Allied Home Health Care Services

The agency failed to complete an initial start of care assessment within 48 hours of the referral order date for 2 of 12 sampled patients (Patient 2 and Patient 4).

The agency failed to ensure the physical therapist completed and uploaded a plan of care into the electronic medical record for 1 of 12 patients (Patient 1).

The home health agency (HHA) failed to maintain an EP plan that was reviewed and updated at least every two years.

The home health agency (HHA) failed to ensure the emergency preparedness (EP) plan addressed the patient population and the type of services the HHA had the ability to provide in an emergency.

The home health agency (HHA) failed to ensure the plan included a process for cooperating and collaborating with local, regional, State, and Federal EP officials' efforts to maintain an integrated response during a disaster or emergency situation.

The home health agency (HHA) failed to ensure the EP plan's policies and procedures were reviewed and updated at least every two years.

The home health agency (HHA) failed to ensure procedures were developed to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation.

The home health agency (HHA) failed to ensure the communication plan complied with Federal, State, and local laws and was reviewed and updated at least every two years.

The home health agency (HHA) failed to ensure the Emergency Preparedness (EP) communication plan included contact information for Federal, State, regional, and local EP staff.

The home health agency (HHA) failed to ensure the EP communication plan included the method to be used to share information and medical documentation for patients under their care with other health providers to ensure continuity of care was maintained.

The home health agency (HHA) failed to ensure the EP communication plan included a means of providing information about the HHA's occupancy, needs, and the agency's ability to assist the authority having jurisdiction during an emergency.

The home health agency (HHA) failed to provide documentation of testing of the emergency preparedness (EP) plan.

The home health agency (HHA) failed to ensure the agency's COVID-19 vaccination policy contained all the required content.

The home health agency (HHA) failed to ensure physician or allowed practitioner orders were received prior to patient care being performed for five (Patient (P) 1, P2, P3, P4, P7) of seven patient records reviewed from a sample of seven patients.

The home health agency (HHA) failed to ensure services were provided as ordered by the physician in the patient's plan of care (POC) for one (Patient (P) 2) of seven sampled patients.

The home health agency (HHA) failed to ensure the physician was notified of a missed physical therapy (PT) visit in accordance with the agency policy for one (Patient (P) 1) of seven sampled patients.

The home health agency (HHA) failed to ensure written documentation of the delegation of administrator duties in the absence of the administrator was accurate.

The facility failed to ensure the EPP was based on and included a facility-based and community-based risk assessment.

The Home Health Agency (HHA) failed to collaborate with the local Office of Emergency Management (OEM) to maintain an integrated response during a disaster or emergency.

The HHA failed to develop a system of medical documentation to preserve, protect, and maintain confidentiality of patient information and secures and maintains availability of the records.

The HHA failed to establish a system/process for emergency staffing or use of volunteers in an emergency.

The HHA failed to participate in a community-based, full-scale emergency exercise on an annual basis as a part of the HHA's Emergency Preparedness Program (EPP).

The Home Health Agency (HHA) failed to ensure Outcome and Assessment Information Set (OASIS) standardized assessment tool was transmitted to the Centers for Medicare and Medicaid Services (CMS).

The Home Health Agency (HHA) failed to maintain a Quality Assurance Performance Improvement (QAPI) program which measured, analyzed, and tracked quality indicators demonstrating improvement in outcomes and quality of care.

The Home Health Agency (HHA) failed to collect data and analyze data collection to implement preventative actions and make systemic improvement in HHA operations.

The agency failed to initiate and document a "Performance Improvement Project (PIP)" that would reflect the scope and complexity of services and demonstrate progress toward identified measurable goals.

The Governing Body did not ensure the Home Health Agency (HHA) had an ongoing program for Quality Assurance Performance Improvement (QAPI) that was implemented and maintained to address priorities for improvement in quality of care and patient safety, and that all improvement actions were evaluated…

The Home Health Agency (HHA) failed to ensure 1 of 7 sampled patients (P) (Patient #4 (P4) had a complete medication review.

The Home Health Agency (HHA) failed to develop a Quality Assessment and Performance Improvement (QAPI) program that included high risk, high volume or problem prone areas.

The Home Health Agency (HHA) failed to develop a quality assessment and performance improvement (QAPI) program that considered incidence, prevalence and severity of problems in high risk, high volume areas.