Pure Home Health Care LLC

The agency failed to ensure the alternate administrator was authorized in writing as a pre-designated person qualified to assume the same responsibilities and obligations as the administrator in the administrator's absence.

The agency failed to ensure administrator was responsible for day-to-day operations of the HHA, including telecommunications, by failing to ensure that a reliable mode of communication is in place on-call/after-hours that allows patients/family to reach agency staff in the event of a change in…

The agency failed to ensure an emergency preparedness plan included a documented, facility and community based risk assessment, including an all hazards approach, failed to include strategies for addressing emergency events identified by the risk assessment, failed to include a process for…

The agency failed to ensure that all patients received the contact information for the agency administrator, including the administrator's name and business phone number in order to receive complaints (See G414); failed to ensure patients participate and be informed about the care and services to…

The registered nurse failed to conduct the initial assessment visit within 48 hours of the referral to determine the immediate care and support needs of the patient (See G514); failed to ensure the comprehensive assessment was completed within 5 days of the start of care (G520); failed to ensure…

The agency failed to ensure the needs of the patient was met for 1 of 1 newly admitted patient record reviewed (See G570); failed to ensure the registered nurse communicated/ collaborated with and received orders from the physician after the start of care evaluation visit (See G572); failed to…

The administrator failed to ensure the agency implemented an active QAPI (Quality Assurance Performance Improvement) Program which identified measurable indicators for improving health outcomes, patient safety, and quality of care; failed to measure, analyze, and track quality indicators and other…

The Administrator failed to ensure they were responsible for the day to day operation of the home health agency in regards to incomplete documentation on comprehensive assessments and medication profiles, lack of individualization of care plans, coordination of care, and services being provided to…

The agency failed to ensure all patients were informed in writing of the agency's policies for transfer and discharge in 2 of 5 active patients reviewed (Patients #4, 6) and 1 patient discharged for cause.

The agency failed to send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals, and treatment preferences to the receiving facility or health care practitioner to ensure effective care transitions in 2 of 2 discharged patients…

The agency failed to ensure the registered nurse communicated/ collaborated with and received orders from the physician after the start of care evaluation or recertification visit for 3 of 5 active patients reviewed.

The bag failed to evidence the ability to utilize a clean/dirty side that would separate hand sanitizer, pens, tablet, etc. from items for care and assessment, such as the stethoscope, thermometer.

The Administrator failed to ensure they had employed a Clinical Manager and/or a qualified Alternate Clinical Manager to provide oversight on making patient and personnel assignments, coordinating patient care, coordinating referrals, assuring that patient needs are continually assessed, and…

The agency failed to ensure that all patients received the contact information for the agency administrator, including the administrator's name and business phone number in order to receive complaints, in 3 (Patient 3, 4, 5) of 3 active patients who received home visits and 1 (Patient #6) of 1…

The agency failed to ensure patients participate and be informed about the care and services to be provided in 3 of 5 active records reviewed . (Patients 4, 5, 6) Findings include: 1. Review of a policy titled "Service Agreement, policy c-160" revealed "A Service Agreement shall be developed with…

The agency failed to ensure patients were informed about the liability for payment in 3 of 5 active records reviewed.

The agency failed to ensure all patients were advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local Home Health Agencies in 4 of 5 active patient records reviewed.

The Patient Bill of Rights failed to evidence the names, addressess, and telephone numbers of the area- Agency on Aging; Center for Independent Living; and the Protection and Advocacy Agency.

The agency failed to assist patients in transferring to another provider when the payer would no longer cover services provided by the agency for 1 of 2 discharged patients reviewed.

The agency failed to ensure they documented in the clinical record the circumstances that warranted discharge for cause, including disruptive or dangerous behavior, and failed to document the agency's efforts to resolve the problem prior to discharging for cause in 1 of 1 patients reviewed for…

The registered nurse failed to conduct the initial assessment visit within 48 hours of the referral to determine the immediate care and support needs of the patient for 1 of 1 newly admitted patient record reviewed.

The agency failed to ensure the comprehensive assessment was completed within 5 days of the start of care for 1 of 1 newly admitted patient record reviewed.

The agency failed to ensure that all patients received a complete and accurate assessment that included health, psychosocial, functional, and cognitive status in 3 of 5 active patients reviewed.

The agency failed to ensure all patients all patients received a comprehensive assessment that included the patient's strengths and care preferences, and included measurable and patient specific goals for 3 of 5 active patients reviewed.

The agency failed to ensure the comprehensive assessment included the reason for continued home health services in 2 of 5 active patients reviewed.

The agency failed to ensure all patients received a complete and accurate assessment that included the patient's medical, nursing, rehabilitative, social, and discharge planning needs in 3 of 5 active records reviewed.

The clinical record for patient #5, the start of care date (SOC) 6/21/21 was reviewed on 7/8/21. The record contained a "Medication Profile" dated 6/21/21, in which the document failed to evidence the patient's allergy to Percocet.

The agency failed to ensure all patients received an individualized and patient specific plan of care, including all pertinent diagnoses, mental/ psychosocial/ cognitive status, types of services, equipment/ supplies needed, frequency, duration, activities, nutritional requirements, all medications…

2. Review of the clinical record for patient #3, certification period 7/3/21 - 8/31/21, failed to evidence documentation or physician's orders that confirmed the physician was contacted after the comprehensive assessment to review findings and obtain orders for further services.

The agency failed to ensure the plan of care was reviewed by the physician responsible for the home health plan of care for 1 of 1 newly admitted patient record reviewed.

The patient lived with a daughter who attempted to help, when possible, but was not comfortable applying the cream to personal areas.

The agency failed to ensure they documented their efforts in coordinating with all disciplines involved in a patients care for 1 (Patient #5) of 1 newly admitted patient record reviewed and failed to ensure the all disciplines coordinated care delivery to meet the patient's needs.

4. During a home visit with patient #4 on 7/3/21 at 1 PM, the admission folder was reviewed and failed to evidence the patient received a schedule for the skilled nurse visits.

2. During a home visit on 7/2/21 at 2:05 PM, the medication profile for patient #4 was reviewed and evidenced the following medications: Aripiprazole (medication for schizophrenia, bipolar disorder, depression, and Tourettes syndrome) 10 mg (milligrams) by mouth daily per the plan of care, however…

The physical therapist and registered nurse failed to assess patient's pain, skin and bowel status during visits in 1 of 1 newly admitted records reviewed.

The skilled nurse failed to ensure the plan of care was developed with the patient and caregivers in 1 of 1 newly admitted patient records reviewed.

The agency failed to provide occupational services as ordered in 1 of 1 record reviewed of a patient needing occupational therapy services.

The physical therapist and clinical manager failed to ensure they communicated with the ordering physician when the start of care is delayed, inability to provide occupational therapy services, and failed to ensure clinicians notified the physician when there is a possible change in condition for 1…

The Administrator failed to ensure they were responsible for the day to day operation of the home health agency in regards to incomplete documentation on comprehensive assessments and medication profiles, lack of individualization of care plans, coordination of care, and services being provided to…

The Administrator failed to ensure they had a pre-designated person, authorized in writing by the Administrator and Governing body, to assume the same responsibilities and obligations as the Administrator.

When queried "Can I have the minutes?" the alternate clinical manager did not initially answer, then stated, "I'll have to find them." When queried as to the date of the most recent IDG meeting, the alternate clinical manager and administrator stated they did not know the date.

The Alternate Clinical Manager failed to ensure referrals received are appropriately reviewed to ensure the agency is able to meet the patient needs upon admission and that there is no delay in services for 1 of 1 newly admitted patient record reviewed.

The Alternate Clinical Manager failed to ensure all patients received a complete and accurate assessment that included the patient's medical, nursing, rehabilitative, social, and discharge planning needs in 3 of 5 active records reviewed.

The Alternate Clinical Manager failed to ensure they communicated/ collaborated with and received orders from the physician after the start of care evaluation or recertification visits for 3 of 5 active patients reviewed.

The Alternate Clinical Manager failed to ensure all disciplines failed to follow professional standards when assessing a patient's pain, skin, and bowel status in 1 of 1 newly admitted records reviewed.

The agency failed to ensure that the skilled nurse followed the visit frequency included on the plan of care in 1 of 4 patients receiving skilled nursing services in a sample of 7. (#4) Findings included: An undated agency policy, titled, "Missed/Refusal of Visits", stated that the HHA [home health…

The agency failed to ensure the skilled nurse included all pertinent diagnoses and patient-specific measurable outcomes or interventions in the plan of care in 1 of 4 (#4) patients receiving skilled nursing services and that the physical therapist (PT) included oxygen as a listed medication on the…

The Registered Nurse/ Case Manager failed to ensure all pertinent diagnoses and patient-specific measurable outcomes or interventions were included in the plan of care in 1 of 4 (#4) patients receiving skilled nursing services and that the physical therapist (PT) included oxygen as a listed…

The skilled nurse failed to ensure visits followed the frequency ordered on the plan of care in 1 of 4 patients receiving skilled nursing services in a sample of 7. (#4) Findings included: An undated agency policy, titled, "Missed/Refusal of Visits", stated that the HHA [home health agency] should…

The skilled nurse failed to document a patient's blood sugars as part of their assessment in 1 of 4 (#4) patients receiving skilled nursing services in a sample of 7 records reviewed.