Balajie Home Health Care, Inc

The agency failed to develop emergency preparedness policies and procedures (see E0013); failed to ensure individual emergency plans were completed as part of the comprehensive patient assessment (see E0017); failed to ensure the communication plan included a method for sharing information and…

The agency failed to ensure a plan of care was developed by the skilled professionals in 1 (P-12) of 13 records reviewed (See G0708); failed to ensure that services ordered by the physician as indicated in the plan of care were provided for 2 (P-11 and P-12) of 13 records reviewed (See G0710)…

The agency failed to provide documentation that an agency home health aide (HA-1) successfully completed a training and competency evaluation program (See G0754); failed to provide documentation of classroom and supervised practical training for an agency home health aide (HA-1) which totaled 75…

The agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan, resulting in the agency's inability to implement appropriate emergency actions.

The agency failed to ensure individual emergency plans were completed as part of the comprehensive patient assessment in 3 (P-5, P-9, and P-10) of 13 records reviewed, resulting in the potential to negatively affect the health and safety of these patients.

The agency failed to ensure the communication plan included a method for sharing information and medical documentation for patients under the agency’s care, resulting in the agency's inability to implement appropriate emergency actions.

The agency failed to develop and maintain an emergency preparedness training program, resulting in the potential to negatively affect the health and safety of all patients served by this agency.

The agency failed to send necessary medical information pertaining to the patient's current course of illness and treatments and treatment preferences to the receiving facility upon transfer to ensure the safe and effective transition of care in 1 (P-3) of 1 record reviewed in which the patient was…

The agency failed to ensure the plan of care included interventions with objectively measurable goals specific to the individualized needs of the patient in 13 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, P-10, P-11, P-12, and P-13) of 13 records reviewed, resulting in the potential for poor…

The agency failed to ensure the home health aide followed accepted standards of practice to prevent the transmission of infectious diseases in 1 (P-10) of 1 sample records reviewed in which home observation with a home health aide was conducted potentially resulting in the transfer of infectious…

The agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the Home Health Aide regarding client needs in 2 (P-6, P-10) of 5 sample records reviewed which included Home Health Aide services, resulting in a lack of guidance for the services to be provided and…

The agency failed to ensure that a physician authenticated the order for Home Care Services in 1 of 13 records (P-2) reviewed, resulting in services being provided without authentication of physician orders.

The agency failed to ensure patients received all services as outlined in the plan of care for 4 (P-5, P-6, P-7, P-13) of 13 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure the comprehensive assessment was completed in a timely manner per agency policy in 1 (P-10) of 13 sample records reviewed potentially resulting in unidentified needs of the patient and poor patient outcomes.

The agency failed to ensure the patient’s clinical record documented all medications for 1 (P-13) of 13 records reviewed, and failed to ensure the comprehensive assessment included a review of all medications to determine any potential adverse effects for 2 (P-9 and P-13) of 13 records reviewed…

The Plan of Care failed to include information related to advanced directives in 1 of 13 records reviewed (P-1).

The agency failed to ensure a plan of care was developed by the skilled professionals in 1 (P-12) of 13 sample records reviewed resulting in the lack of guidelines to care provided and lack of system to ensure physician orders are followed each visit.

The agency failed to ensure that services ordered by the physician as indicated in the plan of care were provided for 2 (P-11 and P-12) of 13 sample records reviewed potentially resulting in unmanaged health concerns and poor outcomes.

The agency failed to ensure the clinical record was complete and included accurate physical therapy notes for 3 (P-4, P-6, P-13) of 13 records reviewed, resulting in the potential for the lack of continuity of care.

The agency failed to ensure skilled professionals communicated assessment findings to the physician for 5 (P-6, P-8, P-9, P-10, and P-12) of 13 records reviewed, resulting in the potential for poor patient outcomes.

The agency failed to ensure the Licensed Practical Nurse was supervised by the Registered Nurse according to agency policy in 1 (P-12) of 12 sample records reviewed for which skilled nursing services were included, resulting in a lack of monitoring performance and provision of service from the…

The agency failed to provide documentation that an agency home health aide (HA-1) successfully completed a training and competency evaluation program resulting in the potential for substandard home health aide services being provided.

The agency failed to provide documentation of classroom and supervised practical training for an agency home health aide (HA-1) which totaled 75 hours.

The agency failed to demonstrate the home health aide received 16 hours of classroom training preceding a minimum of 16 hours supervised practical training as part of a total 75 hours.

The agency failed to provide evidence for a home health aide competency evaluation program resulting in a lack of documented training for an agency home health aide (HA-1).

The agency failed to ensure the home health aide provided services which were included in the plan of care for 1 (P-10) of 1 sample records reviewed in which a joint home visit was conducted with a home health aide.

The agency failed to ensure the home health aide reported changes in the patient’s condition to a registered nurse in 2 (P-6 and P-10) of 5 records reviewed with home health aide services, resulting in the potential for physical decline and unmet care needs for these patients.

The agency failed to ensure the registered nurse completed an on-site supervisory visit to the patient’s home at least every 14 days to supervise the services that were provided by the home health aide for 1 (P-6) of 5 records reviewed in which aide services were provided, resulting in lack of…

The agency failed to ensure the patient's clinical record contained all clinical notes for 1 (P-13) of 13 records reviewed resulting in the potential for missed or unmet patient needs.

The agency failed to ensure the clinical record contained accurate patient contact information for 1 (P-13) of 13 records reviewed, resulting in the potential to negatively affect the health and safety for this patient.

The agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 1 (P-6) of 4 discharge records reviewed, resulting in a lack of information to ensure continuity of care.