Oasis HH Operations LLC

The agency failed to develop an emergency preparedness program specific to the agency and failed to meet the requirements of: (1) a risk assessment and emergency preparedness plan, (2) required policies and procedures, (3) training of staff, and (4) testing and exercises of the plan.

The agency failed to ensure adequate care planning for patients.

The agency's QAPI program failed to show measurable improvement (refer to G642); failed to ensure its QAPI program resulted in sustained improvements to its performance and failed to conduct performance improvement projects (refer to G658) and the agency's governing body failed to ensure resources…

The agency failed to maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases.

The Governing Body and/or Administrator failed to ensure the overall management and organization of resources in order to attain and provide the highest practicable functional status of the agency.

It was identified that the agency failed to maintain an emergency preparedness plan that was reviewed and updated every two years.

The agency's emergency preparedness plan failed to review and update the all-hazard approach to include emerging infectious disease threats.

The agency failed to have a process for cooperation and collaboration with local, regional state and federal emergency preparedness officials efforts to maintain an integrated response during a disaster/emergency situation.

The agency failed to have evidence that the policies and procedures included a risk assessment and a communication plan.

The agency failed to have evidence of policies and procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact.

The agency failed to include the names and contact information for the following in their emergency preparedness communication plan: (1) Staff.

The agency failed to develop and maintain an emergency preparedness communication plan to include all of the following: Primary and alternate means for communicating with the following: (i) [Facility] staff.

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

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

The agency failed to conduct and document annual testing of the emergency preparedness plan (EPP).

The agency failed to maintain documentation of evidence of the staff’s ability to demonstrate knowledge of agency’s emergency preparedness plan.

The agency failed to conduct an additional emergency preparedness exercise to test their emergency plan at least annually.

The agency staff failed to ensure home health services were provided according to the patient's individualized plan of care for two (2) out of seven (7) medical records in the survey sample.

The agency's QAPI program failed to show measurable improvement.

The agency's QAPI program failed to conduct Performance Improvement Projects (PIPs) each year.

The facility failed to ensure the agency's quality improvement program was defined, implemented, and maintained.

The agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.

The agency failed to ensure it established and maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement…

The agency failed to provide infection control education to their staff for seven (7) of (11) personnel files reviewed for which infection control was applicable for job specific tasks.

The Home Health Agency failed to ensure the agency's appliance for conducting testing had been cleared for that purpose by the Food and Drug Administration.

The agency failed to ensure it furnished a skilled service in its entirety directly by agency staff.

The agency failed to ensure staff that have on-going contact with patients who have language barriers, should be trained in effective communication techniques, including the effective use of an interpreter for one (1) of (2) patients in the survey sample identified with a language barrier.

The agency failed to ensure that patients were informed about and consented to the frequency of proposed visits in advance of starting care in one (1) of seven (7) medical records reviewed in the survey sample.

The agency failed to ensure patients were advised of the names, address, and telephone numbers of the following federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Aging and Disability Resource Center, and Quality…

The agency failed to ensure documentation of the existence of and the resolution to each patient complaint.

The agency failed to ensure each patient had a complete and accurate medication profile in two (2) of seven (7) medical records reviewed in the survey sample.

The agency failed to include all required elements on each patient's individualized plan of care.

The agency failed to accurately differentiate personal care aides from home health aides with documented required 75 hours of classroom and supervised practical training for home health aides for three (3) out of six (6) in the survey sample.

The Administrator responsible for the day-to-day operations of the HHA failed to ensure the accuracy of public information materials.

The agency failed to designate a qualified person, who is authorized in writing by the administrator and the governing body, to assume the same responsibilities and obligations as the Administrator.

The agency failed to send the patient's discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit for one (1) of two (2) closed medical records reviewed in the survey sample.

The agency failed to ensure adequate care planning for patients.

The agency failed to address high risk and problem-prone areas with its Quality Assessment and Performance Improvement (QAPI) program for 2018 and 2019 (refer to G648); failed to ensure its QAPI program resulted in sustained improvements to its performance for 2018 and 2019 (refer to G656); and…

The Governing Body and/or Administrator failed to ensure the overall management and organization of resources in order to attain and provide the highest practicable functional status of the agency.

The agency failed to review and update their Emergency Preparedness Plan (EPP) at least every two (2) years.

The agency failed to review and update their Emergency Preparedness Plan (EPP) policies and procedures at least every two (2) years.

The agency failed to implement an emergency preparedness plan (EPP) policy and procedure for informing State and local emergency preparedness officials about patients in need of evacuation from their residences due to an emergency situation.

The agency failed to conduct and document annual testing of the emergency preparedness plan (EPP).

The agency failed to ensure that each patient received home health services according to an individualized written plan of care.

The agency failed to conduct performance improvement projects.

The agency failed to mitigate the risk of transmission of COVID-19. Specifically, the agency failed to implement a screening procedure for visitors to the agency and failed to screen patients for signs and symptoms of and potential risk and exposures of COVID-19 prior to or immediately upon arrival…

The agency failed to coordinate an agency-wide infection control program that included a method for identifying infectious and communicable disease problems.

The agency failed to ensure it maintained an accurate clinical record for each patient in two (2) of ten (10) clinical records reviewed in the survey sample.

The agency failed to update or revise the comprehensive assessment within 48 hours of a patient's return to the home from a hospital admission of 24 hours or more for two (2) of two (2) patients in the survey sample who had a resumption of care following a hospital admission.

The agency failed to ensure all patients' individualized plans of care included all medication and treatments and the types of supplies and equipment required in five (5) of ten (10) clinical records reviewed in the survey sample.

The agency failed to ensure all patient care orders were recorded in the plan of care in three (3) of ten (10) clinical records reviewed in the survey sample.

The agency failed to ensure all services and treatments were administered only as ordered by a physician in two (2) of ten (10) clinical records reviewed in the survey sample.

The agency failed to ensure each patient's plan of care integrated orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient in one (1) of ten (10) patients reviewed in the survey sample.

The agency failed to address high risk and problem-prone areas with its Quality Assessment and Performance Improvement (QAPI) program.

The agency failed to ensure its Quality Assessment and Performance Improvement (QAPI) program resulted in sustained improvements to its performance.

The agency failed to ensure that the Administrator was appointed by the agency's Governing Body.

The agency failed to ensure the Administrator was responsible for all day-to-day operations of the HHA.

The agency failed to ensure that a qualified, pre-designated person had written authorization from the Administrator and Governing Body to assume the roles and responsibilities of the administrator in the administrator's absence.

The agency failed to ensure that patients' plans of care were implemented and updated as required in five (5) of ten (10) clinical records reviewed in the survey sample.

The agency failed to send a completed transfer summary to a hospital where a patient was admitted for care within two (2) business days of becoming aware of the unplanned transfer for three (3) of three (3) patients with unplanned hospital admissions and whose clinical records were reviewed during…