Maple Home Health Care, LLC

The agency failed to ensure that all services furnished under arrangement by 2 of 2 (RN-C, PTA-D) individuals met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)) (see G976); failed to have written agreements with 2 of 2 (RN-C, PTA-D) contracted employees (see G978); and failed…

The agency failed to ensure the medical record contained all physical therapy visit notes for 1 of 7 (P-5) records reviewed (see G1012); and failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 2 of 4 (P-5, P-7) records reviewed (see…

The agency failed to ensure all staff including contracted staff received initial training and training at least every two years in the agency's Emergency Preparedness Plan for 2 of 2 (RN-C and PTA-D) contracted staff, resulting in the agency's inability to ensure staff actions align with the…

The agency failed to provide infection control education for 4 of 4 (Admin-A, CM-B, RN-C, and PTA-D) personnel files reviewed, resulting in a lack of education regarding current infection prevention and treatment practices in the home setting.

The agency failed to ensure that all services furnished under arrangement by 2 of 2 (RN-C, PTA-D) individuals met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that receive contracted services.

The agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the agency contracting for each qualified patient care service.

The agency failed to ensure patients or caregivers were furnished with accurate information to lodge a complaint to the agency, resulting in the potential to negatively affect the health and well-being of all patients admitted to the agency.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 3 of 7 (P-1, P-5, P-7) records reviewed, resulting in incomplete clinical information necessary to determine the needs of these patients and the potential for unmet care needs.

The agency failed to ensure the plan of care included all medications, measurable outcomes and goals for 5 of 7 (P-5, P-6, P-1, P-2, P-3) records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes.

The agency failed to ensure services were provided as ordered by the physician in 1 of 7 (P-6) records reviewed, resulting in the potential to negatively affect the health and well-being of this patient.

The agency failed to provide the patient and caregiver with a copy of written instructions that include the visit schedule, including frequency of visits by the Home Health Agency personnel and personnel acting on behalf of the Home Health Agency in 1 of 3 (P-1) records reviewed with home visits.

The agency failed to ensure patients were provided written information with the name and contact information of the clinical manager, resulting in a lack of information to enable the 9 current patients to contact the clinical manager.

The agency failed to ensure the physical therapist prepared clinical notes for 1 of 7 (P-5) records reviewed, resulting in a lack of information regarding the health status of this patient.

The agency failed to have written agreements with 2 of 2 (RN-C, PTA-D) contracted employees, resulting in a lack of overall responsibility by the agency for the services provided under arrangement.

The agency failed to ensure the medical record contained all physical therapy visit notes for 2 of 7 (P-1, P-5) records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient.

The agency failed to ensure Transfer and Discharge summaries were sent to the physician within 5 business days of the patient's discharge for 4 of 4 (P-2, P-3, P-5, P-7) records reviewed in which the patient was transferred or discharged from the agency, resulting in the physician not having…

The Agency (HHA) failed to provide documented evidence that COVID-19 infection control education was provided to all staff employed by the agency and who were granted clinical privileges, and failed to provide COVID-19 education to agency patients, resulting in the potential for the development and…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and…

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 1 of 1 (MR's #3) records reviewed where Physical Therapy was the only discipline, of 3 total…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 1 of 3 records reviewed (M.R.# 1), failed to document the physician order for nursing services on the POC, and failed to document the frequency and duration for nursing services on the POC…

The agency failed to ensure that discharge and transfer summaries were complete, provided the patient's current health status at the time of discharge and transfer, documented progress toward goals, provided an updated medication list and were sent to the physician in 1 of 3 records (MR #1), and…