Tjf Investment Group Inc

The agency failed to maintain patient information in accordance with the Health Insurance Portability and Privacy Act (HIPPA) for 1 of 1 active patients' medical and insurance information (Patient: #14), found in an agency binder in another patient’s home.

The agency failed to ensure patients received the frequency of services listed in the POC (G0572), POCs were individualized and included all pertinent information (G0574), provide a current POC (G0612), and provide a current medication list (G0616).

The agency failed to submit OASIS (Outcome Assessment Information Set) within 30 days of assessment completion for 2 of 2 patients who received skilled services.

The agency failed to ensure a transfer summary containing necessary medical information pertinent to the patient’s care had been provided to the healthcare practitioner and receiving facility ensuring safe transfer of care for 1 of 1 patient transferred from care.

The agency failed to follow the physician’s orders for 1 of 2 (Patient #3) active records reviewed, receiving SN and HHA services.

The agency failed to ensure the patients were provided with current POCs with instructions regarding care for 2 of 2 patients (Patients: #1, and 3) receiving skilled nursing and HHA services, admission binders reviewed.

The Clinical Manager failed to ensure the HHA care plan was individualized and patient-specific for 1 of 1 active patients (Patient : #1) receiving SN and HHA services with a history of seizures and 1 of 1 patients on hold (Patient: #7).

The agency failed to ensure a Clinical Manager/DON is available to provide HHA and patient oversight for services provided for 1 of 1 agency.

The agency failed to ensure the POC was individualized and included all the required elements in 4 of 4 active patient records reviewed (Patients: #1, 2, 3, and 4) and 1 of 3 inactive patient records.

The agency failed to ensure the patients were provided with a current medication lists for 2 of 2 (Patients: #1 and 3) patients receiving skilled nursing services admission binders reviewed in patient residences.

The agency failed to ensure the HHA reported changes in the patients' condition to the Registered Nurse (RN) in the patient's condition as part of the interdisciplinary team for 1 of 2 patients with falls.

The Administrator failed to be responsible for the day-to-day operations of 1 of 1 home health agency.

The DON failed to ensure visit notes were incorporated within the clinical record in a timely manner for 1 of 2 active patient records (Patient: Patient #3) receiving SN and HHA services.

The agency failed to ensure the physician was notified of missed visits for 1 of 3 active clinical records reviewed.

The agency failed to ensure a Home Health Aide (HHA) supervisory visit was completed every 30 days according to their policy for 1 of 3 active clinical records reviewed.

The agency failed to ensure the comprehensive emergency preparedness program met all requirements to meet the health, safety, and security needs of their staff and patient population for 1 of 1 agency (E0001); failed to ensure an Emergency Preparedness Plan was in place and reviewed every 2 years…

The agency failed to ensure that all disciplines completed the comprehensive assessment within 5 days from the start of care date, (G 514), failed to ensure that the comprehensive assessments were complete and accurately reflected the patients’ status, including current health, psychosocial…

The agency failed to ensure the plans of care were individualized to include all pertinent diagnoses, all equipment, accurate duration of visits, all medications, and treatments, (G0574), treatments are administered only as ordered by a physician, (G0580), and failed to coordinate the delivery or…

The agency failed to use measurable indicators to improve outcomes, patient safety, and quality of care (G 642), failed to document the agency had considered the incidence, prevalence, and high-risk/problem-prone areas to select indicators and identify performance improvement projects (G646)…

The agency failed to ensure the Home Health Aides (HHA) maintained 12- hours of in-service training yearly (G774); failed to ensure the HHA performed HHA duties within their scope of practice for each patient as ordered in 1 of 3 home visits conducted (G802); and failed to ensure HHA supervisory…

The agency failed to submit OASIS (Outcome Assessment Information Set) within 30 days of assessment completion for 1 of 1 patients who received skilled services.

The agency failed to ensure the discharge summaries were sent to the health care practitioner/provider for 2 of 2 discharged records reviewed.

The agency failed to ensure infection control practices were upheld for hand hygiene and gloving for 3 of 3 home visits with Home Health Aides (HHA) providing care.

The agency failed to maintain or integrate a coordinated agency-wide infection control program in 1 of 1 agency.

The agency failed to ensure documentation of the Home Health Aides (HHAs) completed 12 hours of yearly in-service training in 4 of 4 HHA records reviewed.

The agency failed to ensure a Registered Nurse (RN) conducted an initial assessment within 48 hours of referral, or on the physician-ordered start of care date in 1 of 1 newly admitted patient in the last 90 days.

The agency failed to ensure the content of the comprehensive assessment was complete and accurately reflected the patients’ status including relevant medical history and diagnoses, in 6 of 6 active records reviewed.

The agency failed to identify the patient’s strengths, weaknesses, and goals in 6 of 6 records reviewed.

The agency failed to ensure the comprehensive assessment included discharge planning in 1 of 7 active clinical records.

The agency failed to ensure the comprehensive assessment included the patient’s caregivers and their willingness and availability to provide care for 2 of 4 active clinical records reviewed with home visits.

The agency failed to ensure the Plan of Care was individualized and included all the required elements in 6 of 6 active clinic records reviewed.

The agency failed to follow physician's orders for 1 of 6 active records reviewed.

The agency failed to ensure they coordinated care delivery to meet the patient’s needs receiving care from other health providers for 2 of 3 active patient records reviewed.

The agency failed to ensure the Home Health Aide (HHA) performed the appropriate duties of an HHA for 1 of 1 patient receiving Skilled Nursing services.

The agency failed to perform supervisory visits of a Home Health Aide (HHA) every 14 days for 1 of 1 active clinical records reviewed with a patient receiving skilled services.

The Administrator failed to be responsible for the day-to-day operations of 1 of 1 home health agency.

The agency failed to ensure services were provided as ordered on the plan of care and failed to consult the physician when the orders on the plan of care were modified due to missed visits for 1 of 5 active records reviewed.

The agency failed to ensure they reconciled and identified all duplicate drug therapy and compliance with drug therapy for 1 of 7 clinical records reviewed (Patient #4).

The agency failed to ensure the comprehensive assessment was updated and revised as frequently as the the patient's condition warrants due to a major decline or improvement in the patients; health status but no less than the last 5 days of every 60 days beginning with the start of care date.

The agency failed to revise the plan of care to reflect current living status and information regarding updated diabetic management for 1 of 5 active records reviewed.

The agency failed to ensure the home health agency maintained a quality assurance and performance improvement (QAPI) program which documented actions taken that resulted in improvements across the spectrum of care, to include the discharge process, for 1 of 1 home health agency.

The administrator failed to ensure the home health agency establishment of competency documentation for home health aides included documentation of the evaluation of the home health aide skills while performing required tasks with a patient, for 2 of 2 home health aides (employees F & G) in a total…

The registered nurse failed to inform the attending physician and the patient's caregiver parent of a new open area in the scrotal area, for 1 (Patient #6) of 9 patients.

The agency failed to ensure the plan of care orders included the size of tracheotomy tube and the size of the suction catheter for a pediatric patient for 1 (Patient #1) of 2 patients with a tracheotomy, of a sample of 9 patients; failed to ensure 1 (Patient #1) of 9 patients duration of services…

The Registered Nurse failed to ensure visits were provided as ordered on the plan of care for 2 (Patient #1 and 6) of 9 patients.

The agency failed to ensure the administrator, or a pre-designated person was available during all hours of operation, for 1 of 1 home health agency on 1 (1-7-19)of 6 surveyed dates.