicated the status of the patient's declining health utilizing a Text messaging system, from a total of 17…

The Agency failed to ensure the Home Health Aide provided care in accordance with the written plan of care for 1 (MR #4) of 1 patient observed during a Home Health Aide home visit, from a total of 17 sampled records resulting in the patient not receiving care and services as ordered and unmet care…

The agency (HHA) failed to ensure employee qualifications were documented in the employee's files for 4 of 8 employee files (MSW #1, OT #2, LPN #2 and RN #2) reviewed, from a total of 8 employee files reviewed, resulting in the potential for care being provided by unqualified personnel.

The agency failed to ensure the speech therapist documented clinical notes for 1 of 3 (MR#17) records reviewed with speech therapy services, resulting in a lack of information regarding the care provided by speech therapy and the patients progress towards therapy goals.

The agency failed to insure a detailed discharge summary was sent to the physician within 5 business days of discharge for 3 of 5 (MR# 3, 9,16) discharge records reviewed; and failed to ensure a detailed transfer summary was sent to the receiving health care facility within 2 business of becoming…