Home Health la Monserrate Inc

The facility failed to evidence the development, implementation, evaluation, and maintenance of an effective, ongoing, Home Health Agency (HHA)-wide, data-driven QAPI program.

The facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency.

The facility failed to maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

The facility failed to develop primary / alternate means for communication with staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws.

The facility failed to maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

The facility failed to encode and electronically transmit each completed OASIS assessment to CMS within 30 days of completing of the assessment of the beneficiary on 6 out of 7 records reviewed (RR-H.V #1, #3 and, R.R #1, #2, #3 and #4) . Findings include: During interview with the supervisor…

The facility failed to ensure that for each patient that receive home health services an individualized plan of care that identifies patient-specific measurable outcomes and goals is developed and implemented, for 2 out of 7 records reviewed (R.R. #1 and #2).

The facility failed to design and implement QAPI that must at least be capable of showing measurable improvement on indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The facility failed to include in the QAPI program quality indicator data, including measures derived from OASIS, were applicable, and other relevant data, in the design of its program.

The facility failed to maintain performance improvement activities that are focused on indicators related with patient outcomes and all Home Health Agency (HHA) services.

The facility failed to ensure that one or more specific quality improvement projects are undertaken each year.

The facility failed to ensure that accepted standards of practice, to prevent the transmission of infections and communicable diseases are adopted related to place personal protective equipment (PPE), hand wash, disinfection of non-critical equipment.

The facility failed to ensure that all discipline credential files are in compliance with applicable federal and local law for health agencies related to personnel.

The facility failed to inform patients of the hotline telephone number established by the State Agency for the purpose of receiving complaints.

The facility failed to promote patient's right to be informed of the access to auxiliary aids and language services and how to access these services.

The agency failed to ensure that the comprehensive assessment must be completed within 5 days of the start of care for 2 out of 7 records reviewed (R.R. #1 and #2).

The facility failed ensure the registered nurse must complete the comprehensive assessment, for 2 out of 7 records reviewed (R.R. #1, #2).

The facility failed to have a mechanism in place to ensure that actions aimed at performance improvement, are implemented and that those actions, are measured its success to ensure that improvements are sustained.

The facility failed to ensure that the Skilled professionals must assume responsibility for, but not to be restricted to preparing clinical notes for 1 out of 7 records reviewed (R.R. #1).

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

The facility failed to ensure that skill professional services follow accepted standards of practice to prevent the transmission of infections and communicable diseases for 1 out of 3 home visits (H.V #2).

The facility failed to have the patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes and plan of care for 2 out of 7 records reviewed (R.R. #1, #2).

The agency failed to ensure that the registered nurse conduct the initial assessment according to physician referral for 1 out of 8 records reviewed.

The facility failed to ensure that different discipline coordinate patient care assuring that staff communicate any patient concern that not affect patient visits for 1 out of 8 records reviewed.

The agency failed to ensure that skilled professional services follow accepted standards of practice to prevent the transmission of infections and communicable diseases for 1 out of 3 home visit (H.V #1).

The facility failed to develop and maintain an emergency preparedness plan that include strategies for addressing emergency events identified by the risk assessment and other emergencies that would affect the facility ability to provide care.

The facility failed to ensure that the emergency plan policies and procedures are develop to facilitate the support of volunteers and other healthcare professionals in an emergency.

The facility failed to encode and electronically transmit each completed OASIS assessment to CMS within 30 days of completing of the assessment of the beneficiary on 4 out of 4 cases reviewed ( HV # 1 & #2 ,RR # 1 & # 2 ) . Findings include: 1. A mechanism to ensure that facility enter and transmit…

The facility failed to ensure that all discipline credential files are in compliance with applicable federal and local law for health agencies related to personnel credential files (C.F).