Activ-Care Home Health Services, Inc

The Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster (E0004); failed to ensure an emergency plan existed that was based on a…

The Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency.

The agency failed to ensure its Emergency Preparedness policies and procedures had been reviewed and updated at least every 2 years, resulting in the potential for inappropriate responses in the event of an actual emergency.

The facility failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State and local laws that had been reviewed and updated at least every 2 years, resulting in the potential for ineffective communication and unmet patient care needs in the event of…

The facility failed to develop and maintain an emergency preparedness communication plan that included updated contact information for all current staff, entities providing services under contract and patient's physicians, resulting in the lack of effective communication in the event of an actual…

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section that had been reviewed and updated at least every 2 years.

The Agency failed to provide documented evidence to ensure all new and existing staff, including contracted staff and volunteers as appropriate, received initial and ongoing training in emergency preparedness policies and procedures, and failed to maintain documentation of training's for the above…

The Agency failed to provide documentation for the required community/facility 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 ill-prepared in the event of an actual emergency.

The agency failed to ensure services were provided as ordered, and in accordance with the specified visit frequency for 4 (P-1, P-2, P-3, P-4) patients, from a total of 7 sampled records reviewed, resulting in the potential for poor grooming, decline in physiological functioning and unmet care…

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented its quality improvement projects, the reasons for conducting these projects with measurable progress achieved for calendar years 2023 and 2024, resulting in the Agency's inability to improve in…

The agency failed to ensure the home health agency staff used standard precautions while providing care to the patients in 1 of 3 (P-7) records reviewed that included observation of home care staff providing services to patients resulting in the potential of spreading infections to the patient.

The Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs, that included safety precautions, prior to the provision of care in 2 (P-1, P-2) of 4 records in which Home Health Aide services were ordered, from a total…

The response was, "We offer Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST) and Home Health aide (HHa) services." When asked what service was provided directly by the agency, Adm #1 stated, "HHa." The contracts were reviewed on…

The agency failed to ensure patient's protected health information was appropriately stored and safeguarded, resulting in the potential for unauthorized use.

The Agency failed to ensure that 2 (P-2, P-5) of 3 patients observed during a home visit and 1 (P-3) of 7 records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion…

The agency 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, and history of events leading to current home care needs in 3…

The agency failed to ensure the patient's medical needs were adequately met in the patient's home for 1 (P-2) patient who required Speech Therapy services, from a total of 7 sampled records reviewed, resulting in the potential for worsening of health conditions.

The agency failed to ensure the Initial Assessment included a comprehensive drug review to ascertain any adverse reactions for 5 (P-1, P-3, P-4, P-5, P-7) patients, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects.

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient for 5 (P-1, P-2, P-3, P-4, P-6) records, from a total of 7 sampled records reviewed, resulting in patients not receiving…

The agency failed to ensure its skilled disciplines provided care and services only as ordered by the Physician for 1 (P-1) patient who was discharged prior to completion of services and 1 (P-4) patient who received services without an order, from a total of 7 sampled records reviewed.

The Agency had failed to promptly notify the Physician concerning vital signs outside of the specified reportable parameters for 2 (P-1, P-3) of 7 records reviewed, resulting in a potential poor clinical outcome.

The agency failed to ensure its skilled disciplines coordinated services for 1 (P-1) patient who continued to receive services after discharge from the agency, from a total of 7 sampled records reviewed, resulting lack of coordinated care and the potential for substandard care.

The Home Health Aide failed to provide care and services as ordered in the Aide Care Plan for 1 (P-1) patient, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns and unmet care needs.

The agency failed to ensure they adequately documented on-site supervisory visit to the patient's home to supervise the services that were provided by the home health aide for 1 (P-4) of 4 records reviewed in which aide services had been provide, from a total sample of 7 records reviewed, resulting…

The Administrator failed to ensure the Clinical Manager was available at all times during operating hours, resulting in the lack of clinical supervision and oversight and the potential for unmet care needs for all patients currently serviced by this agency.

The Clinical Manager failed to ensure the patient's needs were continually assessed for 1 (P-2) patient observed during a home visit, who required Speech Therapy services and ongoing assessments, from a total 7 sampled records reviewed, resulting in lack of assurance that assessments are performed…

The agency failed to ensure clinical notes were accurate for 3 (P-3, P-4, P-5) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to include measurable goals in the plan of care in 2 of 7 records (P-6, P-7) to determine the patient's progress towards obtaining the goals.

The agency failed to document a discharge summary with all required information, and failed to provide the primary care professional responsible for providing care and services to the patient with a copy of the discharge summary within 5 business days of the discharge in 2 of 2 discharge (P-1, P-7)…