Immaculate Health Care Services Inc

The Agency's staff failed to electronically transmit each completed OASIS assessment in accordance with the CMS timely guidelines within 30 days for four (4) of ten (10) submitted OASIS assessments records, for the period of 08/15/2022 through 02/21/2023. Findings included: The Home Health Agency…

The agency's staff failed to conduct accurate medication reviews for three (3) of five (5) current clinical records reviews including two (2) patients for home visits conducted (Patients # 1, 2 and 5).

The Home Health Agency failed to ensure the clinician developed an individualized Plan of Care and included all required elements including all pertinent diagnoses, medications, and other required elements relative to the patient for three (3) of the seven (7) active clinical records reviewed…

The Home Health Agency failed to submit completed discharge summaries within five (5) business days of discharge to the primary care physicians for two (2) of two (2) closed clinical record reviews.

The agency failed to develop, implement, evaluate, and maintain an effective, ongoing, Home Health Agency-wide, data-driven Quality Assessment and Performance Improvement Program (QAPI).

The Home Health Agency failed to develop and maintain a (QAPI) Quality Assessment and Performance Improvement Program.

The Home Health Agency failed to develop a (QAPI) Quality Assessment and Performance Improvement Program utilizing quality indicator data, including measures derived from OASIS [Outcome & Assessment Information Set], and other relevant data in the design of its program, and failed to collect and…

The Home Health Agency failed to conduct performance improvement projects.

The Home Health Agency failed to ensure that its governing body has the responsibility to define, implement and maintain an ongoing program for quality improvement.

The Home Health Agency failed to maintain a coordinated agency - wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the Home Health Agency's quality assessment and performance improvement…

The agency's staff failed to conduct accurate medication reviews for two (2) of three (3) patients for home visits conducted (Patients #1, and 2).