Clayview Home Health Services, Inc

The home health provider failed to ensure the registered nurse (RN) completed the initial assessment within 48 hours of the patient's referral or return home in, but not limited to, one of five full records reviewed (Record/Patient #1).

The home health provider failed to ensure that all medications the patient was taking were current in one of two home visit observation records reviewed (Record/Patient #1).

The provider failed to ensure that each patient's written individualized plan of care included the frequency and duration of visits to be made, patient-specific interventions and education, measurable outcomes and goals identified in the comprehensive assessment, and all safety measures regarding…

The home health provider failed to ensure skilled professional services were provided in an acceptable manner and as ordered by the physician in one of five full records reviewed (Record/Patient #4).

The provider failed to establish an emergency preparedness program to meet the federal, state, and local emergency preparedness program requirements.

The home health provider failed to promote and protect the following patient rights: - Provide contact information for the home health agency (HHA) administrator, that included the administrator's name (G414); - Make complaints to the home health provider regarding care that fails to be furnished…

The agency failed to ensure that a complete and accurate patient specific comprehensive assessment was completed for each patient.

The home health provider failed to: - Implement an effective discharge planning process (G562); and - Send all necessary medical information pertaining to the patient, to the receiving facility or health care practitioner to ensure the safe and effective transition of care (G564).

The agency failed to: - Ensure each patient received a written individualized plan of care (POC) with patient specific, measurable outcomes and goals (G572); -Ensure each patient received an individualized plan of care, which included a description of the patient's risk for emergency department…

The agency failed to: - Ensure there was evidence that the agency is measuring, analyzing, and tracking quality indicators (G642); - Ensure the agency used data collected to monitor the effectiveness and safety of the services and quality of care and identifying opportunities for improvement…

The home health provider failed to: - Ensure that accepted standards of practice to prevent the transmissions of infections and communicable diseases were followed (G682); and - Maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation…

The home health provider failed to: - Ensure ongoing interdisciplinary assessment of the patient (G706); and - Communicate with all physicians involved in the plan of care (G718).

The home health provider failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to showed a functioning governing body, administrative, and clinical manager oversight to…

The home health provider failed to: - Ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge process (G1022); and - Ensure all documented entries included…

The provider failed to review and update their EP plan every two years.

The provider failed to document an all hazards risk assessment to address emergency events identified by the risk assessment.

The provider failed to include the types of services the hospice would be able to provide in an emergency.

The agency failed to ensure each patient had an individualized emergency plan documented as part of the patient's comprehensive assessment in five of six records reviewed (Records/Patients #1, #2 #3, #4, and #5).

The agency failed to include a procedure for informing state and local officials of patients in need of evacuation during an emergency.

The home health provider failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish, and maintain a program that addressed procedures to follow up with on-duty staff, and patients to determine services that are needed.

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the provider failed to review, and update a written emergency communication plan at least every two years.

The provider failed to ensure names, and contact information for staff, entities providing services under arrangement, patient's physicians, and volunteers were included in the EP plan.

The provider failed to ensure contact information was included, and updated for federal, tribal, or other sources of assistance.

The provider failed to ensure that emergency preparedness training was provided every two years to all existing employees, and individuals providing services under arrangement, in one of four employee files reviewed (E-1).

The home health provider failed to conduct an annual, individual, facility-based functional exercise to test the emergency plan annually, and analyze the agency's response, and revise the agency's emergency plan as needed.

The home health provider failed to implement an effective discharge planning process, in one of two discharge records reviewed (Record/Patient #6).

The home health provider failed to send all necessary medical information pertaining to the patient, to the receiving facility or health care practitioner to ensure the safe and effective transition of care, in one of two discharge records reviewed (Record/Patient #6).

The home health provider failed to provide each patient with an individualized plan of care that was established and signed by the physician, in four out of six records reviewed (Records/Patients #1, #2, #3, and #4).

The agency failed to provide evidence that the agency was measuring, analyzing, and tracking quality indicators.

The agency failed to provide evidence that collection of quality data was on going to: - Monitor the effectiveness and safety of the services and quality of care; and - Identify opportunities for improvement.

The agency failed to provide evidence that the performance improvement activities were focused on high risk, high volume, or problems-prone areas This deficient practice has the potential to affect the quality of care and safety of all agency patients.

The agency failed to provide evidence of performance improvement activities to track adverse patient events, analyze their causes, and implement preventative actions.

The agency failed to provide evidence of any performance improvement activities that were focused on high risk, high volume, or problem prone areas.

The agency failed to provide evidence that the governing body was responsible for ensuring the agency had an ongoing program for quality improvement and patient safety.

The home health provider failed to ensure that accepted standards of practice to prevent the transmissions of infections and communicable diseases were followed in one of three home visits conducted (Record/Patient #1).

The home health provider failed to maintain a coordinated agency-wide program for prevention, control and investigation of infectious and communicable diseases that was part of the agency's quality assessment and performance improvement (QAPI) program.

The home health provider failed to demonstrate and ensure the governing body had assumed effective oversight responsibility for the operation of the agency.

The home health provider failed to ensure all documented entries included appropriate authentication that included, the time the plans of care were completed, the plan of care signed by the nurse, plans of care signed and dated by the physician, and documentation of the visits were completed…

The home health provider failed to provide contact information, that included the administrators name in order to receive complaints, in one of three home observation visits (Record/Patient #1).

The home health provider failed to document concerns from a patient regarding abrupt discharge without notice in advance of terminating on-going care, in one of six full records reviewed (Record/Patient #6).

The home health provider failed to provide written notice in advance of terminating on-going care to the patient, in one of two discharge records reviewed (Record/Patient #6).

The provider failed to provide written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week).

The home health provider failed to arrange a safe and appropriate transfer to other care entity when the needs of the patient exceeded the HHA’s (home health agency) capabilities, in one of six full records reviewed (Record/Patient #6).

The home health provider failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date, in one of six records reviewed (Record/Patient #5).

The home health provider failed to ensure the skilled clinician’s assessments of patients accurately reflected the patient’s current health status, in four of six full records reviewed (Records/Patients #1, #3, #4, and #6).

The home health provider failed to ensure a complete/accurate medication review, and/or update of the patient’s medications was completed, in three of six full records reviewed (Records/Patients #1, #3, and #6).

The home health provider failed to ensure that each patients' written individualized care plan included all the required elements, in four of six records reviewed (Records/Patients #1, #3, #4, and #6).

The home health provider failed to ensure that all patient care orders were included on the plan of care (POC), in one of six records reviewed (Record/Patient #4).

The home health provider failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner, in four of six full records reviewed (Records/Patients #1, #2 #3 and #4).

The home health provider failed to ensure the individualized plan of care was reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care, no less frequently than every sixty days, beginning with the start of care, in one of six record reviews…

The home health provider failed to promptly alert the physician to changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered, in two of six full records reviewed (Records/Patients #1 and #6).

The provider failed to include the name and contact information of the home health provider’s clinical manager in two of three home visits (Records/Patients #2 and #3).

The agency failed to provide evidence of any performance improvement activities that were focused on high risk, high volume, or problems-prone areas.

The home health provider failed to ensure ongoing interdisciplinary assessment of the patient, in one of six full records reviewed (Record/Patient #6).

The home health provider failed to communicate with all physicians involved in the plan of care (POC) in one of six full records reviewed (Record/Patient #3).

Based on the results of this extended level survey, resulting in noncompliance with ten Conditions of Participation: Patient rights; Comprehensive Assessment of Patients; Discharge Planning; Care Planning, Coordination of Services, and Quality of Care; Quality Assessment and Performance…

The agency failed to show the administrator was responsible for all day to day operations of the home health provider.

The home health provider failed to ensure a completed discharge summary was sent to the health care professional responsible for providing care and services to the patient after discharge, in one of two discharge records reviewed (Record/Patient #6).

The agency failed to meet the requirements for the Condition of Participation: Emergency Preparedness, when the agency failed to: - Update the Emergency Preparedness Plan every two years (0004); - Have in place a process that cooperated and collaborated with state and federal Emergency Preparedness…

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information based on the new home health regulations effective 01/13/18. The agency failed to provide in writing, in advance of furnishing care, the…

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

The agency failed to meet the requirements for the Condition of Participation: Skilled Professional Services, when the agency failed to: - Ensure skilled staff provided ongoing interdisciplinary assessment of the patients (G706).

The agency failed to review and update their Emergency Preparedness Plan every two years.

The agency failed to have in place a process that cooperated and collaborated with state and federal Emergency Preparedness officials to maintain an integrated response during a disaster or emergency situation.

The agency failed to categorize class priority of patients (acuity status) in the event of an emergency as part of the comprehensive assessment and failed to provide/leave a copy of the assessment in the patient's home in three (Record/Patient #1, #2, and #3) of three home visit patients.

The agency failed to develop an emergency preparedness system of documentation that preserved patient information, protected confidentiality, and secured and maintained the availability of records.

The agency failed to develop an emergency preparedness plan that included a communication plan with contact information for federal emergency preparedness staff.

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 information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities…

The agency failed to provide each patient with an individualized plan of care that was established by the physician in, but not limited to, one (Record/Patient #2) of five records reviewed.

The agency failed to ensure that occupational therapy (OT) evaluation assessments were completed within 48 hours of receipt of a referral in one (Record/Patient #3) of five patient records reviewed.

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 agency must obtain the patient/representative signature confirming that he/she has received a copy of the notice of rights and…

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 written notice to the patient about their right to have a copy of the patient's rights and responsibilities provided to a…

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 patient has the right to participate in, be informed about, and consent or refuse care, in advance of and during treatment, where…

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 patient has the right to be advised of financial liability changes as soon as possible, in advance of the next home health visit.

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 patient has the right to receive proper written notice, in advance of a specific service being furnished, if the agency believes…

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) be advised of the names, addresses, and telephone numbers of the following Federally funded…

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) have a right to be informed of the agency's policies for transfer and discharge when the…

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) have a right to be informed of the agency's policies for transfer and discharge when the…

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 patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician…

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) have a right to be informed of the agency's policies for transfer and discharge when the…

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 regarding the patient rights when the agency determines that the patient or other persons in the home has behavior that is disruptive, abusive or…

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 agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for…

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 if the patient is being considered for a discharge for cause, the agency must make efforts to resolve the problem.

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 agency must document the problem and efforts made to resolve the problem, if the patient is considered for a discharge for…

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) have a right to be informed of the agency's policies for transfer and discharge if the…

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 patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency…

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 has the right to be informed that the agency must investigate complaints made by the patient regarding treatment or…

The agency failed to ensure that each patients' written individualized care plan included all the required elements in, but not limited to, two (Record/Patient #2, and #4) of five records reviewed.

The agency failed to ensure all patient care orders were recorded in the plan of care in, but not limited to one (Patient/Record #3) of five records reviewed.

The agency failed to ensure each patient received written information related to visit schedule/instructions in two of three applicable cases (Records/Patients #1 and #3).

The agency failed to ensure each patient received updated/current written instructions related to the patient's medication schedule in, but not limited to, two (Record/Patient #1 and #3) of three home visit observations.

The agency failed to ensure all skilled professionals providing service conducted ongoing assessments of the patient in, but not limited to, two (Record/Patient #3 and #4) of five records reviewed.

The agency failed to ensure a qualified, pre-designated person who is authorized in writing by the administrator and the governing body assumes the same responsibilities and obligations as the administrator when the administrator is not available.

The agency failed to ensure all staff complied with Federal laws for making the Hepatitis B vaccine available in two (E1 and E2) of four employee files reviewed; and based on review of Section 192.2490.12 RSMo and Section 192.2495.6 and 192.2495.7 RSMo, and 19 CSR-30-26.101 (1)(B)(3), agency policy…