One at Home - Dade

The home health agency failed to maintain documentation of the comprehensive assessment that must be updated and revised as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status for 1 out of 10 Sampled Patients (SP).

The home health agency failed to promptly alert the relevant physician(s) to any changes that suggest the plan of care should be altered for 1 out of 4 Sampled Patients (SP).

The home health agency failed to coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate in 1 out 4 Sampled Patients (SP).

The home health agency staff failed to provide service(s) that are ordered by the physician as indicated in the Plan of Care (POC) for 1 out 4 Sampled Patients (SP).

The home health agency failed to ensure that an onsite visit to the patient's home no less frequently than every 14 days is conducted for supervision of the Home Health Aide (HHA) by a Registered Nurse or other appropriate skilled professional in 1 out of 4 Sampled Patients (SP).

This CONDITION is not met as evidence by: Based on interview, clinical record review and review of policies and procedures, it was determined that the Home Health Agency (HHA) failed to ensure the care follows the written plan of care established by the physician (Refer to G-578) and provide…

This CONDITION is not met as evidence by: Based on interview, clinical record review and review of policies and procedures, it was determined that the Home Health Agency (HHA) failed to maintain ongoing interdisciplinary assessment of the patient (Refer to G-706) and failed to maintain…

The provider failed to submit the encoded OASIS (Outcome and Assessment Information Set) data that must accurately reflect the patient's status at the time of assessment for 1 out of 3 Sampled Patients (SP).

The provider failed to demonstrate it sent all necessary medical information pertaining to the patient's current course of illness and treatment to the receiving facility or health care practitioner to ensure the safe and effective transition of care for 1 out 3 Sampled Patients (SP).

The provider failed to ensure the care follows the written plan of care (POC) established by the physician on 1 out of 3 Sampled Patients (SP).

The provider failed to demonstrate the patient and/or caregiver participated in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to revising the plan of care; the frequency of visits; any factors that could impact treatment…

The provider failed to administer treatments only as ordered by a physician for 1 out of 3 Sampled Patients (SP).

The provider failed to consult the physician about the patient's condition or needs that suggest the plan of care should be altered for 1 out 3 Sampled Patients (SP).

The provider failed to inform of any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the Home Health Agency (HHA) plan of care for 1 out of…

The provider failed to maintain ongoing interdisciplinary assessment of the patient for 1 out 3 Sampled Patients (SP).

The provider failed to maintain communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care for 1 out of 3 Sampled Patients (SP).

The clinical manager failed to coordinate patient care for 1 out 3 Sampled Patients (SP).

The provider failed to ensure the clinical record included a completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the Home Health Agency (HHA) becomes aware of the…

The provider failed to coordinate care delivery to meet the patient's needs for 1 out of 3 Sampled Patients (SP).

The Home Health Agency failed to notify the ordering physician(s) of a review and revision of the plan of care for 3 out of 6 Sampled Patients (SP).

The Home Health Agency failed to ensure the clinical record includes all entries appropriately authenticated (signature and a title), dated, and timed for 1 out 6 Sampled Patient (SP).

The Home Health Agency failed to demonstrate it had provided written notice of the patient's rights and responsibilities, and the Home Health Agency's transfer and discharge policies for 1 out of 6 Sampled Patients (SP).

The Home Health Agency failed to ensure that the patient was informed in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished for 3 out of 6 Sampled Patients (SP).

The Home Health Agency failed to have a completed individualized plan of care for 2 out of 6 Sampled Patients (SP).

The Home Health Agency failed to maintain the content of clinical record that includes services rendered by the home health agency for 1 out of 6 Sampled Patients (SP).

The provider failed to ensure the care follows the written plan of care (POC) established by the physician on 1 out of 4 Sampled Patients (SP).

The provider failed to ensure that the patients were informed in advance of the discipline(s) frequency of visits proposed to be furnished for 4 out of 4 Sampled Patients (SP).

The provider failed to document the orders in the patient's clinical record, and sign, date, and time the orders in 1 out of 4 Sampled Patients (SP).

The home health agency staff failed to provide service(s) that are ordered by the physician as indicated in the Plan of Care (POC) for 1 out 4 Sampled Patients (SP).

The provider failed to be in conformance with the physician orders for 3 out of 4 (#1, #2, #4) sample patients (SP).

The Home Health Agency failed to ensure that clinical documentation were legible and clearly written for 3 out of 4 sampled patients.

The provider failed to include in the individualized plan of care, a description of the patient's risk for emergency department visits/hospital re-admission, information related to any advanced directives, and all goals for 4 out of 4 (#1, #2, #3, #4) Sampled Patients (SP).

The provider failed to ensure that 2 out of 4 (#3, #4) sample patients (SP) plan of care included all orders.

The provider failed to ensure that the verbal order for 1 out of 4 (#4) sample patients (SP) contain correct information.

The Home Health agency failed to ensure that one out of four sampled patients' records contained clinical notes that reflected that skilled nursing services were provided.

The provider failed to ensure that the patients were informed in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished and the sources of payments for 2 out of 3 Sampled Patients (SP).