Toledo Home Healthcare LLC

The agency failed to maintain the comprehensive emergency preparedness program per the requirement of 42CFR 484.22. The agency census was 19. Findings include: During interview with administrative Staff A on 06/18/18 at 3:21 PM a request was made for emergency preparedness documentation.

The agency failed to ensure the plan of care included all required elements (G 574) and failed to ensure the physician was notified of abnormal findings that may alter the plan of care (G 590).

The agency failed to provide documented evidence of ongoing data collection for quality assurance monitoring (G644) and failed to provide documented evidence of ongoing quality assurance and performance improvement activities (G646).

The agency failed to ensure Quality performance data was monitored (G948); failed to ensure the clinical manager was available during all operating hours (G 950) and failed to ensure the clinical manager provided oversight of all patient care services and personnel (G 958).The cumulative effect of…

Staff interview the agency failed to encode and submit OASIS (Outcome Assessment and Information Set) Assessments for three of four patients identified by the agency receiving skilled services.

Staff interview the agency failed to follow the plan of care for two (Patients #6 and #7) of seven patients reviewed for compliance with physician's plan of care.

The agency failed to provide documented evidence data collection for any ongoing quality assurance and performance improvement activities.

Agency documentation and administrative staff interview the agency failed to provide documented evidence of ongoing quality assurance and performance improvement projects or activities.

The agency failed to ensure the clinic manager/director of nursing provided oversight for the provision of patient care.

Staff interview the agency failed to ensure nurses completed their documentation timely and authenticated their documentation to reflect an accurate date.

Staff interview the agency failed to ensure the notice of patient rights was presented in the patient's language.

The agency failed to have updated medication profiles for two (Patients #1 and #2) of seven patients reviewed for updated medication profiles as part of the comprehensive assessment.

Agency policy and procedure review and staff interview the agency failed to include all diagnoses, frequency, duration or description of the services provided on the plans of care for four (Patients #1, #2, #3 and #5 ) of seven patients reviewed for a comprehensive plan of care.

Staff interview the agency failed to provide documentation the physician was notified for two patients with abnormal assessment findings (Patient#1 and #3) in a sample of seven patients.

The agency home health aides failed to follow the Aide Plan of Care or perform personal care services as ordered.

The agency failed to ensure timely supervisory visits were conducted for four of four patients (#1, #2, #3 and #4) reviewed.

The agency failed to perform the required Supervisory Visit with the Home Health Aide present during a sixty day recertification period.

The agency failed to ensure the administrator managed the Quality Performance program.

The agency organizational chart and interview with the clinical manager the agency failed to ensure the clinical manager was available during operational hours.