Medi-Plex Healthcare Professionals, LLC

The home health provider failed to ensure their clinicians followed standard precautions, to prevent the transmission of infections and communicable diseases in two of three home visit observations (Records/Patients #2 and #4).

The home health provider failed to ensure clinicians perform a review of all medications the patient was currently using in two of six records (Records/Patients #1 and #2).

The home health provider failed to ensure the clinicians provided the services that were ordered by the physician as indicated in the plan of care in one of six records reviewed (Record/Patient #4).

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: - Provide an individualized plan of care that included all required elements (G574); - Provide a visit schedule, including…

The agency failed to meet the requirements for the Condition of Participation: Skilled Professional Services, when the agency failed to: - Ensure skilled professional staff provided the services that were ordered by the physician as indicated in the plan of care (G710); - Ensure the skilled…

The agency failed to ensure staff were provided emergency preparedness training annually for one (Employee #2) of three employee files reviewed.

The agency failed to conduct exercises to test the emergency plan annually and analyze the agency's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the agency's emergency plan as needed.

The agency failed to ensure staff were provided infection control training annually for one (Employee #2) of three employee files reviewed.

The agency failed to update the written notice of patient rights to meet the requirements of the updated Federal home health regulations effective 11/29/2019 to include the patient has the right to be advised orally and in writing of the extent to which payment for services may be expected from…

The agency failed to ensure staff reviewed of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions in two (Records/Patients #1 and #3) of three home visit records reviewed.

The agency failed to ensure that each patients' written individualized care plan included all the required elements in, but not limited to, three (Records/Patients #1, #2, and #5) of five full records reviewed.

The agency failed to ensure the staff provided a written visit schedule to patients that included what discipline was visiting, and the frequency of visits in one (Patient/Record #2) of three home visits.

The agency failed to assure the patient/caregiver was notified of any treatments to be administered by the agency personnel in one (Record/Patient #1) of three applicable records reviewed.

The agency failed to ensure each patient received written information related to the name and contact information of the agency's clinical manager in the admission packet during the initial assessment in one (Record/Patient #2) of three applicable home visits.

The agency failed to ensure professional staff provided services ordered by the physician as indicated in the plan of care for two (Records/Patients #1 and #4) of five records reviewed.

The agency failed to ensure that skilled professional staff prepared complete clinical documentation in four (Records/Patients #2, #3, and #5) of five full records reviewed.

The agency failed to ensure staff were provided with agency in-service training in one (Employee #2) of three employee files reviewed.

The agency failed to ensure that the aide provided services that were included in the plan of care in one (Record/Patient #3) of two applicable records.

The agency failed to ensure encoded OASIS data accurately reflected the patient's status in two (Records/Patients #1 and #5) of five applicable cases.

The agency failed to include patient specific, measureable outcomes and goals and specific procedures and modalities for therapy services on the interim physician order to update the plan of care after the start of care in, but not limited to, two (Records/Patients #4 and #5) of five sample cases.

Staff interview the agency failed to provide the patient written information regarding visit schedules and frequency of visits for all disciplines, patient medication schedule/instructions, treatments to be administered, other pertinent instruction related to the patient's care and treatments, and…

The agency failed to ensure clinical staff followed infection control policies/procedures during two (Records/Patients #1 and #3) of three applicable home visit observations.

The agency failed to ensure the registered nurse (RN) prepared and/or updated the home health aide assignment in two (Records/Patients #1 and #4) of two applicable cases.

The agency failed to provide written notice of all the patient's rights and responsibilities under this rule in one (Record/Patient #5) of one applicable case admitted to the agency under the new federal home health regulations on or after 01/13/18. This deficient practice has the potential to…

The agency failed to provide accurate contact information for the agency's administrator in one (Record/Patient #5) of one applicable case admitted to the agency under the new federal home health regulations on or after 01/13/18. This deficient practice has the potential to affect the exercise of…

The agency failed to provide documentation that the patient was advised of the extent to which planned services would be covered by insurance in one (Record/Patient #3) of one patient in the sample with insurance as payer.

The agency failed to provide required information for Federally-funded and state-funded entities that serve the area where the patient resides (Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization)…

The agency failed to ensure the comprehensive assessment for the start of care accurately reflected the patient's status and included the patient's current health, psychosocial, functionally cognitive status to to support the need for skilled home health services in, but not limited to, one…

The agency failed to provide a complete comprehensive assessment of medications at the resumption of care in, but not limited to, one (Record/Patient #3) of three patients observed during home visits.

The agency failed to ensure a complete plan of care was developed in, but not limited to, three (Records/Patients #1, #2, and #3) of five cases.

The agency failed to provide skilled nursing, home health aide, and therapy services as ordered by the physician on the plan of care in, but not limited to, two (Records/Patients #2 and #4) of five cases.

The agency failed to ensure the registered nurse (RN) assessed/documented a patient's wound per agency policy and in accordance with the plan of care in, but not limited to, one (Record/Patient #4) of four applicable wound care patients in the sample.

The agency failed to ensure the home health aide documented all services provided in two (Records/Patients #1 and #4) of two applicable cases.

The agency failed to ensure the accuracy of home health aide supervisory visits documented by the registered nurse (RN) in one (Record/Patient #4) of two applicable cases when no home health aide visits were made prior to the documented first supervisory visit.

The agency failed to ensure the clinical record contained accurate physician orders when interim physician orders were sent for signature to the wrong physician in one (Record/Patient #1) of five applicable cases.