Atlantic Home Health Care, Inc

The agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years (E0004); failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach (E0006); failed to ensure…

The Agency failed to develop a Quality Assessment and Performance Improvement Program that measures, tracks, and analyzes quality indicators to assess quality, processes of care, and services for the agency.

The agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years resulting in lack of direction for agency personnel in the event of an actual emergency or disaster.

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, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency.

The agency failed to ensure their emergency preparedness policies and procedures were reviewed and updated at least every 2 years, resulting in the agency's inability to ensure staff actions during an emergency aligned with current practices and guidelines.

The agency failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment for 2 (P-4, P-5) records of patients who required individualized assessments in Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for…

The agency failed to develop an Emergency Preparedness Policy/Plan, that included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs, resulting in the potential for the interruption in needed care and services for staff and all 11 patients…

The agency failed to develop and maintain a communication plan for emergency preparedness that included methods of communication and strategies that had been updated at least every 2 years, resulting in the inability to communicate with staff and officials in the event of an actual disaster, and…

The agency failed to develop and maintain an emergency preparedness communication plan that had been reviewed/updated at least every 2 years and included contact information for all current staff, patient's physicians, and volunteers, as appropriate, resulting in the lack of effective communication…

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 trainings, resulting in the potential for inappropriate…

The agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency.

The agency failed to ensure its skilled discipline honored the ordered visit frequency for 1 (P-4) of 7 sampled records reviewed, resulting in the patient not receiving care according to their identified needs and the potential for unmet care needs.

The agency failed to collect data to monitor and measure indicators to use in it's QAPI program based on agency processes and negative patient outcomes.

The agency failed to include program data in the agency QAPI Program.

The agency failed to focus on high risk, high volume, or problem-prone areas, failed to consider incidence, prevalence, and severity of problems in those areas that lead to immediate correction of any identified problems that directly or potentially threaten the health and safety of patients.

The agency failed to track adverse patient events, analyze their causes, and implement actions.

The agency failed to ensure at least one performance improvement project was in development, on-going, or completed.

The governing body failed to assume overall responsibility for ensuring that the QAPI Program reflects the complexity of the Home Health Agency and its services, involves all services, focuses on indicators related to improved outcomes, and takes actions that address the HHA's performance across…

The agency failed to ensure its skilled discipline utilized Infection Control standards of practice during the provision of care and services for 1 (P-5) of 3 patients observed during a home visit from a total of 7 sampled records reviewed, resulting in the potential for the development and spread…

The agency failed to develop an effective coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program.

The agency failed to include contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packets, resulting in the potential for unaddressed concerns.

The agency failed to ensure the Registered Nurse conducted the Initial Comprehensive Assessment within 48 hours of the date of referral for 3 (P-1, P-2, P-7) 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 referral for 1 (P-6) of 1 record reviewed with PT services only ordered, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and…

The agency failed to ensure Activity of Daily Living needs were adequately met in the patient's home for 1 (P-4) of 1 patient assessed as needing assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, psychological decline, and unmet care…

The agency failed to ensure the plan of care covered all pertinent interventions, reportable parameters, and objectively measurable goals specific to the needs of the patient for 5 (P-1, P-2, P-3, P-4, P-7) of 7 sampled records reviewed, resulting in patients not receiving care specific to their…

The agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure Physical Therapy services were provided as ordered for 1 (P-5) of 7 records with Physical Therapy services ordered from a total of 7 sampled records reviewed, resulting in the potential for physical decline, and unmet care needs.

The agency failed to ensure there was a written contract established with/for individuals who were granted clinical privileges and provided home health services to the agency's patients, resulting in lack of administrative responsibility, patient oversight and the potential for poor patient…

The agency failed to ensure the discharge summaries were complete, provided the patient's current health status at the time of transfer, progress toward goals, and forwarded to the Physician within 5 days of the date of discharge in 2 (P-3 and P-4) of 2 records in which the patient was discharged…

The Agency failed to produce evidence upon request that Covid-19 infection control education had been provided to clinical staff employed by the Agency since the beginning of the pandemic, resulting in the potential for the development and spread of the Covid-19 infection among staff and all 3…

The agency failed to develop an emergency preparedness plan that must be reviewed, updated and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel (see E 0004); failed to develop an emergency preparedness plan that must be reviewed and updated at least…

The Agency failed to ensure the Registered Nurse (RN) followed accepted standards of practice in assuming responsibility for the care of 1 (MR #7) of 4 patients with congestive heart failure, from a total of 7 sampled patient records reviewed (See G704); failed to ensure that occupational therapy…

The Agency failed to develop an emergency preparedness plan that must be reviewed and updated to include strategies to address the Covid-19 global pandemic, resulting in no directions for Agency personnel in the event of an actual emergency or disaster.

The agency failed to develop an Emergency Preparedness Plan that was based on both a facility-based and community-based all-hazards risk assessment, resulting in the potential for being unprepared to respond effectively in the event of an emergency.

The Agency failed to develop an Emergency Preparedness Plan that included policy and procedure concerning the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs during the COVID-19 crisis, resulting in the potential for the interruption in needed…

The Agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws, and must be reviewed and updated at least every 2 years, resulting in the Agency's inability to ensure the coordination of patient care in the event of an actual…

The Agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan.

The Governing Body failed to approve the frequency and detail of data collected to monitor the effectiveness, safety of services, quality of care, and identify opportunities for improvement for the agency’s Quality Assurance and Performance Improvement program which could potentially result in poor…

The agency failed to provide data showing measurable progress achieved for their Performance Improvement Project which could potentially result in poor patient outcomes and services.

The Agency failed to ensure the registered nurse (RN) notified the physician of a SCIC (significant change in condition) in 1 (MR#7) of 4 records reviewed with congestive heart failure, from a total sample of 7 records reviewed, resulting in a poor patient outcome.

The Administrator failed to produce documentation of CMS (Centers for Medicare & Medicaid Services) final approval concerning a change of address, resulting in the Agency to be operating out of compliance with Federal requirements.

The Agency failed to ensure the registered nurse acquired physician approval concerning major drug to drug interactions and duplicative drug therapies for 4 (MR's # 1, 3, 5, 6) of 7 records reviewed; and failed to have skilled nursing perform a comprehensive drug review in 1 (MR #4) of 1 record for…

The Agency failed to ensure skilled nursing (SN) included individualized, patient-specific, measurable outcomes and goals in the plan of care for 2 (MR's #3, 7) of 7 sample records; failed to incorporate quantitative parameters to notify the physician for exacerbation (worsening) of CHF symptoms…

The agency failed to ensure that occupational therapy services were provided as ordered by the physician and failed to provide the frequency of physical therapy ordered by the physician in 1 of 7 (MR #2) records reviewed resulting in the potential for poor patient outcomes for this patient.

The Agency failed to ensure the registered nurse (RN) provided appropriate oversight and communication with the licensed practical nurse (LPN) in 1 (MR#7) of 1 record reviewed in which the patient had been assigned LPN care to furnish the patient's needs, from a total sample of 7 records reviewed…

The agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 3 (MR's #1, 2, 4) of 5 sample discharge records reviewed; and failed ensure a detailed transfer summary was sent to the physician within 2 business days of transfer for 1…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening visitors and all 24 staff employed by this agency and those (21 staff) who were granted clinical privileges, resulting in the…

The Agency failed to provide documented evidence that Covid-19 infection control education was provided to all 24 staff employed by the agency staff, 21 of which were granted clinical privileges, resulting in the potential for the development and spread of the Covid-19 infection to staff and all 5…

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy; and failed to ensure the physician was informed of drug interactions for 4 of 7 (MR# 1, 4, 5, 7)…

The Agency failed to ensure the physician was promptly notified of the patient's abnormal vital sign for 1 patient (MR #2) of a total of 7 records, resulting in untreated health issues and the potential for poor patient outcomes.

The agency failed to ensure an on-site supervisory visits to the patient's home at least every 14 days to supervise the services that were provided by the home health aide for 1 of 2 records reviewed (MR# 1) in which aide services had been provided, from a total sample of 7 records reviewed…