Am - Pm Home Health Services LLC

The agency failed to ensure patients were seen within 48 hours of receiving a referral or after an inpatient stay for 3 of 6 active clinical records reviewed.

The agency failed to ensure an individualized plan of care was created for 3 of 6 active clinical records reviewed (Patients #1, 2, and 5).

The agency failed to ensure patient's comprehensive assessment was updated and revised when there was a change in condition in 1 of 5 active clinical records reviewed.

The agency failed to ensure a written competency and a skills competency was completed on 1 of 3 HHA record reviews.

The agency failed to ensure the aide care plan was updated after a change in condition of a patient in 1 of 5 active clinical records reviewed.

The agency failed to ensure the comprehensive assessment reflected the patient's relevant medical history and current health problems; the patient's psychosocial status, such as ability to participate in care, ability to identify and meet one's needs, and support systems available; and education…

The agency failed to ensure the admitting clinician collaborated with the ordering physician after home health admission visits or recertifications were performed, to ensure the plan of care was established with the ordering provider in 4 of 6 active clinical records reviewed.

The agency failed to ensure all orders were integrated into the Plan of Care 1 of 6 active record reviews.

The agency failed to ensure the HHA's (Home Health Aides) provided services delegated in the home health aide plan of care in 6 (Patients #1, 2, 3, 4, 5, and 6) of 6 patients' whose clinical records were reviewed.

The agency failed to ensure the accuracy of supervisor visits for HHA's (Home Health Aides) providing services according to the plan of care for 6 of 6 active clinical records reviewed.

The agency failed to ensure an Emergency Preparedness was maintained, reviewed, and/or revised if needed, with tabletop exercise conducted with an after-action analysis documented since 2020 for 1 of 1 Emergency Preparedness program.

The agency failed to ensure they met the needs of 5 of 5 active (Patient #1, 2, 3, 4, and 8) patients whose clinical record was reviewed by failing to provide patient-specific interventions, education, and measurable outcomes and goal (G574), having failed to promptly inform the physician of missed…

The agency failed to provide documentation they had maintained a Quality Assessment and Performance Improvement program for 2023. The cumulative effects of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for…

The agency failed to implement COVID-19 policies and procedures for the Centers for Medicare and Medicaid Services (CMS) vaccine mandate of 100% compliance for employees that provide direct care on behalf of the agency to be fully vaccinated or have a record of an approved medical or religious…

The agency failed to implement standard precautions to include the CMS COVID-19 vaccination mandate and failed to implement mitigation precautions for unvaccinated healthcare professionals providing direct patient care during the entire COVID-19 public health emergency pandemic.

The agency failed to maintain a quality assurance performance improvement program (QAPI) that provided surveillance, tracking, and investigation of infectious and communicable diseases including COVID-19 from 3-4- 2020 until current (the duration of the public health emergency for COVID-19) for 1…

The agency failed to ensure their COVID-19 Vaccine Mandate policy and procedures were implemented and failed to ensure that the agency met the COVID-19 Vaccine Mandate at 100% compliance for 21 of 21 employees that provide the agency's direct care and the with the potential of adverse outcomes for…

The agency failed to demonstrate members of the governing body were responsible and completed a review of the agency’s budget and Quality Assurance Performance Improvement Plan (QAPI) for 2022 and 2023. Findings Include: 1. On 04-20-2023 at 12:05 PM, a review of the agency’s Admission packet was…

The agency failed to ensure the plan of care contained specific individualized interventions and goals for 5 of 5 (Patients #1, 2, 3, 6, and 8) active clinical records reviewed and include the frequency of skilled nursing visits in 1 of 5 (Patient #3) active clinical records reviewed, as required…

The agency failed to promptly notify the attending physician of a hold in home health aide care visits until the last day of the hold or until after the visits were held for 1 of 2 (Patient #3) active clinical records reviewed with missed care visits.

The agency failed to provide an updated list of medications, schedules, dosages, and indications in 1 (Patient #4) of 3 home visits.

The agency failed to answer their 24-hours per day number 3 of 3 different days the number was called with the potential to affect all 27 agency patients.

The agency failed to develop and implement an all hazard approach to their emergency preparedness plan that included emerging infectious disease and strategies for addressing the emergency events identified in their hazard vulnerability analysis for 1 of 1 agency.

The agency failed to include policies and procedures to inform state and local officials of any on-duty staff or patients that they were unable to be contacted during or due to an emergency for 1 of 1 agency.

The agency failed to ensure it had solicited volunteers for service during a disaster or emergency, to include the their roles for integration with health care professionals during the disaster/emergency for 1 of 1 home health agency disaster preparedness plan.

The agency failed to ensure the development and implementation of an emergency communication plan for 1 of 1 agency.

The facility failed to develop a method for sharing information and medical documentation for patients under the agency's care during disaster relief purposes for 1 of 1 agency emergency preparedness plan.

The agency failed to ensure the Registered Nurse provided current and complete written care instructions for the home health aide in 1 (Patient #5) of 2 aide home visits in a total sample of 7 clinical records.

The agency failed to maintain and provide documentation of home health aide competency evaluation and skills check-off for 2 (Employee C & E) of 3 home health aide records reviewed.