Caresphere, LLC

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including provision of optimal care to achieve the goals and outcomes identified in the patient's plan of care.

The agency failed to provide access to documentation needed to conduct a complaint investigation.

The governing body failed to ensure a qualified registered nurse (RN) was hired for the position of Clinical Manager /Supervising nurse.

The agency failed to ensure a registered nurse (RN) completed a comprehensive assessment for two (2) of four (4) CR reviewed.

The agency failed to ensure the patient's plan of care covered all required elements for four (4) of four (4) clinical records (CR) reviewed (CR#1, 2, 3, 4).

The agency failed to provide documentation that all patient care was provided as ordered in the plan of care for two (2) of four (4) clinical records (CR) reviewed (CR#1 and 4) Findings include: Review of clinical records (CR) on May 21, 2025, from approximately 1:00 P.M. to 3:00 P.M. revealed the…

The agency failed to follow their policy related to substance abuse for one (1) of four (4) PF reviewed.

The agency failed to ensure a registered nurse conducted the initial evaluation, completed a comprehensive assessment, review all medications, and update the comprehensive assessment the last 5 days of every 60 days.

The agency failed to ensure patient’s received appropriate care planning, coordination of services, and quality of care.

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including provision of optimal care to achieve the goals and outcomes identified in the patient’s plan of care.

The agency failed to follow its own policy and ensure that staff completed a comprehensive assessment visit at least every sixty (60) days or as often as the patients condition changed for seven (7) of the seven (7) clinical records (CR) reviewed (CR#1-CR#7).

The agency failed to provide access to documentation needed to conduct a State re-licensure survey.

The governing body and the administrator failed to ensure a qualified registered nurse (RN) was hired for the position of Clinical Manager /Supervising nurse.

The agency failed to follow its own policy and ensure that a registered nurse (RN) conducts the initial assessment/comprehensive assessment visit for seven (7) of the seven (7) clinical records (CR) reviewed (CR#1-CR#7).

The agency failed to ensure a comprehensive assessment was conducted no later than (5) calendar days after the start of care for seven (7) out of seven (7) CR reviewed (CR#1-CR#7).

The agency failed to provide documentation showing staff completed evaluations of all patient medications per policy including but not limited to: any potential adverse effects, any drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate…

The agency failed to ensure that a reassessment occurred within the last five (5) days of every sixty (60) day recertification period for seven (7) of seven (7) CR's reviewed.

The agency failed to ensure the patient's plan of care covered all required elements including but not limited to: specific interventions to be provided by the staff skilled and non-skilled, duration of services for seven (7) of seven (7) clinical records (CR) reviewed (CR#1-CR#7).

The agency failed to provide documentation that all patient care was provided as ordered in the plan of care for seven (7) of seven (7) clinical records (CR) reviewed (CR#1-CR#7).

The agency failed to ensure the physician reviewed and revised the plan of care no less frequently than once every 60 days for three (3) of seven (7) clinical records (CR) reviewed (CR#4, 5, and 7).

The agency failed to maintain documentation of supervisory visits of the LPN (licensed practical nurse) and HHA (Home Health Aide) by a RN (Registered Nurse) in accordance with the plan of treatment for five (5) out of the seven (7) CRs reviewed.

The agency failed to follow its own policy and state law to conduct a state, federal, and child line background checks upon hire for two (2) out of nine (9) employee files; the agency failed to ensure that employees were screened for mycobacterium tuberculosis (TB) upon hire for one (1) out of nine…

The agency failed to ensure a registered nurse (RN) made the initial evaluation visit and initiated the plan of treatment, regularly reevaluated the patient's nursing needs made necessary revisions to the plan of treatment for seven (7) out of seven (7) CR reviewed (CR#1-CR#7).

The agency failed to protect patients individually identifiable health information for one (1) of one (1) observations (Observation #1).

The agency failed to ensure a registered nurse conducted the initial evaluation and failed to ensure a registered nurse completed a comprehensive assessment.

The agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system, for three (3) out of eight (8) patient clinical records (CR) reviewed (CR#3, CR#4, CR#6).

The agency failed to complete the initial assessment visit for two (2) of eight (8) clinical records (CR#4, CR#8).

The agency failed to ensure a comprehensive assessment was conducted no later than (30) calendar days (Centers for Medicare & Medicaid Services (30) day blanket waiver (updated 06/16/22) after the start of care for two (2) out of eight (8) patient clinical records (CR) reviewed (EF#4, EF#8).

The agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional within five (5) business days (Centers for Medicare & Medicaid Services (10) day blanket waiver (updated 06/16/22) of the patient discharge for one (1) of two (2)…