Healthmasters Inc

The agency failed to electronically report and transmit an OASIS (Outcome and Assessment Information Set) assessment in 2 of 2 clinical records reviewed receiving skilled nursing services.

The agency failed to show measurable improvements in indicators to improve health outcomes and quality of care.

The home health agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program utilized data from the patients’ hospitalizations and infections to identify opportunities for improvement and monitor the quality of care.

The governing body failed to ensure an ongoing program for quality improvement was implemented and maintained.

The registered nurse (RN) failed to provide supervision of the licensed practical nurse (LPN) in 1 of 2 clinical records reviewed with services provided by a licensed practical nurse.

The clinician failed to sign clinical notes in 4 of 6 clinical records reviewed (#1, 2, 5, 6) and failed to make changes in the clinical record per agency policy in 1 of 4 clinical records reviewed receiving home health aide services.

The agency failed to ensure the patients had the right to participate in, be informed of, and consent to care in advance of treatment in 2 of 2 clinical records reviewed without a current plan of care.

The agency failed to ensure the comprehensive assessment reflected the patient’s current health status in 4 of 4 clinical records reviewed with a current comprehensive assessment.

The home health agency failed to update the patient’s comprehensive assessment within 48 hours of the patient’s return to the home from the hospital admission of 24 hours or more in 2 of 2 records reviewed with hospitalizations.

The agency failed to ensure verbal orders were documented in the clinical record in 1 of 1 clinical record reviewed with a tracheostomy (a hole surgically inserted into the neck and into the windpipe to assist with breathing).

The home health agency failed to promptly alert physician of changes in conditions that suggests the plan of care should be altered in 3 of 4 clinical records reviewed with current plans of care.

The agency failed to ensure the plan of care was revised to reflect changes in 2 of 2 clinical records reviewed with a hospitalization.

The agency failed to communicate to all physicians involved in the plan of care in 1 of 1 clinical record reviewed with anticoagulant medication (medication used to thin the blood to prevent/treat blood clots).

The agency failed to ensure the performance improvement activities focused on areas of high risk and high volume.

The agency failed to ensure the home health aide (HHA) was supervised to ensure the aides furnished care that followed the patient’s plan of care in 3 of 4 clinical records reviewed with home health aide services.

The clinical manager failed to provide oversight over assuring the patient needs were continually assessed in 2 of 2 clinical records reviewed with skilled nursing services.

The clinical manager failed to provide oversight over the development, implementation, and updates of the individualized plan of care in 2 of 2 clinical records reviewed without a current plan of care.

The agency failed to have at least one performance improvement project either in development, on-going or completed.

The agency failed to ensure the home health aide (HHA) provided services included in the plan of care in 2 of 5 records reviewed receiving only home health aide services (#2, 6).

The home health agency failed to maintain an emergency preparedness plan that was reviewed and/or updated at least every 2 years (see tag E0004); ensured the plan included a current facility-based or community-based risk assessment, to include the COVID-19 pandemic; or strategies for addressing…

The agency failed to ensure the initial comprehensive assessment was completed by a registered nurse (RN) (#1) (see tag G514); failed to ensure the patient’s medication list was current, reviewed at least every 60 days, included all medications the patient used, the route, the dose, and/or the…

The home health agency failed to develop and implement an effective discharge planning process, which included a process to assist patients (who would transfer to another home health agency, or discharged to a long-term inpatient setting) and their caregivers in selecting a post-acute care provider…

The home health agency failed to ensure the patient's plan of care was established, periodically reviewed (at least every 60 days), and signed by the certifying physician, and failed to ensure the patient received the skilled nursing services as ordered in the patient's most recent plan of care…

The home health agency (HHA) failed to develop, implement, evaluate, or maintain a quality assurance/performance improvement (QAPI) program or maintained documentary evidence of its QAPI program.

The home health agency failed to maintain a coordinated agency-wide infection control program as part of the agency's quality assessment and performance improvement (QAPI) program (see tag G680); failed to provide staff with infection control education at least annually, provide staff, patients…

The home health agency failed to ensure the registered nurse (RN) provided a current, written HHA plan of care/aide care plan (see tag G798); failed to ensure the HHA provided services only as ordered by the physician (see tag G800); failed to ensure the RN made a supervisory visit (either by phone…

The agency's governing body failed to provide responsibility of the agency's overall management and operation, including the development/maintenance of operational policies/procedures, the emergency preparedness program, and its quality assessment and performance improvement (QAPI) program (see tag…

The home health agency failed to ensure the patient's clinical record contained a current comprehensive assessment, all of the assessments from the most recent home health admission, or plans of care that were signed by the certifying physician (see tag G1012); failed to ensure the patient's…

The home health agency failed to maintain an emergency preparedness plan that was reviewed and/or updated at least every 2 years.

The agency failed to ensure the emergency preparedness plan included a current facility-based or community-based risk assessment, which included the COVID-19 pandemic; or strategies for addressing emergency events identified by the risk assessment or the COVID-19 pandemic.

The home health agency failed to maintain current emergency preparedness policies and procedures, with review and update(s) at least every 2 years.

The agency's emergency preparedness policies and procedures failed to include contingency plans for provision of uninterrupted care for patients with suspected/confirmed COVID-19. Findings include: An undated agency policy received on 6/09/2022 titled "Disaster/Emergency Preparedness" failed to…

The agency failed to develop and maintain an emergency preparedness communication plan which included the use of volunteers or other emergency staffing in the event of an emergency to ensure the healthcare needs of the patients were met.

The home health agency failed to develop and maintain an emergency preparedness communication plan which included names and contact information for patients' physicians, or volunteers.

The home health agency failed to develop and maintain an emergency preparedness communication plan which included an alternate means for communicating with agency staff.

The home health agency failed to maintain an emergency preparedness training and testing program, that was reviewed and/or updated at least annually, per the agency's own policy.

The agency failed to ensure emergency preparedness training was provided at least annually (per the agency's own policy), or more often as needed; or maintained documentation of all emergency preparedness training.

The agency failed to evidence it conducted exercises to test the emergency plan annually.

The home health agency failed to develop and implement an effective discharge planning process, which included a process to assist patients (who would transfer to another home health agency, or discharged to a long-term inpatient setting) and their caregivers in selecting a post-acute care provider.

The home health agency failed to send a discharge summary to the patient's physician upon discharge from home health services, for 1 of 1 discharged records reviewed (#7).

The home health agency failed to ensure the patient's plan of care was periodically reviewed (at least every 60 days); and failed to ensure the patient received the skilled nursing services as ordered in the patient's most recent plan of care for 7 of 7 clinical records reviewed (#1, 2, 3, 4, 5, 6…

The registered nurse (RN) failed to conform with the physician's orders as noted on the plan of care for 1 of 2 records records reviewed with patients who received skilled nursing services (#4).

The home health agency failed to maintain a coordinated agency-wide infection control program as part of the agency's quality assessment and performance improvement (QAPI) program, and failed to document patient infections for 2 of 2 home visits observed with recent report of infection(s) (#1, 5).

The home health agency failed to provide staff with infection control education at least annually; failed to provide employees, patients and/or caregiver(s) with COVID-19 pandemic education; and failed to provide employees with COVID-19 vaccination mandate requirements, for 5 of 5 employee records…

The home health agency failed to ensure all staff was fully vaccinated for COVID-19; failed to develop and implement policies and procedures to ensure that all staff were fully vaccinated for COVID-19 for 5 of 9 reported employees; or a process for tracking and securely documenting the COVID-19…

The home health agency failed to ensure the registered nurse (RN) provided a current, written home health aide (HHA) plan of care/aide care plan for 5 of 5 patients who received HHA services (#2, 3, 4, 5, 6).

The agency's governing body failed to provide responsibility of the agency's overall management and operation, including the development/maintenance of operational policies/procedures, the emergency preparedness program, and its quality assessment and performance improvement (QAPI) program.

The home health agency failed to ensure all patients’ clinical records were safeguarded against loss or unauthorized use.

The agency failed to ensure the initial comprehensive assessment was completed by a registered nurse (RN) for 1 of 1 home visits observed with a patient who received skilled nursing services (#1).

The agency failed to ensure the initial comprehensive assessment was completed by a registered nurse (RN) for 1 of 1 home visits observed with a patient who received skilled nursing services (#1).

The registered nurse (RN) failed to ensure the patient’s medication list was current, reviewed at least every 60 days, included all medications the patient used, the route, the dose, and/or the indications for use; and/or failed to ensure a drug regimen review was completed to identify duplicate…

The agency failed to ensure the registered nurse (RN) completed multiple comprehensive re-assessments within the last 5 days of every 60 days beginning with the start-of-care date for 6 of 6 clinical records reviewed which required comprehensive reassessments (#1, 2, 3, 4, 5, 6).

The patient's plan of care failed to include all pertinent diagnoses, the types of services, supplies, and equipment required, the frequency and duration of visits to be made, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to…

The home health agency failed to ensure drugs and/or treatments were administered only as ordered on the plan of care for 1 of 3 home visits observed (#1).

The home health agency failed to ensure ongoing, interdisciplinary coordination of care for 1 of 3 home visits observed (#1).

The home health agency failed to ensure it provided the name and contact information for the clinical manager to all agency patients.

The home health agency failed to ensure the registered nurse (RN) and/or licensed practical nurse (LPN) completed clinical documents to include assessment findings, and/or medications/treatments administered, for 1 of 1 home visits with skilled nursing services (#1).

The home health agency failed to ensure nursing services were provided under the supervision of a registered nurse (RN) for 1 of 1 home visits observed with a licensed practical nurse (LPN) (#1).

The home health agency failed to ensure it maintained documentation that demonstrated home health aides (HHAs) received at least 12 hours of in-service training during each 12-month period.

The home health agency failed to ensure the registered nurse (RN) made a supervisory visit (either by phone or on-site) at least every 60 days for 5 of 5 clinical records reviewed with patients who received only home health aide (HHA) services (#2, 3, 4, 5, 6).

The agency's administrator failed to be responsible for the day-to day operations of the agency.

The home health agency failed to ensure the clinical manager was available during all operating hours.

The clinical manager failed to provide direct oversight/assignment of staff and patient schedules.

The home health agency failed to ensure the patient's clinical record contained a current comprehensive assessment, all of the assessments from the most recent home health admission, or plans of care that were signed by the certifying physician, for 7 of 7 records reviewed (#1, 2, 3, 4, 5, 6, 7).

The agency failed to implement, evaluate, and maintain an effective QAPI (Quality Assurance and Performance Improvement) Program for 1 of 1 agency (See G640); failed to ensure the program was capable of showing measurable improvement to improve health outcomes, patient safety, and quality of care…

The agency failed to follow their policy to ensure HHA (Home Health Aide) Care Plans were updated at least every 60 days for 2 of 3 active clinical records reviewed with a HHA.

The agency failed to ensure RNs (Registered Nurses) completed HHA (Home Health Aide) Supervisory Visits at least every 60 (sixty) days for 1 of 3 clinical records reviewed with HHA services.

The Governing Boday failed to ensure they were responsible for the agency's overall quaility assessment and performance improvement program for 1 of 1 agency.

The agency failed to ensure a review of all patients medications were performed at least every 60 (sixty) days for 4 of 5 active patient medical records reviewed.

The agency failed to ensure skilled professionals participated in the agency's Quality Assessment Performance Improvement Program (QAPI) for 1 of 1 agency.

The agency failed to ensure RNs (Registered Nurses) completed HHA (Home Health Aide) Supervisory Visits at least every 14 (fourteen) days for 1 of 3 clinical records reviewed with HHA services.

The agency failed to ensure Clinical Records were filed in the patient's charts within 14 days per agency policy for 4 of 5 active patient records reviewed.