Caremax Home Health

The facility failed to ensure multidisciplinary visit notes and plan of care (POC) assessments for seven out of seven patients (Patient 1, 2, 3, 4, 5, 6 & 7) were signed accurately and timely according to the policies and procedures (P&P) and facility protocol.

The facility failed to develop, implement, and document an effective, ongoing data-driven Quality Assessment and Performance Improvement (QAPI) program for completion of clinical notes and annual tuberculosis (TB) test.

The facility failed to ensure that supervisory nurse (RN) home visits were implemented no less than 14 days as indicated in the facility policy for one (Patient 3) of 7 patients.

The home health agency (HHA) failed to ensure: the patients received all the ordered services, staff documented with an explanation of the missed visits and notified the physician to approve changes in the plan of care for seven of seven sampled patients.

The home health agency failed to ensure three of seven sampled patients (Patients 1, 2 and 3) for home visit, were provided with written information containing: 1. The visit schedule of the ordered skilled care services.

The home health agency failed to provide oversight of patient care services for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7) and of staff responsibility in the proper implementation of these services when: 1. Patient 1 missed one SN (skilled nursing) home visit for the…

The home health agency (HHA) failed to ensure one of seven sampled patients' (Patient 6), refusal to receive Physical Therapy (PT) services was communicated with the physician and documented in the clinical record.

The home health agency (HHA) failed to ensure the physician orders incorporated in the plan of care for two (Patient 4 and 2) of seven sampled patients were authenticated, clarified and signed by the physician within an established timeframe as indicated in the HHA’s policy.

The home health agency failed to ensure the attending physician was notified of any changes in the skilled care home visit orders for seven out of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7) when: 1. Patient 1 missed one SN (skilled nursing) home visit for the recertification period…

The home health agency failed to ensure missed skilled care home visits and notification to physicians of the missed visits and/or order changes were documented in the clinical record of seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7) when: 1. Patient 1 missed one SN (skilled…