Prime Care Home Health Services

The agency failed to develop and implement individualized emergency preparedness plans for the patients, which provided appropriate instructions, in the event of an emergency in 5 of 5 active clinical records reviewed.

The agency failed to ensure the encoded OASIS (Outcome and Assessment Information Set, a comprehensive assessment data collection tool) accurately reflected the patient’s status in 3 of 6 clinical records reviewed with OASIS submissions.

The agency failed to ensure coordination of care with the health care practitioner to ensure safe and effective transition of care for 1 of 1 discharge clinical record reviewed.

The home health agency failed to ensure patient met goals for discharge in 1of 1 closed clinical records reviewed.

The agency failed to ensure the initial assessment was completed within 48 hours of the referral in 4 of 5 active clinical records reviewed.

The agency failed to ensure the comprehensive assessment reflected the patient’s health status in 5 of 5 clinical records reviewed.

The agency failed to ensure the comprehensive assessment included the identification of the patient’s primary caregiver, their willingness and ability to provide care, and their availability and schedule in 1 of 1 clinical record reviewed with wounds.

The agency failed to ensure the physical therapist provided services as ordered by the physician in the plan of care in 3 of 4 active clinical records reviewed receiving physical therapy (PT) services.

The home health aide (HHA) failed to report patient falls in 1 of 1 clinical record reviewed with HHA services.

The clinical manager failed to provide oversight of personnel assignments in 1 of 1 home visits with the home health aide.

The clinical manager failed to ensure the development and implementation of the plan of care in 1 of 1 clinical record reviewed with wounds.

The agency failed to ensure the skilled nurse provided wound care in accordance with current clinical practice guidelines in 1 of 1 clinical record reviewed with a wound.

The home health agency failed to ensure the organization and management of the home health agency as follows: the administrator failed to ensure the governing body reviewed the quality assessment and performance improvement program (see tag G0942); the administrator failed to maintain the…

The agency failed to implement a discharge planning process that assisted patients and their caregivers in selecting a care provider using quality measures that are applicable to the patient’s goals of care and treatment preferences in 2 of 2 clinical records with pending discharge.

The home health agency failed to conduct a performance improvement project annually.

The home health agency failed to implement policies and procedures to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated; and failed to include policies and procedures that were implemented…

The home health agency failed to review all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy in 4 of 6…

The agency failed to communicate discharge plans to the physician and patient’s representative in 2 of 2 clinical record reviews with medical social work (MSW) services.

The agency failed to ensure all orders were integrated into the plan of care in 1 of 1 clinical record reviewed with a hospitalization.

The agency failed to coordinate care with other agencies providing services to the patient in 1 of 1 clinical record reviewed receiving services from another home care agency.

The home health agency’s performance improvement activities failed to lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.

The home health agency failed to ensure all skilled profession staff participate in the home health agency’s QAPI (quality assessment performance improvement) program.

The home health agency failed to have the home health aide provide services that are ordered by the physician included in the plan of care in 1of 1 clinical records reviewed with a home health aide.

The administrator failed to be responsible for the day-to-day operations of the agency.

The clinical manager failed to provide clinical oversight of the coordination of patient referrals in 2 of 2 clinical records reviewed with referrals.

The home health agency failed to ensure all clinicians performed hand hygiene to prevent the possible spread of communicable diseases for 1 of 1 home visit with a Registered Nurse (RN).

The home health agency failed to ensure all patients had a home health aide care plan for 1 of 1 active clinical record reviewed where home health aide services were provided.

The home health agency failed to ensure all clinical record documentation was accurate and complete for 3 of 4 active clinical records reviewed.

The home health agency failed to ensure: the plan of care was reviewed by the physician, individualized and followed by all agency staff (See tag G0572); the plan of care included all required information for the treatment of the patient (See tag G0574); all patient care orders were recorded in the…

The home health agency failed to ensure the patient received all services as ordered on the plan of care, and/or had an individualized plan of care which included patient-specific, measurable goals and outcomes in 5 of 7 clinical records reviewed.

The agency failed to ensure the patient/caregiver consented to in advance, to the frequency of services that were being furnished in 7 of 7 complete clinical records reviewed.

The home health agency failed to ensure the medical plan of care was complete and included medications, the indication for medications, and all diagnoses in 6 of 7 records reviewed (#1, #2, #3, #4, #6, #7) 1. The agency's policy titled "Physician Participation in Plan of Care" dated August 2011…

The agency failed to record all patient care orders, including verbal orders, in the plan of care in 1 of 5 active clinical records reviewed.

The home health agency failed to administer services and treatments only as ordered by a physician in 2 of 5 active clinical records reviewed without a home visit.

The agency failed to promptly alert the physician to changes in the patients’ conditions which suggested outcomes were not being achieved in 2 of 5 active clinical records reviewed.

The agency failed to ensure the patient received appropriate discharge teaching in 2 of 2 discharged records reviewed (#6, #7).

The home health agency failed to ensure a written schedule was provided to patients in 2 of 2 home visits conducted (#1. #2) The findings include: 1. An undated agency policy obtained on 10/5/2022, titled Home Care Patient Rights and Responsibilities” stated “The patient has the right to: ...…

The agency failed to provide written instructions to the patient for the patient's medication schedule and instructions in 2 of 2 home visits conducted.

The home health agency failed to ensure patients received in writing any treatments to be administered by personnel and personnel acting on behalf of the home health agency in 2 of 2 home visits conducted (#1, #2).

The home health agency failed to ensure patients received the name and contact information for the clinical manager in writing in 2 of 2 home visits conducted (#1, #2).

The agency failed to ensure the clinical record included the patient's goals and progress towards the goals in the plan of care in 1 of 2 closed clinical records reviewed.