Barnabas Health Care Services, Inc

The facility failed to conduct testing of the emergency preparedness plan at least every two years.

The facility failed to investigate a complaint related to medication set up for 1 of 2 patients (P3) reviewed who received skilled services from the agency.

The agency failed to ensure medications were reconciled and/or set up as ordered for 4 of 7 clients (P2, P5, P1, P3) whose medications were reviewed during home visits or record review.

The agency failed to ensure medications were administered only as ordered by a physician or allowed practitioner for 1 of 2 patients (P2) observed during a skilled nursing home visit.

The agency failed to ensure client code status was accurately identified on the plan of care for 1 of 7 patients (P5) reviewed for code status.

The agency failed to ensure a registered nurse made an onsite, in person visit every 60 days for personal care attendant (PCA) supervision for 2 of 2 patients (P8, P9) reviewed for non-skilled agency patients receiving PCA services under the agency's comprehensive home care license.

The facility failed to participate in a full scale emergency exercise, and or a table top exercise at least annually.

The agency failed to send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care and treatment preferences, to the receiving facility to ensure a safe and effective transition of care for 1 of 2 patients (P7) reviewed, who…

The agency failed to ensure the physician orders were followed for 1 of 7 patients (P5) who had in home physical therapy and in home occupational therapy ordered, but the services had not been provided, and the physician had not been notified the services were not provided.

The facility failed to identify specific performance measures for implementation to improve the patient outcomes related to medication safety, hospitalization, emergency room visits, nutrition, falls, and malnutrition as indicated on the tracking spreadsheet.

The facility failed to ensure 6 of 20 staff members , licensed practical nurse (LPN)-A, home health aide (HHA)-A, HHA-B, HHA-C, personal care attendant (PCA)-A, and housekeeper (HSK)-A, were vaccinated with a complete primary series of COVID-19 vaccine and/or had an approved or pending exemption on…

The agency failed to ensure each patient had an initial assessment visit within 48 hours of the referral date for 4 of 7 patients (P3, P4, P6, P7) reviewed, in the sample.

The agency failed to complete a comprehensive discharge assessment when the agency discharged a patient from skilled nursing care for 1 of 2 skilled patients (P6), reviewed.

The agency failed to identify the duration of visits to be made on the plan of care for 6 of 7 patients (P1, P3, P4, P5, P6, P7), reviewed in the sample.

The agency failed to update the plan of care to reflect current treatment implemented for 1 of 2 patients (P3) reviewed for treatments.

The agency failed to ensure home health aides provided services ordered by the physician, included in the plan of care and consistent with the home health aide training for 1 of 1 patients (P3) with home health aide services for personal care, observed during a home visit.

The agency failed to discharge 3 of 8 patients (P4, P1, and P2) for an appropriate cause, and did not report potential neglect to the state agency when they were discharged with continued care needs and no resources.

The home health agency (HHA) failed to meet the Condition of Participation at 484.70, Infection Prevention and Control.

The agency failed to implement appropriate infection control practices related to COVID-19 in relation to conducting health screenings for Healthcare Workers (HCW's) and patients prior to visits.

The agency failed to develop and implement an infection control program.

The agency failed to develop policies and procedures to ensure all staff were vaccinated for COVID-19, failed to develop a process to track and document staff vaccination status, failed to develop a process by which staff may request an exemption for COVID-19 vaccination requirements, and failed to…

The agency failed to discharge 3 of 8 patients (P1, P2, P4) who were covered under Veteran's Affairs (VA) for appropriate cause, when the patient's were discharged from the agency without notice or assistance in identifying other entities in the area that may be able to meet the patient's needs.

The agency failed to document any of the complaints the agency received, the investigation of complaints received or the resolution of the complaints received.

The agency failed to immediately report to the State Agency (SA), an allegation of neglect for 1 of 8 patients (P1) when the agency discharged P1 without notice or resources and who lived alone and needed assistance with bathing and medication set up.

The home health agency (HHA) failed to document discharge information and send to the patient's primary physician for 3 of 8 patients (P1, P2, and P4) whose records were reviewed.

The facility failed to comprehensively develop emergency preparedness policies and procedures,based on the agency and community risks assessments and communication plans, for all required and agency-identified hazards.

The facility failed to implement a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness (EP) officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts…

The facility failed to ensure their emergency preparedness policies and procedures were based on the facility and community-based risk assessment and communication plan utilizing an all hazards approach.This had the potential to affect 38 patients served by the agency.

The facility failed to ensure their emergency preparedness policies and procedures addressed the use of volunteers in an emergency, or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge…

The facility failed to ensure two exercises including either a full-scale and/or table top exercises were completed to test their emergency preparedness plan.

The facility failed to demonstrate implementation of a process for improvement with tracking and analysis of the information to determine the effectiveness of the quality assurance program as it related to the identified areas of medication safety, hospitalization, emergency room visits, nutrition…

The facility failed to identify specific performance measures for implementation to improve the patient outcomes related to medication safety, hospitalization, emergency room visits, nutrition, falls, and malnutrition as indicated on the tracking spreadsheet.

The licensee failed to ensure the employee record included the required content for three of seven employees (E-B, E-C, and E4) with records reviewed.