Memorialcare Home Health, LLC

The agency failed to ensure their comprehensive emergency preparedness program included a facility based risk assessment, utilizing an all hazards approach.

The agency failed to ensure the emergency preparedness plan included procedures to follow up with on-duty staff and patients to determine services needed and procedures to inform state and local officials of any on-duty staff or patients they are unable to contact.

The agency failed to ensure the emergency preparedness P&P addressed a system of medical documentation that protected confidentiality of the patient information, and secured and maintained availability of records.

The agency failed to ensure the emergency preparedness communication plan included the updated name and contact information of the entities provided services under agreement, patients' physician, and volunteers.

The agency failed to ensure the emergency preparedness communication plan included the contact name and information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance.

The agency failed to ensure initial training in the emergency preparedness program was provided to volunteers and contracted individuals providing services under arrangement and documentation of all the emergency preparedness training was maintained.

The agency failed to maintain the infection control data as part of the QAPI program.

The agency failed to ensure the medication profiles were updated for four of 17 sampled patients (Patients 12, 13, 14, and 16), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients.

The agency failed to ensure the comprehensive assessment was completed within the last five days of every 60 days for one of 17 sampled patients (Patient 3).

The agency failed to ensure the POCs addressed specific interventions related to the patient’s care and treatment for three of 17 sampled patients (Patients 3, 7, and 17).

The agency failed to ensure the physician’s orders related to wound care treatment were included in the POC for three of 17 sampled patients (Patients 2, 3, and 12).

The agency failed to ensure the physician's verbal orders were signed and dated by the qualified staff for furnishing or supervising the care for three of 17 of sampled patients (Patients 2, 4, and 5), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to communicate with the physician about the patients' care needs for two of 17 sampled patients (Patients 5 and 6).

The agency failed to ensure the PCG was provided with proper education regarding wound care management for one of 17 sampled patients (Patient 2).

The agency failed to provide written SN visit schedule for three of 17 sampled patients (Patients 13, 15, and 16), creating the risk of not providing the necessary information to these patients.

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for eleven of 17 sampled patients (Patients 1, 3, 4, 5, 6, 7, 8, 9, 10, 12, and 16).

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for eight of 17 sampled patients (Patients 2, 3, 7, 10, 11, 12, 16, and 17), creating the increased risk of substandard healthcare outcomes to these patients.

The agency failed to ensure the RN provided supervisions to the LVNs to ensure quality care and services were provided for three of 17 sampled patients (Patients 2, 3, and 7).

The agency failed to provide services in accordance with the clinical practice guidelines and accepted professional standards of practice for two of 17 sampled patients (Patients 3 and 8).

The agency failed to ensure the discharge/transfer summaries for two of 17 sampled patients (Patients 2 and 4) were completed.

The agency failed to ensure the patient-specific care needs as identified in the comprehensive assessments and specified in the individualized written plans of care were met as evidenced by: 1. The agency failed to ensure the POCs included specific interventions related to visit frequency, time…

The agency failed to ensure the quality of skilled professional services as evidenced by: 1. The agency failed to ensure the SN coordicated care to meet the patients' care needs.

The agency failed to maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's POC for each medical, nursing, and rehabilitative needs as evidenced by: 1. The agency's GB failed to assume full legal authority…

The agency failed to ensure the emergency preparedness P&P addressed the procedures to inform State and local emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency situation based on the patient's medical and psychiatric condition and…

The agency failed to ensure the emergency preparedness P&P addressed the procedures to follow up with the on-duty staff and patients to determine if the interruption of services occurred and inform the State and local officials of any on-duty staff or patients that they were unable to contact…

The agency failed to develop and implement an emergency preparedness P&P addressing a system of medical documentation that protected confidentiality of the patient information, and secured and maintained availability of records.

The agency failed to ensure the emergency preparedness P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The agency failed to ensure the emergency preparedness communication plan included a method for sharing information and medical documentation for patients under the HHA's care, as necessary, with other health providers to maintain the continuity of care.

The agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.

The agency failed to ensure the initial training in the emergency preparedness program was provided to all staff, including the contracted individuals providing services under arrangement.

The agency failed to ensure the unified and integrated emergency preparedness program demonstrated that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program; be developed and maintained in a manner…

The agency failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets, creating the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the HHA.

The GB failed to assume full legal authority and responsiblity for the agency's overall management and operation and the provision of all home health services to ensure compliance with the COPs under 484.60 Care Planning, Coordination, Quality of Care and 484.75 (Skilled Professional Services) were…

The agency failed to ensure the clinical records were complete for 11 of 19 sampled patients (Patients 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, and 16 ), creating the risk of substandard care provided to these patients as their clinical information was not complete.

The agency failed to ensure the grievance was thoroughly investigated for one nonsampled patients (Patients A), creating the risk of violating the patient's rights and not providing quality of care and services to this patient.

The agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for eight of 19 sampled patients (Patients 4, 9, 13, 14, 15, 17, 18, and 19), creating the risk of…

The agency failed to ensure the review of the patient's medications included all of the patient's medications for three of 19 sampled patients (Patients 6, 7, and 8), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug…

The agency failed to ensure the comprehensive assessments were updated within the last 5 days of every 60 days for four of 19 sampled patients (Patients 1, 3, 7, and 18), creating the increased risk of not addressing the care needs for these patients.

The agency failed to ensure the POCs included specific interventions related to visit frequency, time frame for weight loss to be reported, and wound care for five of 19 sampled patients (Patients 1, 6, 9, 17, and 19), creating the risk of not addressing the care needs for these patients.

The agency failed to ensure the treatments were administered only as ordered by the physician for two of 19 sampled patients (Patients 2 and 19), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to ensure the physician's orders were signed by the physician within 30 working days as per the State regulations for seven of 19 sampled patients (Patients 2, 3, 4, 7, 15, 17, and 18), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to coordinate care to meet the patients' care needs for nine of 19 sampled patients (Patients 1, 2, 3, 4, 6, 7, 13, 18, and 19), creating the risk of not providing the necessary care and services to these patients.

The agency failed to provide the written instructions outlining the SN visit schedule for one of 19 sampled patients (Patient 8), creating the risk of not providing the necessary information to this patient.

The agency failed to provide the written instructions outlining the patient medication schedule/instructions, including: medication name, dosage and frequency and which medications would be administered by the HHA personnel and personnel acting on behalf of the HHA for one of 19 sampled patients…

The agency failed to provide the written instructions outlining any treatments to be administered by the HHA personnel and personnel acting on behalf of the HHA for one of 19 sampled patients (Patient 8), creating the risk of not providing the necessary information to this patient Findings: Review…

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for 17 of 19 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 15, 16, 18, and 19), creating the risk of not providing appropriate, consistent, and quality care to these…

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for six of 19 sampled patients (Patients 6, 7, 8, 9, 15, and 19), creating the increased risk of substandard healthcare outcomes to this patient.

The agency failed to ensure the agency's RN provided supervisions to the SN to ensure quality of care and services provided for one of 19 sampled patients (Patient 7), creating the risk of a substandard healthcare outcome to this patient.

The agency failed to ensure the CHHA provided care and services in accordance with the POC for four of 19 sampled patients (Patients 7, 12, 16, and 18), creating the risk of not providing necessary care and services to these patients.

The agency failed to ensure the agency's RN provided supervision to the CHHA no less frequently than every 14 days to ensure quality of care and services provided for two of 19 sampled patients (Patients 7 and 18), creating the risk of substandard health outcomes to these patients.

The agency's Administrator failed to be responsible for the day-to-day operations, creating the increased risk of substandard of healthcare outcomes to the patients receiving services from the HHA.

The agency failed to ensure the SNs provided care and services related to wound and pain assessments in accordance with professional standards and principles for four of 19 sampled patients (Patients 6, 7, 8, and 19) creating the risk of not providing appropriate care to these patients.

The agency failed to ensure the completed discharge summary was sent to the primary care practitioner after discharge from the HHA within five business days of the discharge date for seven of eight sampled discharged patients (Patient 1, 2, 3, 4, 5, 14, and 17), creating the risk of not providing…