Americare Home Health Solutions

The home health provider failed to ensure that the Outcome and Assessment Information Set (OASIS; a standardized data collection tool) was electronically transmitted to the CMS system within the required timeframe in 222 of 2442 (9.09%) of the assessments submitted.

The home health provider failed to ensure the accuracy of documentation in one of five full records reviewed (Record/Patient #2).

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

The home health provider failed to ensure the plan of care (POC) included only pertinent diagnosis, interventions to address patient needs, and safety measures in two of five full records reviewed (Records/Patients #2, and #3).

The agency failed to provide care and services that met the requirements for the Condition of Participation: Patient Rights.

The agency failed to provide care and services that met the requirements for the Condition of Participation: Care Planning, coordination, and quality of care.

The agency failed to provide care and services that met the requirements for the Condition of Participation: Infection Prevention and Control.

The agency failed to provide care and services that met the requirements for the Condition of Participation: Skilled Professional Services.

The agency failed to organize, manage, and administer its resources in a manner that met the requirements for the Condition of Participation: Organization and Administration of Services.

The agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, and individuals providing services under arrangement and maintain documentation of the training in two (Employees #1 and #4) of four personnel files reviewed.

The agency failed to document a follow-up analysis/evaluation when the agency activated their emergency plan in three of three emergency plan exercises reviewed.

The agency failed to ensure the written notice of patient’s rights included that information must be provided to patients in plain language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at…

The provider failed to ensure that patient’s received the home health services that are written in their individualized plan of care in, but not limited to, two (Records/Patients #2 and #4) of five full records reviewed.

The agency failed to ensure staff followed acceptable standards of practice for infection control in three (Records/Patients #1, #2, and #3) of three home visit observations.

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases as an integral part of the agency QAPI program.

The agency failed to maintain a coordinated agency-wide infection control program that included infection control education upon hire for a contracted staff in one (Employee #4) of four personnel files reviewed.

The agency failed to ensure one (Employee #1) of nine employees reviewed had an approved exemption from the COVID-19 vaccination.

The agency failed to ensure staff followed their policy and procedure for wound and pain assessments in two (Records/Patients #1 and #3) of five full records reviewed.

The agency failed to ensure the governing body assumed full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, its operational plans, and its quality assessment and performance improvement (QAPI) program.

The agency failed to ensure that written notice of the patient’s rights and responsibilities and the agency transfer and discharge policies is understandable to persons who have limited English proficiency and accessible to individuals with disabilities.

The agency failed to provide the written notice of patient rights that included the patient’s right to have a copy of the patient’s rights and responsibilities and the agency’s transfer and discharge policies provided to a patient-selected representative within four business days of the initial…

The provider failed to ensure the patient has the right to receive all services outlined in the plan of care in one (Record/Patient #4) of five full records reviewed.

The agency failed to provide patients with the correct hours of operation for the state toll free home health hotline telephone number.

The agency failed to ensure the patient was advised of the name, address, and telephone number of the Federally-funded and state-funded entities that serve the area where the patient resides.

The agency failed to ensure the patient was informed of the right to access auxiliary aids and language services and how to access these services.

The agency failed to maintain an accurate/updated medication profile in three (Records/Patients #1, #2, and #3) of three home visit observations and failed to document a medication review by a nurse in one (Record/Patient #6) of one record reviewed that received therapy services only.

The agency failed to develop a complete, individualized plan of care (POC) for three (Records/Patients #1, #2, and #5) of five full records reviewed.

The agency failed to promptly alert the physician or allowed practitioner to changes in the patient’s condition in one (Record/Patient #1) of five full records reviewed.

The agency failed to coordinate care regarding patient needs in two (Records/Patients #1 and #3) of five full records reviewed.

The agency failed to ensure staff documented complete pain assessments and wound assessments in two (Records/Patients #1 and #3) of five full records reviewed.

The agency failed to follow the physician ordered plan of care (POC) in two (Records/Patients #1 and #3) of five full records reviewed.

The agency failed to ensure staff documented accurate information in two (Records/Patients #1 and #3) of five full records reviewed.

The agency failed to ensure staff were provided with annual agency in-service training in one (Employee #1) of four personnel files reviewed.

Based on the results of this extended level survey, resulting in noncompliance with four Conditions of Participation: Care planning, coordination of services, and quality care; Skilled professional services; Infection control and prevention, and Organization and administration of services, the…

The administrator was not aware of the location of results of the Family Care Safety Registry (FCSR) checks, Employee Disqualification List (EDL) checks, infection control training, annual agency in-service training, Alzheimer’s training, and emergency preparedness training missing from the…

The agency failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice when it failed to verify results of the Family Care Safety Registry (FCSR) for two (Employees #1 and #2) of four employee files reviewed, the Employee…

The agency failed to provide initial and annual emergency preparedness training to all employees in two (Employee (Emp) B and C) of three employee files reviewed.

The agency failed to ensure that the encoded OASIS (Outcome and Assessment Information Set) data accurately reflected the patient's status at the time of the assessment in one (Record/Patient #4) of five records reviewed.

The agency failed to ensure staff followed infection control standards of practice in two (Records/Patients #4 and #5) of three home visit observations.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the rights of the patient and representative (if any) regarding contact information for the home health agency administrator, to receive…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) has the right to participate in, be informed about, and consent or refuse, with respect to…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) has the right to be advised of the names, addresses, and telephone numbers of federal and…

The agency failed to ensure the patient's current health status was assessed and documented in one (Patient/Record #1) of five records reviewed.

The agency failed to ensure an accurate medication reconciliation was completed in, but not limited to two (Records/Patients #2 and #5) of five records.

The agency failed to ensure the patient received an individualized plan of care (POC) that included all the required items in, but not limited to three (Records/Patients #2, #3, and #5) of five records reviewed.

The agency failed to ensure each patient received written information related to visit schedule/instructions, in two (Records/Patients #2 and #5) of three applicable home visits.

The agency failed to ensure each patient received written information related to the name and contact information of the home health agency's clinical manager in two (Records/Patients #2 and #5) of three applicable cases.

The agency failed to ensure Alzheimer's and dementia training for persons providing direct patient care included: - Overview of Alzheimer's Disease and related dementias; - Communicating with persons with dementia; - Behavior management; - Promoting independence in activities of daily living; and -…

The agency failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the agency/services within five business days of the patient's discharge…