Above & Beyond Homecare Inc

The home health agency failed to ensure employees followed standards of practice for bag technique to reduce the spread of infections for 1 of 1 home visit observations with the alternate Clinical Manager.

The agency failed to ensure home health aide services were provided as ordered and services were not reduced or placed on hold due to lack of staffing in 3 of 5 active records reviewed with orders for home health aide services only (#7, 10, and 11).

The home health agency failed to direct their staff on specific products to use in the home for the decontamination of reusable tools and equipment and failed to follow accepted standards of practice and their own policies to prevent the transmission of infections and communicable diseases for 2 of…

The agency failed to ensure the safety of ALL patients and employees in regards to the lack of enforcement of the additional precautions intended to mitigate the transmission and spread of COVID-19. Findings include: During an interview on 3/29/2022 at the entrance conference, Employee B, the…

The home health agency failed to ensure that orders for home health aides (HHA) on the plan of care were present on the Aide Care Plan for 1 of 7 active records with HHA orders reviewed (Patient #2).

The home health agency failed to ensure the registered nurse [RN] accurately assessed blindness as a sensory loss, in 1 of 5 active clinical records reviewed (Patient #2).

The agency failed to provide all services outlined in the plan of care for 1 of 5 clinical records reviewed (#2).

The agency failed to thoroughly investigate and document complaints for 1 of 1 patient complaints reviewed (#3).

The comprehensive assessment failed to contain all information about the current health status for 1 of 5 records reviewed (#1).

The agency failed to ensure the Registered Nurse coordinated with other agencies providing care to their patients for 1 of 5 records reviewed (#2).

The agency failed to ensure the home health aide was providing services in accordance with the plan of care/aide care plan for 1 of 5 records reviewed (#1).

The agency failed to ensure they provided an advance notice of an impending discharge to a patient representative for 1 of 1 complete record reviewed of a patient who was being discharged in a sample of 3. (#1) Findings include: The clinical record of patient #1 was reviewed on 6/4/19 and indicated…

The agency failed to ensure they arranged a safe and appropriate transfer to other care agencies for 1 of 1 complete record review of a patient who was being discharged in a sample of 3. (#1) Findings include: The clinical record of patient #1 was reviewed on 6/4/19 and indicated a start of care…

The agency failed to ensure they provided an advance notice of an impending discharge and that the notice was for a period of 60-days, as prescribed in their policy, to a patient representative for 1 of 1 complete record reviewed of a patient who was being discharged in a sample of 3. (#1) Findings…

The agency failed to ensure patients received the name of the Administrator to contact to voice complaints or grievances (G414); failed to ensure that the right to make a complaint to the home health agency was provided to the patient written and verbally upon admission (G432); failed to evidence…

The registered nurse (RN) failed to complete the initial assessment within 48 hours of referral or the physician ordered start date (see tag G514); failed to ensure the comprehensive assessment accurately described the patient's status, to measure or describe wounds (see tag G526); failed to…

Agency failed to ensure the patient was admitted according to a physician order, failed to ensure the plan of care was developed in accordance to the physician order, failed to ensure the plan of care was developed in collaboration with the primary care physician, and failed to ensure the plan of…

The agency failed to develop an effective, ongoing, home health agency wide, data-driven Quality Assurance and Performance Improvement [QAPI] program (see tag 640); failed to show measurable improvement in health outcomes, patient safety, and quality of care and failed to measure, analyze, and…

The agency failed to ensure personnel followed infection control precautions when caring for patients with communicable diseases and wounds (See G682).

The skilled nurse (SN) failed to ensure nursing visits with wound patients were rescheduled, failed to ensure blood sugars were assessed at each visit, failed to ensure skin impairments/ wounds were assessed with each skilled nursing visit, and failed to ensure a patient with lethargy was assessed…

The agency administrator failed to ensure that all prospective home health aide (HHA) employees performed all tasks required, in their entirety with a patient and not simulated, as required to show competence for placement on the home health aide registry; and, failed to ensure a registered nurse…

The agency's governing body failed to responsibly manage and evaluate the day to day operations, provisions of home health services, and develop a QAPI program to identify data-driven, clinical concerns, that reflected the complexities of the agency QAPI [quality assessment performance improvement]…

The agency failed to ensure the patient's record contained physician orders for delivery of care received (See G1012); failed to ensure contact information for the patient / caregiver was kept up to date and accurate (See G1018); and failed to ensure the plan of care and clinical record contained…

The agency failed to ensure accurate Outcome and Assessment Information Set (OASIS) was submitted for 2 of 20 records reviewed (#11, 14) Findings include: 1. The clinical record of patient #11 was reviewed on 4/22/19 and indicated a start of care date of 6/29/16. The record contained a plan of care…

The comprehensive assessment failed to accurately reflect the patient's status in 4 of 20 records reviewed.

The registered nurse (RN) failed to ensure the visits were made so that comprehensive assessments were updated with accurate and pertinent information and changes for 5 of 20 records reviewed.

The agency failed to ensure the patient was admitted according to a physician order, failed to ensure the plan of care was developed in accordance to the physician order, failed to ensure the plan of care was developed in collaboration with the primary care physician, and failed to ensure the plan…

The agency failed to ensure they showed measureable improvement in health outcomes, patient safety, and quality of care and failed to measure, analyze, and track the quality indicators of adverse patient events for 1 of 1 agency.

The agency failed to obtain and utilize qualtity indicator data derived from OASIS [outcome and assessment information set], and additional related patient data to monitor safety and effectiveness and quality of services provided for 1 of 1 agency.

The agency failed to evidence tracking and analyzing of adverse events and the implementation preventative actions for 1 of 1 agency.

The agency failed to evidence performance improvement projects to reflect the complexity of the patients it served and measureable progress achieved for projects undertaken for 1 of 1 agency.

The agency's governing body failed to ensure the QAPI program identified clinical concerns, was data-driven, and reflected the complexities of the agency to maintain an ongoing program for quality improvement for 1 of 1 agency.

The agency failed to ensure personnel followed infection control precautions when caring for patients with communicable diseases and wounds in 4 of 5 home visits in a sample of 20 records reviewed.

The agency administrator failed to ensure that all prospective home health aide (HHA) employees performed all tasks required, in their entirety with a patient and not simulated, as required to show competence for placement on the home health aide registry; and, failed to ensure a registered nurse…

The agency failed to ensure all HHA [home health aides] completed the required minimum of 12 hours of in-service training in a 12 month period for 2 of 6 HHA employee files reviewed (Employee E and LL).

The registered nurse (RN) failed to ensure that an aide care plan was completed for each shift and /or each discipline for home health aide (HHA), attendant care (ATTC), and homemaker (HMK), failed to ensure that the aide care plan was individualized, and failed to ensure that the aides followed…

The agency's governing body failed to responsibly manage and evaluate the day to day operations, provisions of home health services, and develop a QAPI program to identify data-driven, clinical concerns, that reflected the complexities of the agency potentially affecting all 307 patients for 1 of 1…

The Clinical Manager/ Director of Nursing failed to ensure oversight of patient care was provided in 1 of 6 chart audits reviewed.

The agency failed to ensure patients received the name of the Administrator to contact to voice complaints or grievances in 1 of 1 agency reviewed, with the potential to affect all 307 patients.

The agency failed to ensure that the right to make a complaint to the home health agency was provided to the patient written and verbally upon admission for 1 of 1 agency.

The agency failed to evidence contact information of Federal and State entities that serve the patients' area of residence, to include the following: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and the Quality Improvement…

The agency failed to ensure patients were informed of access to auxiliary aids and language services, and how to access them in 1 of 1 agency.

The agency failed to follow their complaint policy to ensure all complaints were investigated and resolved for 1 of 1 agency.

The registered nurse (RN) failed to complete the initial assessment within 48 hours of referral or the physician ordered start date for 3 of 20 records reviewed.

The comprehensive assessment failed to contain information about the current health status, psychosocial, functional and cognitive status of the patient for 11 of 20 patients reviewed.

The comprehensive assessment failed to contain individual patient goals and preferences identified by the patient for 9 of 20 records reviewed.

The comprehensive assessment failed to include all medical, nursing, social, rehab, and discharge planning needs for 9 of 20 records reviewed.

The registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications, drug interactions were identified, and medication lists were accurately maintained for 6 of 20 records reviewed.

The agency failed to ensure a resumption of care assessment was completed by a registered nurse within 48 hours after a hospital admission greater than 24 hours in 1 of 20 records reviewed.

The agency failed to ensure the plan of care (POC) included all pertinent diagnoses, treatments, goals, and correct frequencies of visits in 12 of 20 records reviewed.

The agency failed to ensure the skilled nurse did not provide wound care absent of a physician's order or to provide instructions to the patient regarding wound care without a physician's order in 1 of 4 patients with wounds (#3) and failed to ensure trch care was not provided in the absence of a…

The agency failed to ensure that all orders received by a nurse practitioner or physician assistant was not accepted unless there was a co-signature obtained from the collaborating physician and that the agency policy was written accordingly for 1 of 20 records reviewed (#19) Findings include…

The agency failed to ensure registered nurses (RN) reported changes to the physician for 6 of 20 records reviewed.

The agency failed to communicate with all physicians involved in the patient's care for 1 of 20 records reviewed.

The agency failed to ensure the registered nurse (RN) coordinated orders with all physicians related to the plan of care for 2 of 6 patients reviewed.

The agency failed to ensure all members on the health care team communicated specific orders for wound care; failed to evidence dressing changes were completed in accordance with the specific, ordered visits, and that updates were completed of the wound status for 1 of 4 patients with wounds in a…

The agency failed to ensure coordination was completed with the patient / family to ensure the needs of the patient were met for 1 of 20 records reviewed (#12).

The agency failed to identify and focus the QAPI [quality assurance and performance improvement] and PIP [performance improvement program] programs on high risk, high volume or problem-prone patient areas for 1 of 1 agency.

The agency failed to evidence implementation of immediate correction for an identified problem that directly or potentially threatened the health and safety of patients for 1 of 1 agency.

The agency failed to implement and measure its success in tracking performance after a performance improvement project [PIP's] need for falls was identified for 1 of 1 agency.

The skilled nurse failed to ensure nursing visits with wound patients were rescheduled, failed to ensure blood sugars were assessed at each visit for 1 of 5 (#3) patients with wounds, failed to ensure skin impairments/ wounds were assessed with each skilled nursing visit for 4 of 5 patients with…

The registered nurse (RN) failed to follow the plan of care for 5 of 20 patients reviewed.

The skilled nurse (SN) failed to ensure visit notes were signed by the patient and not by the non-visiting Director of Nursing (DON) for 2 of 20 patient records (#2, 13) and failed to ensure visit notes were accurate and consistent in 3 of 20 records reviewed.

The skilled nurse (SN) failed to ensure the ordering physician was notified and orders clarified prior to the development of the plan of care; and failed to communicate that a patient refused insulin for 5 of 20 records reviewed.

The agency failed to provide input and participation in the QAPI program from all skilled professionals to assure the effectiveness of the program for 1 of 1 agency.

The registered nurse (RN) failed to ensure the licensed practical nurse (LPN) was overseen in completing wound care and in educating the patient as ordered by the physician in 1 of 5 patients with wounds in a sample of 20 records reviewed.

The registered nurse (RN) failed to complete on-site supervisory visits every two weeks for 1 of 20 records reviewed.

The Administrator failed to ensure they were responsible for all day-today operations and failed to ensure that an on-call nurse was available to patients 24/7 for 1 of 1 agency reviewed.

The Administrator failed to ensure that the Clinical Manager/ Director of Nursing (DON) was available during all operating hours for 1 of 1 agency.

The Clinical Manager/ Director of Nursing (DON) failed to make patient and personnel assignments for 1 of 1 agency Findings include: The DON failed to oversee the assignments of clinical staff as evidenced by: During an interview on 4/23/19 at 3:25 PM, the DON stated she did not know how the aides…

The Clinical Manager/ Director of Nursing failed to ensure all members on the health care team coordinated amongst each other, with physicians, and assisted living facilities for 3 of 20 patient records reviewed.

The Clinical Manager/ Director of Nursing (DON) failed to coordinate referrals, including the branches for 1 of 1 agency.

The Clinical Manager/ Director of Nursing failed to ensure that patients received continuous assessments and/ or resumption of care assessments for 4 of 20 clinical records reviewed in a sample of 20. (#3, 9, 11, 13) Findings include: 1. Record review of patient #3's re-certification comprehensive…

The Clinical manager failed to ensure the plan of care (POC) was developed and implemented in 3 of 20 records reviewed.

The parent agency failed to provide direct support and administrative control for 2 of 2 branch locations for 1 of 1 agency.

The Clinical Manager failed to ensure skilled nurse (SN) performed a complete physical assessment per professional standards for 1 of 2 skilled nurse home visits observed (#14).

The agency failed to ensure the patient's record contained physician orders for delivery of care received in 3 of 20 records reviewed (#1, 3, 5).

The agency failed to ensure contact information for the patient / caregiver was kept up to date and accurate for 1 of 20 records reviewed (#20) Findings include: The clinical record of patient #20 was reviewed on 4/24/19 and indicated a start of care date of 2/20/12. The record contained a plan of…

The agency failed to ensure the plan of care and clinical record contained the accurate physician information in 1 of 20 records reviewed.