Open Arms Home Health Care - Council Bluffs, LLC

The agency: 1) failed to develop a Quality Assessment and Performance Improvement (QAPI) program which showed measurable improvements in indicators related to patient health, safety and quality of care outcomes and ensure the agency measured, analyzed and tracked quality indicators, including…

The agency failed to: 1) determine satisfactory competency with basic skills prior to assigning an aide to a patient (G768); 2) assure all aides are assigned to a patient by a registered nurse working for the agency and duties are patient specific (G798); 3) ensure home health aides performed tasks…

The agency failed to: 1) Complete discharge summaries and send to the physician caring for the patient within 5 business days after the discharge.

The home health agency failed to ensure the clinical record included a copy of the patient's individualized emergency plan developed as part of the comprehensive assessment for 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) with a record review which included a…

The agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation.

The agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles for 9 of 9 contracted staff and 21 of 21 directly hired staff.

The hospice failed to ensure participation in 2 emergency preparedness exercises prior to 11/15/17 and documented 1 of 2 drills/actual events in 2018. The agency reported a current census of 16 patients at the time of the survey.

The agency failed to transmit OASIS data within 30 days of the OASIS M0090 date for 4 of 8 sampled patients requiring transmission of OASIS data (Patients #2, #5, #8 and #10).

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program which showed measurable improvements in indicators related to patient health, safety and quality of care outcomes and ensure agency staff measured, analyzed and tracked quality indicators, including adverse…

The agency failed to ensure agency staff used quality indicator data, including data derived from Outcome and Assessment Information Set (OASIS) and other relevant data to monitor the effectiveness, safety of services and quality of care, identify opportunities for improvement and ensure the…

The agency failed to ensure agency staff identified performance improvement activities to track adverse patient events, analyze cause and implement preventative actions.

The agency failed to ensure agency staff conducted performance improvement projects reflecting the scope, complexity and past performance of the agency's services, documented the reasons for conducting the performance improvement projects chosen and the measurable progress achieved on those…

The agency failed to ensure the governing body oversaw an ongoing Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care and patents safety, ensure the governing body evaluated all improvement actions for effectiveness; ensure the…

The agency failed to ensure the home health aides successfully completed competencies in all basic home health aide skills which require a registered nurse, or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct…

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) or other appropriate skilled professional to agency home health aides for 9 of 9 sampled patients receiving home health aide services (Patients #1, #2, #3, #4, #5, #6, #7, #8 and…

The agency failed to maintain a complete, up-to-date clinical record; failed to ensure authentication of hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature; failed to complete timely documentation as directed by…

The agency failed to ensure that all patient clinical record documentation was maintained in a secure and confidential manner for patients receiving home care services from the agency.

The agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the…

The agency failed to complete a drug regimen review (DRR) with each comprehensive assessment for 9 of 10 sampled patients (Patients #2, #3, #4, #5, #6, #7, #8, #9 and #10 ).

The agency failed to ensure the completion of all pertinent components of the update to the comprehensive assessment at recertification in the last 5 days of each certification period for 7 of 8 sampled patients requiring a recertification (Patients #2, #3, #4, #6, #7, #8 and #9).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient, risk of emergency room and hospital readmission for 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #8, #9 and #10).

The agency failed to update the Plan of Care with all new physician orders for 8 of 10 sampled patients with interim orders.

The agency failed to provide therapy services as ordered by the physician for 1 of 2 sampled patients receiving therapy services from the agency (Patients #10).

The agency failed to ensure patient care delivery was coordinated in a way to meet patient individualized needs for 1 of 10 sampled patients (Patient #7).

The agency failed to ensure agency staff focused performance improvement activities on high risk, high volume or problem prone areas.

The agency failed to ensure agency staff considered incidence, prevalence and severity of a problems associated with high risk, high volume and problem prone areas.

The agency failed to ensure agency staff identified whether there was a high risk, high volume, problem prone area that directly or potentially threaten the health and safety of patients and required immediate correction.

The agency failed to ensure agency staff conducted performance improvement projects reflecting the scope, complexity and past performance of the agency's services, documented the reasons for conducting the performance improvement projects chosen and the measurable progress achieved on those…

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 9 of 9 sampled patients receiving home health aide services (Patients…

The agency failed to ensure a registered nurse (RN) or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 2 sampled patients who received hands on personal care services in conjunction with therapy services (Patient #10).

The agency failed to ensure a registered nurse completed home health aide supervision at least every 60 days while observing each home health aide present and providing direct patient care for 2 of 2 sampled patients who received hands on personal care services with no skilled service provision.

The agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks…

The agency failed to complete and send a discharge summary to the physician responsible for providing care to the patient within 5 business days of the patient's discharge for 2 of 2 sampled discharged patients (Patients #9 and #10).