At Home Care Agency

The Home Health Agency (HHA) failed to ensure that patient care plans were individualized, updated, and executed.

The Home Health Agency (HHA) failed to develop and maintain a data-driven Quality Assurance Performance Improvement (QAPI) program.

The Home Health Agency (HHA) failed to ensure that skilled professionals participated in ongoing interdisciplinary patient assessments and in the Quality Assurance and Performance Improvement (QAPI) program.

The Home Health Agency (HHA) failed to ensure that the Governing Body maintained oversight of the management and operations of the HHA's home health services, including the Quality Assessment and Performance Improvement Program.

The Home Health Agency (HHA) failed to conduct testing of the emergency plan.

The Home Health Agency (HHA) failed to identify quality indicators through measurement, analysis, and tracking of adverse or negative patient outcomes.

The Home Health Agency (HHA) failed to collect and incorporate data for the Quality Assurance Performance Improvement (QAPI) program indicators.

The Home Health Agency (HHA) failed to conduct performance improvement projects based on high risk, high volume and problem-prone areas.

The Home Health Agency (HHA) failed to ensure that two of three (EMP1 and EMP5) skilled nursing staff sampled were competent to perform skilled tasks prior to providing patient care.

The Home Health Agency (HHA) failed to ensure that the governing body was providing oversight of all home health services including the Quality Assurance and Performance Improvement (QAPI) program.

The Home Health Agency (HHA) failed to ensure that documentation in one of four (PT1) active patient samples was correct and complete.

The Home Health Agency (HHA) failed to ensure that care plans were accurate and followed for four of four (PT1, PT2, PT3, and PT4) active patients sampled.

The Home Health Agency (HHA) failed to ensure that patient care plans were updated for four of four (PT1, PT2, PT3, and PT4) active patients sampled.

The Home Health Agency (HHA) failed to ensure that skilled nursing staff communicated with patient's physician regarding care plans for one of four (PT1) active patients sampled.

The Home Health Agency (HHA) failed to perform on-going interdisciplinary team assessments for four of four (PT1, PT2, PT3, and PT4) active patients sampled.

The Home Health Agency (HHA) failed to ensure that skilled nursing staff were participating in the agency's Quality Assurance Performance Improvement (QAPI) program.

The Home Health Agency (HHA) failed to complete a discharge summary and forward it to the health care professional who was responsible for providing care and services to the patient after discharge for one of two (PT6) sampled discharged patients.

The agency failed to electronically report all OASIS data collected in accordance with 484.55. Findings included: iQIES report titled “HHA List – No Successful Production Submissions Report” completed on 2/25/2022 indicated At Home Care Agency, CCN #087043, had no OASIS Submission and no Accepted…

The agency failed to include the names and contact information of patient’s physicians in the agency’s Emergency Preparedness Communication Plan.

The agency did not include OASIS data in the process of their QAPI program or in the QAPI scope of activities.

For 1 of 2 patients (Patient #3) observed during a home visit, the agency staff failed to adhere to accepted standards of practice regarding infection prevention and hand hygiene.

The agency failed to ensure that all staff are fully vaccinated for COVID-19. Findings included: The agency policy entitled “COVID-19 Final Rule – COVID-19 Staff Vaccination in Home Health” stated, “…All eligible staff must have received the necessary shots to be fully vaccinated…by (Phase II)…

That: for 2 of 7 patients (Patients #2, #5) in the sample, the Comprehensive Assessment failed to include information about the patient’s current health status.

That: for 2 of 7 patients (Patients #2, #5) in the sample, the Comprehensive Assessment failed to include information about the patient’s strengths, limitations, and care preferences.

The agency failed to accurately identify medications patients are currently using in the comprehensive assessment for 3 of 7 patients (Patient #2, #4, #5) in the sample.

The agency failed to update the comprehensive assessment at discharge for 2 of 7 patients (Patients #1, #2) in the sample.

That: for 7 of 7 patients (Patients #1, #2, #3, #4, #5, #6, #7) in the sample, the plan of care failed to include all the required components.

For 6 of 7 patients (Patient’s #1, #3, #4, #5, #6, #7) in the sample who received patient care services, the agency failed to ensure services were administered as ordered by the physician.

The Administrator failed to ensure qualified personnel were employed for 3 of 3 employees (Chore Aide #1, RN #2, Chore Aide #2) sampled.

For 3 of 7 patients (Patient’s #1, #2, #3) in the sample who received patient care services, the agency failed to ensure all interventions, including services, were included in the clinical record.