Allfaith Homecare

The agency failed to ensure the governing body provided oversight of the QAPI program for 94 current patients and all employees.

The agency failed to ensure the initial assessment was performed within 48 hours of the referral for one (Pt #4) of seven patients reviewed.

The agency failed to an OASIS was completed for one (Pt #1) of seven patients.

The agency failed to ensure an individualized POC to was developed for one (Pt #1) of seven patients.

The agency failed to ensure completion of a POC for one (Pt #2) of seven patients.

The agency failed to ensure preparation and availability of a clinical notes for three (Pt #1, 3 and %) of seven patients.

The agency failed to ensure an LPN supervisory visit for one (Pt #3) of seven patients.

The agency failed to ensure a home health aide supervisory visit was completed every 14 days for one (Pt #3) of one patient with home health aide services.

The agency failed to ensure maintenance and update of an emergency preparedness plan for calendar years 2020 and 2021 for all agency patients and staff.

The agency failed to ensure emergency preparedness plan testing was conducted for all agency patients and staff.

The agency failed to ensure development of a POC for one (patient #4) of seven patients.

The agency failed to ensure QAPI documentation was available and able to show measurable improvements in identified indicators and measurements, analysis and tracking of identified indicators for all agency patients on service during 2020 and 2021. A review of QAPI records for calendar years 2020…

The agency failed to ensure program documentation was capable of showing utilization of OASIS data included in QAPI activities for all patients on service during calendar years 2020 and 2021. A review of QAPI records for calendar year 2020 and 2021 showed no OASIS data and no routine collection of…

The agency failed to ensure conduction of PIPs for all patients and agency staff during calendar years 2020 and 2021. A review of QAPI records showed no identification, conduction or evaluation of PIPs for calendar years 2020 and 2021. On 02/01/22 at 2:50 pm, Staff A stated they had no PIPs.

The agency failed to ensure clinical notes were completed and included in the clinical record for 4 (patients #2, 3, 5 and 7) of seven patients.

The agency failed to ensure discharge notification and/or communication was provided for one (Pt #3) of one patient discharged without notification.

The agency failed to ensure communication/coordination with the physician on missed visits for one, (Pt #3) of six patients.