Aimm Home Healthcare

The agency failed to develop a quality assessment and performance improvement program in 2023, 2024, and 2025 per agency policy (see G0642); failed to utilize data for the development of a Quality Assessment Performance Improvement Program for 2023, 2024, and 2025 (see G0644); failed to develop the…

The agency failed to ensure skilled professionals provided ongoing assessment of patients in 3 (P-3, 5, and 6) of 7 records reviewed (see G706); failed to ensure skilled professionals provided services as outline in the plan of care in 3 (P-1, 2, and 6) of 7 records reviewed (see G710); failed to…

The agency failed to ensure the clinical record was accurate and contained all interventions, treatments, services, and responses to treatment in 3 (P-2, 3, and 6) of 7 records reviewed (see G1014); failed to ensure a completed discharge summary was sent to the primary care practitioner or other…

The agency failed to develop emergency preparedness policies and procedures based on the emergency plan and risk assessment, resulting in the potential for an unprepared agency response in the event of an actual emergency.

The agency failed to ensure the emergency plan was tested annually; and failed to ensure participation in a full-scale or facility based functional exercise every 2 years, resulting in the potential for an unprepared agency response in the event of an actual emergency.

The agency failed to develop a quality assessment and performance improvement program for 2023, 2024, and 2025 per agency policy resulting in the inability of the agency to access their process of care, services, and operations for all patients admitted to the agency during the period of review.

The agency failed to utilize data for the development of a Quality Assessment Performance Improvement Program for 2023, 2024, and 2025 resulting in the inability of the agency to identify opportunities of improvement in quality of patient care for all patients services by the agency in the period…

The agency failed to develop the Quality Assessment Performance Improvement Program for 2023, 2024, and 2025 included program activities focusing on high risk and problem prone areas resulting in the agency’s inability to identify factors associated with significant health or safety issues for…

The agency failed to develop a quality assessment performance improvement program that documented a performance improvement projects for 2023, 2024, and 2025 per agency policy resulting in the agency’s inability to improve patient care, health outcomes, and agency performance for all patients who…

The agency failed to maintain an agency wide program for infection surveillance, identification, prevention and control as part of the Quality Assessment Performance Improvement program for 2023, 2024, and 2025 resulting in the potential for development and spread of infectious disease without…

The agency failed to ensure all entries were clear, complete, appropriately authenticated, dated and timed in accordance with agency policy in 6 (P-1, 2, 3, 4, 6, and 7) of 7 sampled records reviewed resulting in unclear, incomplete, and unauthenticated records.

The agency failed to ensure the patient was informed about the frequency of visits for skilled services in 6 (P-1, 3, 4, 5,6, and 7) out of 7 sample records reviewed resulting in a lack of documentation that the patient was aware of visit frequency and the potential that the patient right to be…

The agency failed to ensure the initial assessment to determine immediate care and support needs of the patient was performed within 48 hours of physician referral, patient return home, or physician (or allowed practitioner) ordered start of care date in 5 (P-2, 3, 4, 6, and 7) out of 7 sample…

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 3 (P-1, 3, and 5) of 7 records reviewed, resulting in incomplete clinical information used to determine the needs of these patients and used to assist in…

The agency failed to ensure the discharge planning needs of the patient were accurately reflected in the comprehensive assessment in 1 (P-6) of 7 sample records reviewed potentially resulting in unmet patient care needs upon discharge.

The agency failed to ensure medication reconciliation was performed per policy and as documented in 2 (P-2 and 4) of 7 records reviewed, resulting in the potential to miss harmful medication reactions.

The agency failed to ensure individualized interventions and measurable goals for care were documented on the plan of care for 1 (P-2) of 7 sample records reviewed resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes.

The agency failed to ensure services and treatments were administered only as ordered by the physician or allowed practitioner in 4 (P-1, 2, 3, and 5) of 7 records reviewed, resulting in the potential for unauthorized services to be provide to the patient.

The agency failed to ensure all verbal orders were authenticated and dated by the physician (or allowed practitioner) in 1 (P-4) of 7 sample records reviewed potentially resulting in the physician being unaware of all orders and poor patient outcomes.

The skilled professional failed to ensure an ongoing assessment of the patient in 3 (P-3, 5, and 6) of 7 sample records reviewed resulting in the potential for unidentified needs.

The agency failed to provide services ordered by the physician or allowed practitioner as indicated in the plan of care in 3 (P-1, 2, and 6) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to provide patient and/or caregiver education appropriate to the patient’s diagnoses and needs in 2 (P-5 and 6) of 7 sample records reviewed potentially resulting in lack of knowledge for the patient and/or caregiver, and poor patient outcomes.

The agency failed to ensure skilled professionals prepared clinical notes as required per agency policy in 4 (P-1, 2, and 4) of 7 sample records reviewed resulting in a lack of patient care assessments and potential poor patient outcomes.

The agency failed to ensure the clinical manager was available during all operating hours potentially resulting in lack of prompt care coordination for the 3 active patients at the time of survey.

The agency failed to ensure the clinical record was accurate and contained all interventions, treatments, services, and responses to treatment in 3 (P-2, 3, and 6) of 7 records reviewed, resulting in an incomplete medical record.

The agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge in 4 (P-2, 3, 4, and 5) of 4 discharged records reviewed, resulting in the potential for…

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, including strategies to address the identified risks and the Covid-19 global pandemic, resulting in the potential for lack of preparedness…

The Agency failed to ensure the Registered Nurse conducted the Initial Comprehensive Assessment within 48 hours of the date of referral for 2 (MR's #5, 6) of 3 records reviewed where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care…

The agency failed to develop a Quality Assessment Performance Improvement (QAPI) program to optimize patient outcomes and to have at least one performance improvement project this year.

The agency failed to utilize Infection Control standards during the provision of care and services for 1 (MR #5) of 1 patient observed during a home visit, from a total of 7 sampled records reviewed, resulting in the potential for the development and spread of infection G682); and, failed to…

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, including strategies to address the identified risks and the Covid-19 global pandemic, resulting in the potential for lack of preparedness…

The Agency failed to develop an individualized emergency plan that identified the specific needs of the patient and identified the patient's priority level in the event of an emergency, as well as provide a copy to the patient and or their caregiver for 1 (MR #5) of 1 patient observed during a home…

The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patients, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 7 patients…

The Agency failed to provide initial and ongoing training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of training's, resulting in the potential for inappropriate…

The Agency (HHA) failed to develop a Quality Assessment Performance Improvement (QAPI) program that is at least capable of showing measurable improvements in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The agency failed to collect and monitor data for the Quality Assessment and 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, and there was no documented evidence the…

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency (HHA) failed to initiate at least one performance Improvement Project (PIP) within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs.

The Governing Body failed to ensure that the agency had an ongoing, active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was…

The Physical Therapist failed to utilize Infection Control standards during the provision of care and services for 1 (MR #5) of 1 patient observed during a home visit, from a total of 7 sampled records reviewed, resulting in the potential for the development and spread of infection.

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

The agency failed to include signatures on the medication reconciliation form for 2 records (MR# 2 and 3) from a total of 7 records reviewed, resulting in the potential for adverse medication interactions for agency patients.

The agency failed to ensure that 2 (MR #3 and 5) patients observed during a home visit, from a total of 3 home visits, was included in the overall planning of care, including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish…

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (MR #6) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end covered services.

The Agency failed to document the existence of complaints received, details of the the investigation and the resolution of the complaints, as per this requirement, resulting in the potential for unaddressed patient/family concerns, inability to exercise one's rights and unmet care needs.

The Agency failed to ensure the Registered Nurse conducted the Initial Comprehensive Assessment within 48 hours of the date of referral for 2 (MR's #5, 6) of 3 records reviewed where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care…

The Agency failed to ensure the Physical Therapist conducted the Initial Comprehensive Assessment within 48 hours of the date of the referral for 1 (MR #7) of 1 record reviewed where Physical Therapy was ordered to begin care, from a total of 7 sampled records reviewed, resulting in the potential…

The agency failed to ensure the Comprehensive Assessment accurately reflected the patient's current health status at the time of admission for 7 (MR's #1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in incomplete clinical information to aide in determining the required treatments and needs of the…

The Agency failed to ensure the patient's Activities of Daily Living needs were adequately met in the patient's home in 3 (MR's #5, 6, 7) of 3 records reviewed of patients who required assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for lack of…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the Physician was notified of potential drug interactions in 3 (MR's #5, 6, 7)…

The agency failed to ensure the plan of care included interventions to addressed the reported diagnoses, reportable parameters and objectively measurable goals in 3 of 5 records (MR #1, 5, 6) with skilled nursing services provided, from a total of 7 sampled records reviewed, resulting in patients…

The agency failed to provide 2 (MR #2, 5) of 3 patients observed during a home visit, with a Medication Profile that included the names, dosages, frequencies and side effects of the patient's prescribed medications, in plain language, from a total of 7 sampled records reviewed, resulting in lack of…

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas, Resulting in the potential for agency issues to go unresolved in high risk, high volume or…

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that considered incidence, prevalence, and severity of problems in identified areas of focus, resulting in the potential for the rendering of substandard…

The Agency failed to ensure the Registered Nurse performed complete assessments and re-assessments of the patient's health status and needs in 1 (MR #6) of 1 record of a patient with a diagnosis of Congestive Heart Failure, from of a total sample of 7 records reviewed resulting in the potential for…

The Agency failed to ensure the Physical Therapist provided services as ordered in the Plan of Care for 1 (MR #5) of 1 patient with Physical Therapy services ordered, who was observed during a home visit, resulting in the potential for inappropriate application of therapy exercises, physical…

The Agency failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The agency failed to ensure that discharge and summaries were complete, provided the patient's current health status at the time of discharge, documented progress toward goals, provided an updated medication list and were sent to the physician in 2 of 2 records (MR #'s 4, 6) who were discharged…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 7 records…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 3 of 4 records reviewed with skilled nursing services from a total sample of 7 records reviewed (M.R.#s 4, 6 and 7), resulting in the potential for a plan of care not meeting the patient's needs.