Ambi's Home Health Care, LLC

Deficiencies cited at G572, G576, G580 Findings are: G572 Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the home health services were provided as written in the patient's physician-approved plan of care for 5 of 8 patient records reviewed…

Deficiencies cited at G774, G798, and G808 Findings are: G774 Based on record review, policy and procedure review, and staff interview, the agency failed to ensure 2 of 3 home health aides (HHA, HHA- G and HHA -H) sampled received 12 hours of in-service training during 2023 and 2024. The agency…

Deficiencies cited at G948 and G958 Findings are: G948 Based on clinical record review, Administrator job description, Quality Assurance and Performance Improvement Review, personnel file review, and staff interview, the agency Administrator failed to ensure the regulatory and statutory…

The agency failed to provide emergency preparedness training to all direct and indirect staff at least every 2 years.

The agency failed to ensure the home health services were provided as written in the patient's physician-approved plan of care for 5 of 8 patient records reviewed (Patient 2, 3, 4, 5, and 6).

The agency Quality Assurance and Performance Improvement Program (QAPI) failed to identify, track, analyze, and develop measurable goals and failed to maintain data to evaluate the effectiveness of the agency identified Performance Improvement Plans (PIP) to ensure quality care, services, and…

The agency failed to ensure 2 of 3 home health aides (HHA, HHA- G and HHA -H) sampled received 12 hours of in-service training during 2023 and 2024. The agency employs 7 HHAs.

Staff interview the agency failed to ensure the Home Health Aide (HHA) plan of care (POC) was individualized to meet the patient specific needs for 1 of 3 (Patient 2) patients who received HHA services.

The clinical manager failed to provide oversight of patient care services and personnel.

The agency failed to ensure all clinician notes were complete, authenticated, and dated by the clinician providing the service for 6 of 8 (Patient 1, 2, 3, 4, 7 and 8) clinical records reviewed and failed to have a process in place to ensure authentication occurred when the electronic medical…

The agency failed to complete a comprehensive assessment of the patient’s rehabilitative needs within 5 days after the start of care for 4 of 6 patients who had orders for Occupational Therapy (OT) and/ or Physical Therapy (PT) included on the plan of care (Patient 1, 3, 7, and 8).

The agency failed to ensure all physician orders were accurately recorded in the patient's plan of care for 1 of 1 patient who received wound care (Patient 6).

The agency failed to ensure wound care treatments were completed as ordered for 1 of 1 patient (Patient 6) patient who received wound care treatments.

The agency failed to conduct an on-site visit by a Registered Nurse (RN), to the patient’s home every 14 days, to ensure the Home Health Aide (HHA) followed the patient's plan of care, and to ensure the HHA services meet the patient’s needs for 2 of 3 patients who received HHA services (Patient 2…

The agency Administrator failed to ensure the regulatory and statutory requirements and agency policy and procedures were followed by the agency.

The agency failed to ensure the Home Health Aide (HHA) plan of care was reviewed and updated every 60 days according to the agency policy and procedure, for 3 of 4 patient records reviewed who received HHA services (Patient- 1, 3, and 5).

The agency failed to ensure all orders are included on the patient's plan of care for 1 of 7 clinical records reviewed (Patient- 1).

The agency failed to ensure treatments and services were completed as ordered on the plan of care for 1 of 7 clinical records reviewed (Patient-6).

The agency failed to ensure staff followed the agency policy and procedure for the coordination of the delivery of care among all services providing care for 2 of 7 clinical records reviewed (Patient-4 and Patient-6).

The agency failed to have a process in place to ensure the agency's Quality Assessment and Performance Improvement (QAPI) program continued to be completed during periods of time when agency staff conducted work from home to ensure improvements were sustained.

Policies and procedures and staff interview the agency failed to review the EPP, failed to complete a community based risk assessment using an all-hazards approach, failed to include in the EPP the method to be utilized for sharing medical information regarding patients, and failed to provide…

Deficiency cited at G528. Findings are: G528 Based on review of clinical records, review of policy and procedure and staff interview, the agency failed to include the assessment of the patient's current health status for 1 of 7 patients reviewed (Patient 1) as assessments of the patient did not…

Deficiencies cited at G572, G576, G580, and G590. G572 Based on review of clinical records, review of policy and procedure and staff interview the agency failed to provide services to 7 of 7 patients ( Patients 1, 2, 3, 4, 5, 6, and 7) as written in the individualized plan of care and as outlined…

Deficiencies cited at G642 and G684 G 642 Based on review of policy and procedure, the agency's Quality Assurance and Performance Improvement (QAPI) documentation and staff interview, the agency failed to measure, analyze and track quality indicators to assess the agency's processes, services and…

Deficiencies cited at G710 and G726 G710 Based on review of clinical records, review of policy and procedure and staff interview the agency failed to have a skilled professional evaluate the plans of care for 7 of 7 patients reviewed (Patient 1, 2, 3, 4, 5, 6, and 7) to ensure services were…

Deficiencies cited at G754 and G768 G754 Based on review of policy and procedure, review of personnel files and staff interview the agency failed to ensure Staff member-M had met the requirements for a nurse aide training and competency evaluation program approved by the State of Nebraska and was…

Deficiencies cited at G948, G968 and G982 G948 Based on review of clinical records, personnel files, the agency's Position (job) Description for the Home Health Administrator, policies and procedures and staff interviews the agency Administrator failed to organize and direct the day-to-day…

Agency policies and procedures and staff interviews the agency failed to assure the clinical records for 7 of 7 patients reviewed contained current information for each patient.

Policies and procedures and staff interview the agency failed to maintain and review an Emergency Preparedness (EP) plan for the agency.

The agency failed to complete a facility and community based risk assessment that used an all-hazards approach to ensure the agency's Emergency Preparedness Policy and Procedures were developed to include facility and community specific risks and failed to include the assessment in the agency's…

Policies and procedures and staff interview the agency failed to include in the EPP the agency's means for sharing information and medical documentation for patients under the agency's care, with other health care providers to maintain continuity of care.

Policies and procedures and staff interview the agency failed to provide initial training to 9 of 10 employees reviewed (Staff member F, G, I, J, K, M, A, C, and L).

Staff interview the agency failed to provide services to 7 of 7 patients (Patients 1, 2, 3, 4, 5, 6, and 7) as written in the individualized plan of care and as outlined in physician orders.

The agency failed to measure, analyze and track quality indicators to assess the agency's processes, services and quality of care and the agency failed to track and implement interventions for the prevention of infections in 2020 and 2021. Agency census was 101. These failed practices provided…

The agency failed to track and implement interventions for the prevention of infections in 2020 and 2021. These failed practices provided missed opportunities for the agency to identify areas of infection control concerns, provide opportunities for improvement and to implement interventions for the…

The agency failed to complete a written competency evaluation for 1 of 8 Home Health Aides (HHA) reviewed HHA-I and failed to conduct a skills competency evaluation for 7 of 8 HHA personnel records reviewed (HHA-I, J, K, A, F, G, and M).

Staff interview the agency failed to ensure an employee of the agency provided at least one service to 22 of the 101 patients.

The agency failed to investigate an allegation made by a patient (Patient 1) regarding mistreatment by agency staff.

Staff interview the agency failed to include the assessment of the patient's current health status for 1 of 7 patients reviewed (Patient 1) as assessments of the patient did not identify the presence of pressure ulcers.

Staff interview the agency failed to record the physician orders for wound care on the plan of care for 3 of 3 patients with wounds (Patient 1, 3, and 5).

Staff interview the agency failed to provide drugs as ordered by the physician for 1 of 7 patients reviewed (Patient 1).

Staff interviews the agency failed to promptly alert the patient's physician(s) to changes in the patient's condition or needs and/or to inform the physician of the need to alter the plan of care for 7 of 7 patients reviewed (Patients 1, 2, 3, 4, 5, 6, and 7).

Staff interview the agency failed to have a skilled professional evaluate the plans of care for 7 of 7 patients reviewed (Patient 1, 2, 3, 4, 5, 6, and 7) to ensure services were provided to the patients as ordered by the physician and as indicated in the plan of care.

Personnel files and staff interview the agency failed to provide supervision of the Licensed Practical Nurses (LPNs) employed by the agency by a Registered Nurse (RN) to evaluate performance in providing cares, treatments, patient education, communication with the RN and data collection regarding…

Staff interview the agency failed to ensure staff member-M had met the requirements for a nurse aide training and competency evaluation program approved by the State of Nebraska and was currently in good standing with the state nurse aide registry prior to be permitted to provide services to…

Policies and procedures and staff interviews the agency Administrator failed to organize and direct the day-to-day functions of the agency to ensure compliance with state and federal regulations for home health agencies as required in the agency's Home Health Administrator job description.

Policies and procedures and staff interviews the Clinical Supervisor failed to assure patient plans of care were individualized, updated and implemented for 7 of 7 patients reviewed.

The agency failed to complete and provide a transfer summary to the receiving health care facility when 2 of 7 patients (Patient 1 and 7) were transferred from the agency to another health care facility.

The agency failed to complete a transfer summary for 2 of 2 sampled patients (Patients 1 and 2), who were transferred from the agency.

Staff interview the agency failed to provide written notice to 1 of 4 patients reviewed (Patient 1) of patient rights and responsibilities and the agency's transfer and discharge policies.

Staff interview the agency failed to follow the plan of care and provide wound treatment as ordered by the patient's physician for 1 of 3 patients reviewed (Patient 2).