Vivian Home Health, Inc

The agency failed to ensure the Condition of Participation: G 406 484.50 Patient Rights was in compliance when: 1) Based on observation, interview, and record review, the agency failed to ensure confidential clinical record information was maintained in a safe manner to protect patient…

The agency failed to ensure the Condition of Participation: G 510 484.55 Comprehensive Assessment of Patients was in compliance when: 1) Based on interview and record review, the agency failed to incorporate the OASIS (Outcome Assessment Information Set) items, and the OASIS forms were incomplete…

This condition of participation was not met as evidenced by the agency failing to ensure the Condition of Participation G 640 484:65 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1) Based on interview and record review, the agency failed to analyze and utilize…

The agency failed to ensure the Condition of Participation 484.110 Clinical Records G 1008 was in compliance when: Based on interview and record review, the home health agency failed to ensure that a discharge summary was completed in 1 of 2 patients (Patient 7) discharge records reviewed.

The agency failed to ensure the Condition of Participation: G 1050 484.115 Personnel qualifications was in compliance when: Based on interview and record review, the agency failed to show personnel qualifications of the Administrator.

The HHA failed to provide transfer and discharge paperwork for one of seven sampled patients (Patient 7).

The agency failed to analyze and utilize quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) data in order to assess the agency's processes of care, services, and operations, for seven of seven sampled patients (Patient 1, 2, 3…

The agency's Governing Body did not approve the frequency and detail of the Quality Assessment and Performance Improvement (QAPI) program's data collection, for seven of seven sampled patients (Patient 1, 2, 3, 4, 5, 6 and 7).

The agency's Governing Body (GB) failed to ensure opportunities for improvement addressing gaps in systems or processes by developing and implementing an improvement or corrective plan and continuously monitoring plan for effectiveness of interventions, for seven of seven sampled patients (Patient…

The agency failed to ensure that changes in the Organizational Chart was adopted by the agency.

The Home Health Agency failed to ensure there was a qualified Administrator available to oversee the day to day operations of the agency.

The agency failed to ensure the protection of clinical records and personnel records from unauthorized use in a universe of 23 patients and 17 staff members.

The agency failed to show personnel qualifications for the Administrator.

The agency failed to ensure confidential clinical record information was maintained in a safe manner to protect patient confidentiality for all patients receiving care in the facility, creating a potential to affect all of the agency's 23 current patients.

The agency failed to provide cause of discharge for one of seven sampled patients (Patient 7).

The agency failed to advise or provide a reason of discharge for one of seven sampled patients (Patient 7).

The agency failed to show efforts to resolve any problem prior to the discharge of Patient 7. This failure had the potential for harm to Patient 7 due to not receiving all the care ordered by the physician and being discharged to soon without trying to resolve the initial concerns of Patient 7's…

The agency failed to document efforts to resolve problems regarding one of seven sampled patients (Patient 7).

The agency failed to document efforts to resolve problems regarding one of seven sampled patients (Patient 7).

The agency failed to incorporate the OASIS (Outcome Assessment Information Set) items, and the OASIS forms were incomplete for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The HHA failed to provide transfer and discharge paperwork for one of seven sampled patients (Patient 7).

The agency failed to focus on high risk, high volume, problem-prone areas, or Adverse patient events for the Quality Assessment and Performance Improvement (QAPI) program for seven for seven sampled patients (Patient 1, 2, 3, 4, 5, 6 and 7).

The agency failed to consider incidence, prevalence, and severity of problems in areas and other events, which are negative and unexpected, impacting the patients plan of care for seven of seven sampled patients.

The agency failed to provide a Quality Assessment and Performance Improvement (QAPI) program which would lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of patients for seven of seven sampled patients (Patient 1, 2, 3, 4, 5, 6…

The agency failed to take action aimed at performance improvement, implement those actions, and must measure its success and track performance to ensure that improvements are sustained for a universe of 23 Patients.

The Home Health Agency failed to accurately identify the Integumentary (skin) portion of the clinical note, left blank for Patient 7 and nursing visits declined on 1/15/2020 and not filled out.

The agency failed to ensure skilled professional staff participated in the agency's Quality Assurance and Performance Improvement (QAPI) program for seven of seven patients.

The Administrator failed to ensure responsibility for the day- to-day operations of the agency.

The Home Health Agency failed to ensure there was an Administrator available during the hours of operation as evidenced by the lack of agency oversight.

The Home Health Agency failed to provide the transfer and discharge summary paperwork for one of seven sampled patients (Patient 7).