24 Seven Home Health Care Services, Inc.

The agency failed to ensure the skilled nurse completed visits at the frequency ordered by the physician for 1 of 7 (MR# 5) records reviewed, resulting in the potential for poor patient outcomes for this patient.

The agency failed to ensure the registered nurse prepared written patient care instructions for the aide for 1 of 1 (MR#6) records reviewed in which aide services were provided, resulting in a lack of direction regarding the care and safety measures pertinent to the needs of this patient.

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, and failed to provide documented evidence that the physician was notified of identified drug interactions in 1 (MR# 2) of 7 sampled records reviewed, resulting in the…

The agency failed to ensure the plan of care included measurable skilled nursing goals specific to the needs of the patient, for 5 of 7 records reviewed (MR#s 1, 2, 3, 4, 5), resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress…

The agency failed to ensure to coordinate patient care for 3 of 7 (MR# 5, 6, 7) records reviewed, resulting in a lack of coordinated care delivery to meet the needs of these patients.

The agency failed to ensure a discharge summary was sent to the primary care practitioner within 5 business days of the patient's discharge for 3 of 3 (MR#s 2, 6, 7) discharge records reviewed, and a transfer summary was sent to the receiving health care agency and the physician within 2 business…

The agency failed to provide handwashing education to patients admitted to the agency after the patient was identified to have a knowledge deficit of handwashing and was high risk for infection, resulting in the potential for contracting the COVID-19 infection or passing the virus to others.

The registered nurse failed to document infection control assessments at every skilled nurse visit to ensure the health of the patient and family were free from signs and symptoms of COVID-19, resulting in the potential for acquiring the COVID-19 virus.

The Agency failed to conduct a facility-based and community-based risk (E0006); failed to implement in its Emergency Preparedness plan, the use of volunteers and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care…

The agency failed to ensure that the initial comprehensive assessment visit was made within 48 hours of the date of referral for 1 record (MR#5), resulting in the delay of needed services and the potential for decline in health status (refer to G-514); failed to ensure the registered nurse (RN)…

The agency failed to monitor data for the Quality Assurance Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement (refer to G-644); failed to develop a QAPI program that focused on…

The agency failed to ensure that 1 of 1 Home Health Aide (HHa #1) employed by the Agency, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs (Refer to G-774); failed to maintain documentation of the…

The Agency failed to conduct a facility-based and community-based risk assessment resulting in the potential for failure to identify hazards associated with the facility and less than optimal outcomes during an emergency event.

The Agency failed to include in the Emergency Preparedness policy, the use of volunteers and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency; and failed to…

The Agency failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the following required subject areas (1) Names and contact information for the following: (i) Staff, (ii) Entities providing services under…

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency's emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster.

The Agency failed to provide documentation for the required annual tabletop and community based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being unprepared in the event of an actual emergency.

The Agency failed to provide documentation for the required annual tabletop and community based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being unprepared in the event of an actual emergency.

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future…

The agency failed to ensure the Plan of Care (POC) included objectively measurable and individualized goals and outcomes in 4 of 7 records reviewed (MR#s 4, 5, 6, and 7) of a total of seven records reviewed, resulting in a potential for failure to measure progress toward achievement of desired…

The agency failed to ensure skilled professional services were provided as ordered by the physician for 3 of 7 records reviewed (MR#s 4, 5 and 6), resulting in the potential for poor outcomes for these patients.

The agency failed to monitor data for the Quality Assurance Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement.

The Home Health Agency (HHA) failed to develop a Performance Improvement Plan/activities, as part of the agency's Quality Assessment Performance Improvement (QAPI) program to track the adverse patient events, analyze the cause, and implement preventive actions/interventions, resulting in the…

The agency failed to develop a performance improvement project in 2018 or 2019, resulting in the agency's inability to improve patient outcomes, safety, and quality of care for the agency's 212 current patients serviced in the past one year.

The Governing Body failed to be responsible for ensuring the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, resulting in the potential to adversely affect the quality of care for all…

The Agency failed to ensure the personnel followed accepted Infection Control standards of practice during the provision of care and services for 2 of 2 patients (MR #2& MR#7) observed home visits, from a total of 7 sampled records reviewed, resulting in the potential for the transmission and…

The agency failed to maintain an agency-wide program for the identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential spread of infections between…

The agency failed to ensure that 1 of 1 Home Health Aide (HHa #1) employed by the Agency, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs.

The Agency failed to ensure that 1 of 1 Physical Therapy Assistant (PTA) who was granted clinical privileges, maintained an active and current license when providing care, resulting in the potential for the provision of unsafe care and unmet care needs.

The Agency failed to ensure that 2 of 6 Registered Nurses (RN) employed by this agency, who were granted clinical privileges, maintained an active and current license when providing care, resulting in the potential for the provision of unsafe care and unmet care needs.

The agency failed to ensure they could protect the patient's right to confidentiality of the clinical records maintained by the agency.

The Agency failed to advise their patients of the names, addresses and telephone numbers of federally-funded and state-funded entities that serve the area where the patient resides, resulting in the potential for unmet patient care needs.

The Agency (HHA) failed to ensure that the initial comprehensive assessment visit was made within 48 hours of the date of referral for 1 record (MR#5), from a total of 7 records reviewed, resulting in the delay of needed services and the potential for decline in health status.

The agency failed to ensure the registered nurse (RN) completed a comprehensive assessment that determined eligibility for the home health benefit and homebound status for a Medicare patient for 1 of 7 records reviewed (MR# 7), resulting in the potential for a patient admitted to home care that is…

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on psychosocial, sensory, integumentary, and nutritional assessments for 2 (MR#s 5 and 7) of seven sampled patients reviewed, resulting in incomplete…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 7 records (MR's #1, 2, 3, 4, 5, 6, and 7), from a total of 7 sampled records reviewed, resulting in the potential for harmful medication…

The registered nurse failed to document on the comprehensive assessment the primary caregivers' willingness, ability, their availability and scheduled hours and days to provide care for patients in 3 (MRs 7, 2 and 3) from a total of 7 sampled records reviewed, resulting in a potential for patient…

The agency failed to document the patient's representative (if any) in the comprehensive assessment in 1 (MR#7) from a total of 7 sampled records reviewed, resulting in lack of contact information to communicate the needs of the patient if needed.

The agency failed to ensure the plan of care (POC) was patient specific and individualized to the patient's identified needs, covered all pertinent interventions, and accurately identified the Durable Medical Equipment required by the patient, in 3 of 7 sampled records reviewed (MR's #s 4, 6 and…

The Agency failed to ensure that all medications, treatments and services were administered as ordered by the Physician for 1 of 1 patient (MR #2) observed during a home visit, from a total of 7 patients reviewed, resulting in the potential for the provision of unsafe care and services and unmet…

The Home Health Agency (HHA) failed to develop a QAPI (Quality Assessment Performance Improvement) program that focused on high risk, high volume or problem-prone areas of the agency, to monitor the agency's improvement in these areas resulting in the agency's inability to improve patient care…

The Agency failed to maintain documentation of the required 12 hours of annual Home Health Aide in-services 1 of 1 Home Health aide (HHa) employed by the Agency (HHa's #1 and 2) resulting in lack of evidence of ongoing education and training and the potential for the provision of unsafe care for…

The Home Health aide failed to report vital signs outside the parameters as ordered on the Home Health aide Care Plan in 1 of 2 records reviewed with home health aide services (MR#4), potentially resulting in decline of the patient's condition.

The agency failed to ensure the home health aide (HHA) documented the care provided during the HHA home visits in 1 of 1 patients (MR#4) in which HHA services were ordered, from a total sample of 2 records reviewed in which HHA services were provided, resulting in the agency nurse and supervisors…

The Agency failed to ensure the skilled discipline made an annual joint onsite observation visit at the patient's residence to observe the care being provided, for 1 of 1 Home Health Aides (HHa #1) employed by the Agency, resulting in the potential for the provision of substandard care and unmet…

The agency failed to ensure the transfer summary was complete, provided the patient's current health status at the time of transfer, progress toward goals, and forwarded to the physician or receiving facility in 1 of 1 patient (MR #2) who was transferred to a hospital, from a total of 7 records…