Rims Health Care Inc

The home health provider failed to ensure that an updated all hazards risk assessment was part of the emergency preparedness plan.

The home health provider failed to ensure that staff received Emergency Preparedness Training in one of one employee record reviewed (E-1).

The home health provider failed to ensure staff used acceptable standards of practice for infection control in two of two home visit observations (Records/Patients #1 and #3).

The home health provider failed to ensure that staff received infection control training in one of one employee record reviewed (E-1).

The home health provider failed to ensure the clinical notes were entered into the patient’s record in a timely manner in one of five full records reviewed (Record/Patient #1).

The home health provider failed to include the correct hours of operation for the state telephone hotline in two of two home visit observations (Records/Patients #1 and #2).

The home health provider failed to maintain an accurate, updated medication profile in two of five full records reviewed (Records/Patients #1 and #3).

The home health provider failed to ensure staff developed an individualized, complete plan of care (POC) in two of five full records reviewed (Records/Patients #1 and #3).

The home health provider failed to ensure staff followed the physician ordered plan of care (POC) when staff failed to consistently document weekly weights in one of five full records reviewed (Record/Patient #1).

The home health provider failed to ensure that staff received Alzheimer’s and Dementia training in one of one employee record reviewed (E-1).

The home health provider failed to ensure that transfer summaries were completed in two of two transfer records reviewed (Records/Patients #4 and #5).

The agency failed to provide each patient with a written individualized plan of care (POC) that was established by the physician in, but not limited to, three (Records/Patients #1, #2, and #3) of the seven current agency patients, when the agency skilled nurse (SN) failed to contact the physician…

The agency failed to ensure staff followed infection control standards of practice in one (Record/Patient #1) of three home visit observations.

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is a part of the agency's quality assessment and performance improvement (QAPI) program (a data driven and proactive…

The agency failed to ensure an accurate medication review and/or update of the patient's medications was completed in two (Record/Patient #1 and #3) three home visit observations performed.

The agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in three (Record/Patient #1, #3, and #4) of five full records reviewed.

The agency failed to provide drugs, services and treatments only as ordered by a physician in, but not limited to, two (Record/Patients #2 and #5) out of five full records reviewed.

The agency failed to ensure each patient received written information related to visit schedule/instructions, in three (Record #1, #2, and #3) of three applicable home visits.

The agency failed to provide the patient/caregiver with an updated/current copy of written instructions outlining the patient's medication schedule, including medication name, dosage, and frequency in two (Record/Patient #1 and #3) of three home visit observations.

The agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in, but not limited to, two (Record/Patient #1 and #2) of three home visit observations.

The agency failed to provide services as ordered by the physician on the plan of care (POC , but not limited to. two (Record/Patient #3 and #4) of five full records reviewed.

The agency failed to ensure a completed transfer summary was sent within two business days of a planned transfer to a respite facility and an unplanned transfer to a hospital which affected three (Record/Patient #3 and #4) of five full records reviewed for transfer summaries and failed to send a…

The agency failed to develop and implement a comprehensive emergency preparedness program when the agency failed to: - Develop an emergency preparedness plan that must be reviewed and updated annually (E-0004); - Develop an emergency preparedness plan based on and including a documented facility…

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information based on the new home health regulations effective 01/13/18. The agency failed to provide in writing, in advance of furnishing care the following…

The agency failed to: - Ensure the agency can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence (G570); - Ensure each patient received an individualized plan of care which included a description of the patient's risk for emergency department…

The agency failed to: - Ensure there was evidence that the agency is measuring, analyzing, and tracking quality indicators (G642); - Ensure the agency used data collected to monitor the effectiveness and safety of the services and quality of care and identifying opportunities for improvement…

The agency failed to: - Follow accepted standards of practice (G682); - Maintain/document an infection control program (G684); and - Provide relevant education to patients and caregivers (G686).

The agency failed to ensure: - The governing body assumed full legal authority and responsibility for the agency management, operation, and the provision of all home health services including its quality assessment performance improvement (QAPI) program (G942); - The administrator effectively…

The agency failed to develop an emergency plan to meet the requirement for the agency to review and update the emergency plan at least annually to ensure the plan included all required elements.

The agency failed to develop an emergency plan that was based on a facility based and community based risk assessment utilizing an all-hazards approach and included strategies to address the emergency events identified by the risk assessment.

The agency failed to develop an emergency plan that addressed patient population, including, but not limited to, the type of services the agency has the ability to provide in an emergency; and continuity of operations, including delegations of authority and a succession plans.

The agency failed to develop an emergency plan that included a process for cooperation and collaboration with local, tribal, regional.

The agency failed to develop emergency preparedness policies and procedures.

The agency failed to ensure each patient had an individualized emergency plan documented as part of the patient's comprehensive assessment in five (Records/Patients #1, #2, #3, #4 and #5) of five cases reviewed.

The agency failed to develop emergency preparedness policies and procedures related to informing the state and local emergency preparedness officials regarding the agency's patients who may need evacuation from their residence and the patient's medical, psychiatric condition, and home environment…

The agency failed to develop an emergency preparedness procedure regarding how the agency will follow up with on-duty staff and patients to determine services that are needed and the process for informing State and local officials of any on-duty staff or patients that the agency is unable to…

The agency failed to develop an emergency preparedness policy/procedure regarding a system of documentation that preserves patient information, protects confidentiality, and secures and maintains the availability of records.

The agency failed to develop an emergency preparedness policy/procedure regarding the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integrating State and Federally designated health care professionals to address surge needs during an…

The agency failed to develop an emergency preparedness communication plan that complies with Federal, State, and local laws.

The agency failed to develop an emergency preparedness communication plan that includes the names and contact information for staff, any entities providing services under arrangement, patient's physicians, and volunteers.

The agency failed to develop an emergency preparedness communication plan that includes the contact information for Federal, State, tribal, and local emergency preparedness staff; and any other source of assistance.

The agency failed to develop an emergency preparedness communication plan that includes primary and alternate means of communicating with agency staff, and Federal, State, tribal, regional, and local emergency management agencies.

The agency failed to develop an emergency preparedness communication plan that includes a method for sharing information and medical documentation with other health care providers to maintain continuity of care, and a means of providing information about the general condition and location of the…

The agency failed to develop an emergency preparedness communication plan that includes a means of providing information about the agency's needs; and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center/designee.

The agency failed to develop an emergency preparedness training and testing program.

The agency failed to develop an emergency preparedness plan training program that included initial training in emergency preparedness policies and procedures to all new and existing staff, maintained documentation of all emergency preparedness training, and demonstrated staff knowledge of emergency…

The agency failed to conduct exercises to test the emergency preparedness plan.

The agency failed to ensure encoded OASIS data accurately reflected the patient's status in two (Records/Patients #1 and #3 ) of five applicable cases.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the notice that if a patient has been adjudged to lack legal capacity to make health care decisions under state law by a court of proper…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities…

The agency failed to provide evidence that the agency was measuring, analyzing, and tracking quality indicators.

The agency failed to provide evidence that the frequency and detail of the quality data collection was approved by the agency's governing body, and collection of quality data was on-going to: - Monitor the effectiveness and safety of the services and quality of care; and - Identify opportunities…

The agency failed to provide evidence that performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventive actions.

The agency failed to provide evidence that the governing body was responsible for ensuring an ongoing program for quality improvement and patient safety.

The agency failed to ensure clinical staff followed infection control procedures during two (Records/Patients #2 and #3) of three home visit observations.

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is a part of the agency's quality assessment and performance improvement (QAPI) program.

The agency failed to ensure clinical staff provided relevant infection control education to patients and caregivers in two (Record/Patient #1 and #3) of five records reviewed.

The registered nurse failed to practice according the agency's policies and procedures in, but not limited to, one (Record/Patient #1) of five charts reviewed.

2017 failed to show: - A specific discussion/review of the home health agency quality assurance performance improvement program (QAPI) information occurred; - A review of performance improvement activities that included the tracking of adverse patient events, the causes, and/or the implementation…

The administrator, who is also a member of the governing body, has effectively assumed responsibility for the overall administration, supervisory functions and overall operations of the home health agency.

The agency failed to assure all clinical record entries were legible and clear in, but not limited to two (Record/Patient #1 and #3) of five records reviewed.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include: - Transfer and discharge policies; - Rights and responsibilities that are understandable to persons who have limited English…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the administrator's name and contact information in order to receive patient complaints.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include verbal notice of the patient's rights and responsibilities in the individual's language, free of charge, no later than the completion of…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the written notice to the patient about their right to have a copy of the patient's rights and responsibilities provided to a…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be free from verbal, mental, sexual and physical abuse, including injuries of unknown source, neglect and…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to participate in, be informed about, and consent or refuse care, with respect to completion of all…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to receive all services outlined in the plan of care.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the right to have a confidential clinical record.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of financial liability changes as soon as possible, in advance of the next home health visit.

The agency failed to provide legible information regarding the state toll free home health telephone hotline number and hours of operation in two (Record/Patient #1 and #2) of three home records reviewed.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient/caregiver has the right to be advised of the names, addresses, and telephone numbers of federally and state-funded…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be informed of the right to access auxiliary aids and language services and how to access these services.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed that the transfer or discharge is necessary for the patient's…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency policy for discharge for cause: - Determines that the patient's or other persons in the home, behavior is disruptive…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for discharge for cause, the agency must make efforts to resolve the problem.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must investigate complaints made by the patient, the patient's representative, and the patient's caregivers and family.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must investigate treatment or care that is (or fails to be) furnished inconsistently or furnished inappropriately.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must investigate mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must document both the existence of the complaint and the resolution.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must take action to prevent further potential violations while investigating a complaint.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that any agency staff in the normal course of providing services to patients, who identifies, notices, or recognizes incidences of…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities…

The agency failed to ensure that a complete plan of care (POC) was developed in five (Records/Patients #1, #2, #3, #4, and #5) of five cases.

The agency failed to ensure the frequency of visits were administered only as ordered by a physician in, but not limited to, two (Record/Patient #1 and #3) of five patients reviewed.

The agency failed to obtain and/or follow orders and ensure all physician orders were timed when received in, but not limited to, three (Record/Patient #1, #3, and #4) of five records reviewed.

The agency failed to revise the plan of care following a new diagnosis with medication changes in, but not limited to, one (Record/Patient #3) of five cases.

The agency failed to communicate to the physician revisions to the plan of care following a new diagnosis with medication changes in, but not limited to, one (Record/Patient #3) of five cases.

+Based on home visit observation, and interview, the agency failed to provide the patient and/or caregiver a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel in three (Records/Patients #1, #2, and #3) of three home visit observations.

The agency failed to provide the patient and/or caregiver a copy of written instructions outlining the patient's medication schedule/instructions in plain language, to include the name, dosage, frequency and which medications would be administered by the agency personnel in three (Records/Patients…

The agency failed to provide the patient and/or caregiver a copy of written instructions outlining the patient's wound care in plain language in two (Record/Patient #1 and #3) of three home visit observations.

The agency failed to provide the patient and/or caregiver a copy of written instructions outlining infection control measures for wound care in plain language in two (Record/Patient #1 and #3) of three home visit observations.

The agency failed to provide evidence that the performance improvement activities were focused on high risk, high volume, or problem-prone areas.

The agency failed to provide evidence that the performance improvement activities considered the incidence, prevalence, and severity of problems in high risk, high volume, or problem-prone areas.

The agency failed to provide evidence that the performance improvement activities lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of the patients.

The agency failed to provide evidence that actions aimed at performance improvement occurred, and that the agency measured its success and tracked performance to ensure that improvements are sustained.

The agency failed to ensure staff received the required home health agency sponsored in-service training in, but not limited to, two (Employee: E 4 and E5) of five employee files reviewed.

The agency failed to ensure the administrator provided responsible oversight for the day-to-day operations of the home health agency, when the administrator failed to: - Develop/implement a Quality Assessment and Performance Improvement (QAPI) program; - Provide/document information to the…

The administrator failed to ensure the agency developed personnel policies and provided adequate in-service training to staff.

The agency failed to: - Ensure the staff had completed the criminal disclosure statement, perform a employee disqualification list (EDL) check prior to hire, request/obtain results from the Family Care Safety Registry, offer the hepatitis B vaccine, verify professional licenses, and complete…

The agency failed to ensure the discharge summary was sent to the physician within five business days of discharge in one (Records/Patient #5) of two applicable cases reviewed where a discharge occurred after 1/13/18 when the new federal regulations became effective.