Ahc Hhc, LLC

The agency failed to ensure development of an episodic certification Plan of Care for one (Patient #3) of nine patients.

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure governing body oversite of management and operations of the agency for provisions of care and services, patient safety, allocation of resources, and annual agency program evaluation for calendar year 2023 and 01/01/24 to 10/15/24 for all patients and employees.

The agency failed to ensure review of the Emergency Preparedness program for the agency annually for all patients and employees.

The agency failed to ensure a facility and community-based risk assessment (All Hazards Risk Assessment) was developed and implemented for all patients and employees.

The agency failed to ensure development, implementation and maintenance of processes and contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees.

The agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and employees.

The agency failed to ensure: 1. An emergency preparedness testing and training program was developed, implemented and reviewed/updated at least annually for all patients and employees and; 2. An after-action report was documented after each drill, exercise or plan activation event for all patients…

The agency failed to ensure a transfer/discharge summary was completed at the time of patient transfer/discharge for four (Patients #3, 4, 6 and #7) of nine patients.

The agency failed to ensure development of an episodic certification Plan of Care for one (Patient #5) of nine patients.

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure utilization of OASIS quality indicator source data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI Program activities that included self-monitoring efforts and opportunities that tracked adverse events, analyzed causes, and implemented actions to identify problems to improve care, services and operations for all patients and…

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for calendar years 2023 and 01/01/24 to 10/22/24 for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities which included sources of data, analysis of data and implementation of actions which tracked efforts toward improvement of care and services for all patients and employees.

The agency failed to ensure its infection control program included surveillance monitoring and reporting; and was included in QAPI program activities for all patients and staff.

The agency failed to ensure certified home health aides received twelve hours of in-service (continuing education) per calendar year or per cyclic 12-month periods from 05/12/23 to 10/22/24 for two (CHHA D and F) of two reviewed CHHAs.

The agency failed to ensure governing body oversite of management and operations of the agency for provisions of care and services, patient safety, allocation of resources, and annual agency program evaluation for calendar year 2023 and 01/01/24 to 10/15/24 for all patients and employees.

The agency failed to ensure governing body fiscal planning and oversite of an operating budget and capital expenditure plan for calendar year 2023 and 01/01/24 to 10/15/24 for all patients and employees.

The agency failed to ensure a discharge oasis was completed by the agency for two (Patients #3 and 6) of nine patients.

The agency failed to ensure an individualized patient POC included required content three (Patients #1, 3 and #7) of nine patients.

The agency failed to ensure ongoing discharge planning for six (Patients #1, 3, 4, 5, 6 and #7) of nine patients.

The agency failed to ensure care was coordinated between the agency and physician for three (Patients #4, 6 and #7) of nine patients.

The agency failed to ensure SN conducted every month urinary catheter change/management as ordered on the POC for one (Patient #5) of nine patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure certified home health aide supervisory visits were completed every 14 days for one (Patient #1) of nine patients.

The agency failed to ensure SN visit note documentation was completed for one (Patient #4) of nine patients.

The agency failed to ensure skilled professional service visit note documentation was completed for one (Patient #3) of nine patients.

The agency failed to ensure a completed transfer/discharge summary was provided for two (Patients #5 and #7) of nine patients.

The agency failed to ensure a patient centered QAPI Program for all patients and employees.

The hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for five patients and all employees.

The agency failed to ensure a patient centered QAPI Program for all patients and employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for five patients and all employees.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all five patients and employees.

The agency failed to ensure a patient centered QAPI Program for all patients and employees.

The agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees.

The agency failed to ensure: 1. the physician was notified of finger stick blood sugar levels outside of ordered parameters for one (Patient #3) of seven patients and 2. the physician was notified of weight gain and weight loss outside of ordered parameters for one (Patient #3) of seven patients.