Optimum Care Home Health Agency

The agency's group of professional personnel failed to include a physician in that: On 1/9/18 at 2:00 PM, the agency's administrator identified Female/Registered Nurse /Advanced Practiced Registered Nurse #100 with probated RN license as the agency's Medical Director.

#9 and #10) for services and did not follow the POC for each patient in that: - Patient #1, 3, 4, 6, 7 and 9's POC listed OT services that were not provided. - Patient #1, 3, 4, 6, 7, 8, 9 and 10's POC listed MSW services that were not provided. - Patient #1, 7 and #9's POC listed HHA services that…

The administrator failed to manage the daily operations of the agency in that: 1. The new owner/ administrator did not ensure that the agency have a Medical Director that will advise and supervise the agency on professional issues.

The agency failed to make sure that patient's care and services were coordinated to all health providers in 2 of 2 (#2 and #7) patient's receiving dialysis treatment in that: Patients' #2 and #7 are receiving dialysis treatments at facility #107 and #108 respectively.

The agency's group of professional personnel failed to include a physician in that: On 1/9/18 at 2:00 PM, the agency's administrator identified Female/Registered Nurse /Advanced Practiced Registered Nurse #100 with probated RN license as the agency's Medical Director.

The agency failed to ensure that the group of professional personnel annually reviewed the agency's policies that governs the scope of services offered and to evaluate the overall performance of the agency in that: - The agency failed to provide documentation to show that the agency's group of…

The agency failed to have all members of the group of professional personnel meet frequently to advise the agency on professional issues, participate in the evaluation of the agency's program, and assist in maintaining liaison with other health care providers in the community in that: - The agency…

The agency did not ensure that the agency's group of professionals had dated documented minutes for the year 2017. Failure of the agency to make sure that the group of professionals meet frequently as needed and to have dated documented minutes for 2017 to show issues identified including over all…

#9 and #10) for services and did not follow the POC for each patient in that: - Patient #1, 3, 4, 6, 7 and 9's POC listed OT services that were not provided. - Patient #1, 3, 4, 6, 7, 8, 9 and 10's POC listed MSW services that were not provided. - Patient #1, 7 and #9's POC listed HHA services that…

The registered nurse failed to make sure that the patient's POC were followed in 9 of 10 patient's (#1, 2, 3, 4, 6, 7, 8, 9 and #10) in that: - Patient #1, #3, #6, #7 and #8's O2 saturation were not taken as ordered in the POC and to report when out of the parameter. - Patient #4, #5, #6, #7, #8…

The Registered Nurse failed to make sure that the POC for 9 of 10 patients (#1, 2, 3, 5, 6, 7, 8, 9 and #10) included mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional…

The agency failed to ensure the plans of care (POC) were reviewed by the attending physician at least every 60 days for 10 of 10 ( #1, #2, #3, #4 #5, 6, 7 ,8 , 9 and #10) patient records reviewed in that: The POC's for patient #2, 5, 6 and #7 did not list the name of the physician that authorized…

The registered nurse did not make sure that care was provided with orders in 1 of 1 (#8)patient with psychiatric diagnosis who is receiving IM injection in that: Patient #8 received Invega injection IM without a documented physician order.

The agency failed to ensure that the agency transmitted OASIS (Outcome and Assessment Information Set) assessment data at least monthly from 5/01/17 thru 11/30/2017 in that: The agency did not transmit OASIS data for the month of May 2017 and June 2017. Failure of the agency to transmit OASIS…

The agency failed to ensure that the initial assessment accurately reflected the health status for 1 of 1 ( #8) patient with psychiatric diagnoses receiving intramuscularly antipsychotic medication in that: Patient #8 did not have psychiatric assessment to include assessment of cranial nerve…

The agency failed to ensure that the comprehensive assessment for 2 of 2 discharged patients (#9 and #10) was updated and revised at discharge in that: Patient #9's CR showed SN missed visit on week 8 and week 9. The alternate DON stated that patient #9 was discharged from the agency.