Integrated Community Services Inc

The agency's staff consistently failed to electronically transmit completed OASIS assessments directly to the CMS system, within the timely guidelines of 30 days of completing each beneficiary’s assessments, for 11 of 11 submitted assessment records, for the time periods of 02/25/2022 through…

Agency staff failed to encode OASIS (Outcome and Assessment Information Set) data that accurately reflect the patient's status at the time of assessment for one (1) of ten (10) clinical records, (Patient #6).

The Home Health Agency failed to provide patient-specific, comprehensive assessments for five (5) of five (5) patients receiving Personal Care Aide Services, (Patients # 1, 2, 3, 5, and 9).

Agency staff failed to notify the physician relative to missed visits for one (1) of ten (10) clinical records (Patient #6).

The nursing staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections in the home for one (1) of three (3) home visits conducted, (Patient # 2).

The agency's staff failed to ensure that patients' Plans of Care were individualized and included all required elements in one (1) of ten (10) clinical records (Patient # 6).

Agency staff failed to record all patient care orders, including verbal orders on the Plan of Care for one (1) of ten (10) clinical records (Patient #6).

Failed to ensure a clearly defined organizational structure, that depicts the agency’s lines of authority, to ensure the agency's administrator reported directly to the governing body for one (1) of one (1) employee, (Employee #2).

The nursing staff failed to follow the current clinical practice guidelines and the agency's policy regarding proper storage of Oxygen in the home for one (1) of three (3) home visits conducted, (Patient # 2).

The agency's clinicians failed to document complete discharge summaries for discharged patients in four (4) of four (4) closed clinical records for discharged patients, (Patients #6, 7, 8, and 10).

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey from 11/06/19 through 11/14/19. Based on interviews with the Home Health Agency's agency staff, the agency failed to develop comply with applicable Federal, State and local emergency…

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 comply with Federal, State and local emergency preparedness requirements to develop, establish, and maintain a comprehensive emergency preparedness program that includes an emergency preparedness plan.

The Home Health Agency failed to show that the Policies and Procedures were reviewed and updated at least annually.

The agency failed to maintain a communication plan that is reviewed and updated at least annually.

The agency failed to develop and maintain an emergency training and testing program that is based on the emergency plan, the risk assessment, the policies and procedures, and the communication plan and to conduct exercises to test the emergency plan annually.

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 agency's staff failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases relative to disposal of used sharps in the home for one (1) of four (4) home visits conducted (Patient #4).

The agency's staff failed to document an updated and revised comprehensive assessment at discharge, in one (1) of two (2) closed clinical records for a discharged patient (Patient #7).

The agency's staff failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care for one (1) of four (4) patients for home visits conducted (Patient #2).