Jennifer's Home Health Agency Inc

The home health provider failed to ensure that wound measurements and assessments were completed in one of six records reviewed (Record/Patient #4).

The home health provider failed to ensure that care was supervised by the physical therapist (PT) in one of six records reviewed (Record/Patient #4).

The home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in two of two home visits conducted (Records/Patients #1 and #2).

The home health provider failed to ensure that all pertinent diagnoses, medications, and treatments were included in the plan of care (POC) in two of six records reviewed (Records/Patients #1 and #2).

The home health provider failed to ensure that the plan of care (POC) was followed in four of six records reviewed (Records/Patients #1, #2, #4, and #5).

The home health provider failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the home health provider/services within five business days…

The agency failed to ensure that the OASIS (Outcome and Assessment Information Set, a federally mandated assessment) data accurately reflected the patient's status at the time of the assessment in two of five full records reviewed (Records/Patients #2 and #4).

The home health provider failed to ensure a comprehensive assessment was completed to accurately reflect the patient's status in one of five full records reviewed (Record/Patient #1).

The he home health provider failed to ensure staff followed acceptable standards of practice for infection control in two of three home visit observations (Records/Patients #1 and #3).

The agency failed to ensure one (Record/Patient #4) patient was admitted within 48 hours of referral of five full records reviewed.

The agency failed to maintain an accurate/updated medication profile in three of three home visit observations (Records/Patients #1, #2, and #3).

The home health provider failed to ensure that clinical staff developed a complete plan of care (POC) in, but not limited to, two of five full records reviewed (Records/Patients #2 and #4).

The home health provider failed to document complete/accurate wound assessments in one of five full records reviewed and failed to consistently document complete pain assessments in one of five full records reviewed (Record/Patient #2).

The he home health provider failed to ensure staff followed the physician ordered plan of care (POC) in two of five full records reviewed (Records/Patients #1 and #2).

The home health provider failed to ensure the RN (registered nurse) performed an adequate aide supervisory visit in one of one record reviewed that received aide services (Record/Patient #2).

The agency failed to meet the requirements for the Condition of Participation: Emergency Preparedness, when the agency failed to: - Establish and maintain an emergency preparedness program that meets all the requirements (E0001); - Include strategies for addressing emergency events identified by…

The agency failed to meet the requirements for the Condition of Participation: Comprehensive Assessment of Patients, when the agency failed to ensure: - The RN completed the comprehensive assessment no later than five calendar days after the start of care (SOC) (G520); - The comprehensive…

The agency failed to meet the requirements for the Condition of Participation: Care Planning, Coordination of Services, and Quality of Care, when the agency failed to: -Ensure each patient received a written individualized POC with patient specific, measurable outcomes and goals (G572); -Ensure…

The agency failed to meet the requirements for the Condition of Participation: Quality Assessment and Performance Improvement (QAPI), when the agency failed to: - Ensure there was evidence that the agency is measuring, analyzing, and tracking quality indicators (G642); - Ensure the agency used data…

The agency failed to meet the requirements for the Condition of Participation: Skilled Professional Services, when the agency failed to ensure the provision of services by a skilled professional when the skilled professional failed to: - Ensure services were provided as ordered on the plan of care…

The agency failed to meet the requirements for the Condition of Participation: Organization and Administration of Services, when the agency failed to ensure: - The governing body assumed full legal authority and responsibility for the agency management, operation, and the provision of all home…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program and include strategies for addressing emergency events identified by the risk assessment.

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that addressed the patient population including the type of services the agency had the ability to provide in an emergency; continuity of…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials'…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that developed and implemented emergency preparedness policies and procedures.

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that addressed plans to inform state and local officials about the agency patients in need of evacuation from their residences.

The agency 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 agency failed to establish and maintain a program that addressed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that addressed the use of volunteers in an emergency situation.

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that developed and maintained an emergency preparedness communication plan.

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that developed and maintained an emergency preparedness communication plan that included names and contact information for entities providing…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that developed and maintained an emergency preparedness communication plan that included contact information for Federal, State, tribal…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that developed and maintained an emergency preparedness communication plan that included the primary and an alternate means of communicating…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that addressed a communication plan with a method for sharing information and medical documentation with other health providers to maintain…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that developed and maintained an emergency preparedness communication plan that included a means of providing information about the agency's…

The agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that conducted two exercises per year to test the emergency plan.

The agency failed to ensure encoded OASIS (Outcome and Assessment Information Set) data accurately reflected the patient's status in, but not limited to, two (Records/Patients #1 and #4) of five applicable records.

The agency failed to ensure a complete comprehensive assessment to accurately reflect the patient's status in, but not limited to, two (Record/Patient #2 and #4) of five records reviewed.

The agency failed to ensure the patient received an individualized plan of care (POC) that identifies patient-specific measurable outcomes and goals in, but not limited to, three (Record/Patient #1, #3, and #5) of five records reviewed.

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 that performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventive actions.

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

Findings included: Review of the September 9, 2017 governing body minutes failed to show evidence of: - A specific discussion/review of the home health agency quality assurance performance improvement program (QAPI) information occurred; - Review of performance improvement activities that included…

The agency failed to ensure all documented entries included appropriate authentication that included the time assessments were completed in, but not limited to, two patients (Record/Patient #1 and #3) of five records.

The agency failed to ensure one patient (Record/Patient #1) of five applicable records received the right to have an established plan of care.

The agency failed to ensure the registered nurse (RN) completed the comprehensive assessment no later than five days after the start of care for one patient (Record/Patient #1) out of five applicable records.

The agency failed to ensure a complete comprehensive assessment to accurately reflect the patient's strengths, goals and care preferences in, but not limited to, two (Record/Patient #2 and #4) of five records reviewed.

The agency failed to ensure a complete comprehensive assessment to include a review of all medication the patient is currently using in, but not limited to, three (Record/Patient #1, #2, and #3) of five records reviewed.

The agency failed to provide an individualized plan of care which included a description of the patient's risk for emergency department visits and hospital re-admissions and goals identified by the patient in, but not limited to, two (Record/Patient #2 and #4) of five records reviewed.

The agency failed to provide conformance with the physician orders when the orders failed to show the correct visit frequency, ordered treatments, and complete orders on the plan of care and physician orders in, but not limited to, two (Record/Patient #3, and #4) of five records reviewed.

The agency failed to ensure all physician orders were timed when recieved in but not limited to, three (Record/Patient #2, #3, and #4) of five records reviewed.

The agency failed to ensure the communication to the physician regarding the patient's plan of care in two (Record/Patient #1 and #3) of five records.

The agency failed to ensure the patient was aware of the name and contact information of the clinical manager in, but not limited to, one patient (Record/Patient #1) of five records.. This deficient practice has the potential to affect all patients served by the agency, Findings included…

The agency failed to provide evidence that the performance improvement activities lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of the patients.

The agency failed to ensure the registered nurse (RN) established a plan of care that determined services as ordered by the physician for one (Record/Patient #1) and failed to establish an accurate plan of care for one patient (Record/Patient #2) of five records.

The agency failed to ensure the clinical record contained all required documentation for one patient (Record/Patient #2) out of five records.

The agency failed to communicate with the physician regarding the plan of care for one patient (Record/Patient #1) and failed to communicate with the physician and physical therapist regarding the plan of care for one patient (Record/Patient #2) of five records.

The agency failed to ensure the registered nurse (RN) supervised the licensed practical nurse (LPN) in one (Record/Patient #4) of four applicable case.

The administrator, who is also a member of the governing body, has effectively assumed responsibility for the overall administration, supervisory functions and overall operations of the home health agency.

The administrator failed to ensure the agency hired qualified staff and ensured adequate staff education was provided, when the agency failed to document orientation, training, and competency verification for the staff.

Findings include: Based on current survey findings, the clinical manager (director of nursing) failed to: - Assure complete and accurate comprehensive assessments, including a medication review completed by the registered nurse; - Assure a complete and accurate plan of care; - Assure skilled…

Findings include: Based on current survey findings, the clinical manager (director of nursing) failed to: - Assure complete and accurate comprehensive assessments, including a medication review completed by the registered nurse; - Assure a complete and accurate plan of care; - Assure skilled…

The agency failed to: - Ensure the staff had completed the criminal disclosure statement in, but not limited to, one (Employee E1) of five employee files reviewed; and - Ensure staff had a criminal background check performed prior to hire in, but not limited to, two (Employees: E2 and E3) of five…