Multicare Home Health Services, Inc

The agency failed to ensure patients received an comprehensive assessment after a fall with injury for 1 of 17 patients ( Patient #15) whose records were reviewed.

The agency failed to ensure consents were properly completed in advance of treatment for 1 of 17 patients (Patient #7) whose records were reviewed.

The agency failed to ensure the patients' individualized plan of care/treatment included all the required interventions and medications to address the identified needs for 2 of 17 patients (Patients #8 and #10) whose records were reviewed.

The agency failed to establish and maintain a current, comprehensive Emergency Preparedness program including policies and procedures.

The agency failed to meet discharge for cause criteria.

The agency failed to update, maintain, and execute a comprehensive infection control program, including measures to prevent the spread of COVID-19 and to identify and control infections.

The Governing Body failed to provide effective administrative oversight of the agency.

The agency failed to develop, maintain, review, and update a current and comprehensive Emergency Preparedness program.

The agency failed to conduct a facility-based and community-based risk assessment which included identified strategies for response.

The agency failed to develop a current plan for cooperation and collaboration with local, tribal, regional, State, and Federal EP officials.

The agency failed to develop policies and procedures based on an Emergency Plan.

The agency failed to develop procedures to inform state and local officials about homebound patients in need of evacuation.

The agency failed to develop, document, and maintain emergency policies, procedures and operational plans for the use of volunteers to address surge needs during an emergency.

The agency failed to have a plan for agency communications.

The agency failed to document a plan for primary and alternate means of communicating with federal, state, tribal, regional and local emergency management agencies during an emergency.

The agency failed to develop an emergency preparedness training and testing program.

The agency failed to ensure staff were trained in EP for 7 of 7 staff (Staff A - G) whose personnel files were reviewed.

The agency failed to ensure performance improvement projects were conducted as an ongoing effort to measure progress achieved.

The agency failed to ensure infection control measures were performed by agency staff to prevent the transmission of infection in 1 of 7 patients (#8) whose care was observed.

The agency failed to identify, prevent, control, and investigate infections and failed to ensure its Infection Control Program was an integral part of the agency's QAPI program.

The agency failed to ensure a qualified person was authorized in writing to act as the agency clinical manager, or approval of a qualified person to act in the absence of the Administrator.

The agency failed to ensure entries in the patient record were clear for 1 of 2 patients (Patient #16) who were discharged for cause and whose records were reviewed.

The facility failed to ensure proper steps were completed before a discharge for cause for 1 of 2 patients (Patient #16) who were discharged for cause and whose records were reviewed.

The agency failed to ensure patients' physicians were notified in advance that a discharge for cause was being considered for 2 of 2 patient (#15 and #16) who were discharged for cause and whose record was reviewed.

The agency failed to provide contact information or referrals for 2 of 2 patients (Patients #15 and #16) who were discharged for cause and whose records were reviewed.

The agency failed to document efforts made to resolve problems to prevent discharges for cause for 2 of 2 patients (#15 and #16) who were discharged for cause and whose records were reviewed.

The agency failed to ensure the POC was accurate and included all pertinent interventions and goals for 5 of 17 patients (#12, #2, #8, #10, and #15) whose POCs and records were reviewed.

The agency failed to ensure staff competencies for 2 of 7 staff (Staff B and C) whose personnel files were reviewed.

The agency failed to provide patients/representatives with necessary information, failed to ensure patients were free from abuse, neglect, and unknown injuries, and given the opportunity to consent to services and release of medical information, and failed to document complaints and resolutions.

The agency failed to ensure care and treatments followed the patient's POC, POCs were accurate and included all pertinent items, physicians were alerted to changes in patient condition, care was coordinated between disciplines, and patients were given contact information for the Clinical Manager.

The agency failed to maintain and document a comprehensive infection control plan to identify and control infections.

The Governing Body failed to provide effective administrative oversight of the agency.

The agency failed to ensure encoded OASIS data was accurate at the time of the SOC assessment for 7 of 13 patients (#2, #3, #4, #7, #8, #11, and #12) whose records were reviewed.

The agency failed to ensure care followed the patients' written POC, for 12 of 13 patients (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, and #13) whose records were reviewed.

The agency failed to track adverse patient events, analyze their causes, and implement preventative actions for 1 of 1 patient (Patient #2), who was referred to APS, and whose record was reviewed.

The agency failed to identify, prevent, control, and investigate infections and failed to ensure its Infection Control Program was an integral part of the agency's QAPI program.

The agency failed to ensure its sole MSW was professionally licensed as required by Idaho state law.

The agency failed to ensure physician orders included accurate effective dates, for 1 of 13 patients (Patient #6) whose records were reviewed.

The agency failed to ensure patients/representatives were provided with information on rights and responsibilites, how to contact the agency, and privacy practices, prior to the initiation of care for 1 of 1 patient (Patient #5), whose SOC assessment was observed.

The agency failed to ensure patients were provided a written notice of patients' rights and responsibilities in advance of furnishing care to the patient for 3 of 13 patients (#2, #4, and #7) whose SOC records were reviewed.

The agency failed to ensure written notice of its transfer and discharge policies was provided to patients or their representatives.

The agency failed to ensure patients were free from verbal abuse, neglect, and injuries of unknown source for 1 of 1 patient (Patient #2) who was referred to APS, and whose record was reviewed.

This policy was not followed.

The agency failed to ensure patients were given all information necessary to consent to the release of medical information from other providers, for 13 of 13 patients (#1 - #13) whose records were reviewed.

The agency failed to ensure patients were advised of the contact information for Federally-funded and state-funded entities that served the areas where they live.

The agency failed to ensure patients were informed of their rights to access auxiliary aids and language services, and how to access these services.

The agency failed to ensure the existence of complaints, and their resolutions, were documented for 1 of 1 patient (Patient #2) who was referred to APS, and whose records were reviewed.

The agency failed to ensure medications were reconciled at the time of admission and a medication list was kept current and reconciled for 6 of 13 patients (#1, #4, #6, #9, #10, and #12) whose records were reviewed.

The agency failed to ensure the POC was accurate and included all pertinent allergies, medications, equipment, interventions, and goals for 4 of 13 patients (#1, #8, #11, and #12) whose records were reviewed.

The agency failed to ensure all orders were recorded in the patient's POC for 1 of 4 patients (Patient #11) who were discharged from the agency, and whose records were reviewed.

The agency failed to ensure treatments were administered only as ordered by the physician for 3 of 4 patients (#1, #6, and #11) who received wound care and whose records were reviewed.

The agency failed to ensure staff promptly alerted the physician to changes in patients' condition or needs, for 2 of 13 patients (#2 and #11) whose records were reviewed.

The note documented pain of 9 on a scale of 0 to 10, and stated "Pt pain was limiting her motivation to do exercises today." The note did not state Patient #13's Physical Therapist or RNCM were notified of her pain.

The agency failed to ensure written disclosure of the Clinical Manager's name and contact information.

The agency failed to ensure skilled professional staff performed ongoing interdisciplinary assessment of 3 of 13 patients (#8, #12 and #13) whose records were reviewed.

The agency failed to ensure skilled professionals provided patient education required to promote positive patient outcomes for 1 of 5 patients (Patient #8) whose care was observed, and whose records were reviewed.

The agency failed to ensure contracted staff participated in agency sponsored in-service-training.

The agency failed to ensure care provided by the LPN was supervised by an RN for 1 of 4 patients (Patient #6) who received LPN services and whose records were reviewed.

The agency failed to ensure aides completed vital signs as ordered on the aide care plan for 4 of 4 patients (#1, #2, #10, and #11) who received aide services and whose records were reviewed.

The agency failed to ensure aides reported changes in the patient's condition to an RN for 1 of 4 patients (Patient #10) who received aide services and whose records were reviewed.

The agency failed to ensure patients receiving home health aide services received an on-site supervisory visit at least every 14 days, for 4 of 4 patients (#1, #2, #10, and #11) who received aide services and whose records were reviewed.

The agency failed to ensure patient records included all assessments and clinical notes for 1 of 13 patients (Patient #13) whose records were reviewed.