Optimum Plus Home Care

The agency failed to ensure the plan of care (POC) included all pertinent interventions and monitoring precautions for 1 (Patient/P-1) of 1 record reviewed with congestive heart failure, out of a total of 3 records reviewed, resulting in the potential for this patient not receiving care specific to…

The agency failed to coordinate patient care services to meet the needs of the patient for 1 (Patient/P-1) of 1 record reviewed with an adverse event, resulting in a poor clinical outcome for this patient and the potential for all 63 patients currently receiving services from this agency.

The agency failed to ensure the clinical record was complete, including assessments, notes and evaluations for 1 (Patient/P-1) of 1 record reviewed with an adverse event, from a total of 3 records reviewed, resulting in an incomplete clinical record that failed to document an adverse event/fall…

The agency failed to ensure the home health aides were qualified to provide home health aide service (See 754), failed to maintain sufficient documentation that demonstrated the required training for this section was met (See 766), failed to ensure the home health aide competency evaluation…

The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, entities providing services under arrangement and any volunteers, as appropriate, which had the potential to negatively affect the…

The Agency failed to provide initial training and ongoing training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate; and failed to maintain documentation of training's, resulting in the potential for…

The Agency failed to provide sufficient documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency.

The physical therapist failed to supervise the services provided by the physical therapy assistant at least every 30 days for 1 (P-5) of 2 records reviewed with physical therapy assistant services provided at least 30 days, out of a total of 7 records reviewed, resulting in the potential for unmet…

The Agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide's performance of the required tasks with a patient…

The Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, that included safety precautions and needed care equipment prior to the provision of care in 6 (P-1, P-2, P-3, P-4, P-5, P-6) records in which Home Health…

The Agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs.

The agency failed to ensure that all documents were appropriately signed, dated and timed as appropriate in 2 (P-2, P-3) records, from a total of 7 sampled records reviewed, resulting in lack of verification of consent for treatment and the potential for unmet care needs.

The agency failed to ensure 5 (P-2, P-3, P-5, P-6, P-7) patients were included in the overall planning of care, including being informed of the ordered disciplines and frequency in which visits were to be conducted from a total of 7 sampled records reviewed, resulting in lack of inclusion in…

The agency failed to ensure the patient’s clinical record documented all medications reviewed in 1 (P-6) of 7 records reviewed.

The agency failed to ensure the plan of care included all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 4 (P-2, P-3, P-4, P-5, P-6, P-7) records, from a total of 7 sampled records reviewed, resulting in patients not…

The agency failed to ensure its skilled disciplines performed ongoing assessments for 1 (P-2) of 1 patient with documented health concerns, from a total of 7 sampled records reviewed, resulting in unidentified, untreated health concerns and untimely death of a patient.

The Agency failed to ensure that services were provided as ordered by the Physician and indicated in the Plan of Care for 2 (P-1, P-4) patients who required the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for decline in health and unmet care needs.

The home health agency failed to ensure the home health aides were qualified to provide home health aide service for 4 of 4 contracted aides (HHA #1-4) providing service, for a potential of substandard aide services.

The home health agency failed to maintain sufficient documentation that demonstrated the required training for this section was met for 4 of 4 contracted aides (HHA #1-4), resulting in the potential for proving substandard care and unmet care needs.

The Agency failed to maintain documentation of competency evaluations in 4 of 4 contracted Home Health Aides (HHA #1-4) whose personnel file was reviewed, resulting in the potential for the provision of substandard care and unmet care needs.

The Agency failed to maintain documentation of the required 12 hours of annual Home Health Aide in-services for 4 (HHA #1-4) of 4 contracted Home Health aide files reviewed, resulting in lack of evidence of ongoing education and training and the potential for the provision of unsafe care for all…

The agency failed to ensure its skilled disciplines conducted the required on-site Home Health Aide supervisory visits in the patient's home to ensure the adequate provision of care and services for 4 (P-1, P-4, P-5, P-6) patients ordered to receive Aide services, from a total of 7 sampled records…

The agency failed to ensure home health aides (HHa) that provided services under arrangement met the competency evaluation requirements of this part for 4 of 4 aides (HHA #1-4), from a total sample of 4 aide personnel files reviewed, resulting in the provision of aide services by aides that had not…

The Agency failed to ensure the clinical record was complete and included detailed Physical Therapy and Skilled Nursing notes for 3 (P-1, P-3, P-7) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health…

The Agency failed to ensure the discharge/transfer summary was complete, provided the patient's current health status at the time of discharge/transfer, and forwarded to the physician/receiving facility within the required time frame as per this requirement in 3 (P-3, P-4, P-5) records from a total…

The Agency failed to ensure the plan of care included pertinent treatment/interventions with reportable parameters, and all relevant safety measures to prevent injury in 7 of 7 records (MR#'s 1, 2, 3, 4, 5, 6, and 7) reviewed, resulting in a poor outcome (See G 574); and failed to ensure that…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and…

The agency failed to ensure the plan of care (POC) covered all pertinent interventions with reportable parameters, goals, and all relevant safety measures to prevent injury in 7 of 7 records (MR#'s 1, 2, 3, 4, 5, 6 and 7) from a total of 7 records reviewed, resulting in a poor outcome.

The agency failed to provide physical therapy services as ordered in the plan of care for 1 of 7 (MR# 1) records reviewed in which physical therapy services were ordered from a total sample of 7 records, resulting in the potential for functional decline for this patient.

The agency failed to ensure the physical therapist assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 4 of 7 (MR#'s 3 and 4, 5, 6) records reviewed with therapy services, from a total sample of 7 records, resulting in the potential for…