Marscare

This condition is not met, but did not result in immediate jeopardy, as evidenced by the following standards: 484.102 (a)(1)(2) - Risk assessment 484.102 (a)(4) - Process for cooperation and collaboration 484.102 (b)(2) Secures and maintains availability of records 484.102 (c) Standard…

The agency failed to follow Plan of Care (G572); failed to follow the plan of care in relation to frequency and duration of visits to be made (G574); and failed to follow physician orders (580).

The agency failed to organize manage and administer its resources to attain and maintain the highest practicable functional capacity in providing optimal care and failed to set forth in writing its organizational structure: the governing body failed to assume full legal authority and responsibility…

The Home Health Agency (HHA) failed to encode and transmit OASIS information within 30 days of assessment for one (1) of three (3) adult Clinical (CR) reviewed.

The agency failed to ensure frequency of visits or a treatment or service as required by the plan of care/physician order was conducted as ordered and per agency policy. for # (6) of ten (10) Clinical Records (CR) reviewed (CR#1, 2, 3, 7, 9 and 10).

The agency failed to follow its policy pertaining to infection control for one (1) of one (1) clinical home visits: MR#1 Findings include: On March 19, 2026 at approximately 10:35, review of the agency policy B-180 titled: “Grooming & Dress Code” revealed the following: “Policy:….All employees are…

The agency failed to demonstrate the presence of the following: Infection control education provided to staff at periodic intervals consistent with accepted standards of practice.

The agency failed to ensure documentation of competency evaluations was maintained in the personnel file for two (2) of seven (7) personnel files reviewed.

The agency failed to provide Home Health Aide (HHA) documentation of twelve (12) in-service hours per year for two (2) of two (2) HHAs reviewed.

The governing body failed to assume full legal authority and responsibility for the operation of the agency by failing to appoint a qualified administrator (PF#9), a qualified alternate administrator (PF#8), and a qualified clinical nurse manager/supervising nurse and did not have an alternate…

The administrator failed to ensure the clinical manager provide oversight of patient care and personnel and ensure the availability of the clinical manager during operational hours for one (1) of one (1) PFs.

The agency failed to employ an administrator that meets the following qualifications: 2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health…

The administrator failed to ensure the availability of the clinical manager during operational hours for one (1) of one (1) PFs.

The agency failed indicate the reason for discharge on the Outcome and Assessment Information Set (OASIS) for one (1) out of ten (10) Clinical Record (CR) reviewed.

The agency failed to ensure frequency of visits or a treatment or service as required by the plan of care/physician order was conducted as ordered and per agency policy. for # (6) of ten (10) Clinical Records (CR) reviewed (CR#1, 2, 3, 7, 9 and 10).

The agency failed to ensure frequency of visits or a treatment or service as required by the plan of care was conducted as ordered and per agency policy. for # (6) of ten (10) Clinical Records (CR) reviewed (CR#1, 2, 3, 7, 9 and 10).

The agency failed to follow its policy to ensure that the home health aides had evidence of completing a minimum of 75 hours of classroom instruction prior to or during the first 3 months of employment for one (1) of two (2) home health aides reviewed, (PF #5).

The governing body failed to appoint a qualified administrator for one (1) of (1) PFs.

The administrator failed to ensure the availability of the clinical manager during operational hours for one (1) of one (1) PFs.

The administrator failed to organize and direct agency functions, employ qualified personnel and ensure adequate staff education evaluations, failed to appoint a qualified person to act in absence of the administrator (PF#8) and failed to appoint a qualified clinical manager/director of nursing…

The administrator and governing body failed to authorize qualified pre-designated person to assume the responsibilities of the administrator when the administrator is not available.

The agency failed to ensure clinical record contents were maintained in accordance with agency policy/procedure for three (3) of ten (10) Clinical records (CR) reviewed.

The agency failed to base the emergency preparedness plan on/or to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

The facility failed to ensure its communication plan contained updated contact information for staff and patients receiving services from the agency.

The agency failed to establish and maintain an emergency preparedness communication plan that included contact information for local/regional/state/federal emergency preparedness staff.

The agency failed to develop and maintain an emergency preparedness plan training and testing program that was reviewed and updated at least every two (2) years, which includes the time period prior to the Covid-19 pandemic.

The agency failed to ensure complete documentation that the home health aide completed a minimum of seventy-five (75) hour home health aide training program for two (2) of three (3) home health aide personal files (PF).

The administrator failed to provide documentation of: 1. Completed orientation checklist for twelve (12) of twelve (12) PF’s reviewed, (PF #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12).

The agency failed to follow its policy regarding items to be included in the plan of care for three (3) of three (3) CR reviewed.