Berhan Home Health Care Agency Inc

The Home Health Agency failed to maintain a comprehensive Emergency Preparedness program as evidenced by the following: The home health agency failed to update the Emergency Preparedness plan every 2 years.

The Home Health Agency failed to meet the Condition of Participation for Reporting Outcome and Assessment Information Set (OASIS) Information by failing to electronically report all OASIS data as evidenced by the following: 1.The Home Health Agency failed to encode individual client assessment data…

The Home Health Agency (HHA) failed to meet the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) by failing to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program as evidenced by the following: 1.The Home Health…

The Home Health Agency failed to meet the Condition of Participation for Infection Prevention and Control by failing to maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases as evidenced by the following: 1.The…

The home health agency failed to update the Emergency Preparedness plan.

The Home Health Agency failed to update hazard vulnerability assessments.

The home health agency failed to inform local emergency preparedness officials regarding homebound patients in need of evacuation from their residence at any time during an emergency situation.

The home health agency failed to maintain a current communication plan for the readily identification and notification of on duty staff.

The home health agency failed to routinely test the Emergency Preparedness plan.

The home health agency failed to provide Emergency Preparedness education for four (4) out of five (5) personnel records reviewed (Employee #4, #8, #18, and #19).

The home health agency failed to encode individual client assessment data within 30 days for 11 out of 44 patients sampled (Patient #5, #11, #13, #18, #19, #21, #22, #29, #31, #33, and #34).

The Home Health Agency failed to submit Outcome and Assessment Information Set (OASIS) data that accurately reflected the patient's status at the time of filing for one (1) out of seven (7) patients sampled (Patient #19).

The Home Health Agency’s Quality Assessment and Performance Improvement (QAPI) failed to establish a program driven on quality indicators and patient care data.

The Home Health Agency's Quality Assessment and Performance Improvement (QAPI) program failed to track identified patient specific data.

The Home Health Agency’s Quality Assessment Performance Improvement (QAPI) program failed to adhere to a planned performance improvement program and failed to document progress or modifications.

The Home Health Agency's Governing Body failed to maintain documentation of communication with the agency's Quality Assessment and Performance Improvement (QAPI) program.

The Home Health Agency's rehabilitation staff failed to comply with Infection Prevention policy in the direct care of one (1) out of two (2) patients sampled (Patient #48).

The Home Health Agency’s Infection Control program failed to utilize tracking of patients and staff with suspected infections.

The Home Health Agency failed to complete comprehensive assessments within the permitted five (5) day timeframe for two (2) out of eight (8) patients sampled (Patient #13 and #45).

Skilled nursing failed to (1) comply with physician’s order regarding wound care for three (3) of nine (9) patients reviewed, (Patients #19, #45, and #49), (2) frequency of visits per physician’s order for three of (3) of nine (9) reviewed (Patients # 13, 46, and #49) and (3)failed to reconcile…

The home health agency failed to comply with employment policies for background checks and preemployment health screening for 16 out of 17 records reviewed (Employee #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19).

The agency's staff failed to review and revise of the plan of care for one (1) of ten (10) clinical records (Patient#1).

The agency's staff failed to review of all medications the patient was using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for one…

The agency's clinician failed to document complete, updated, and revised comprehensive assessments at discharge to include summaries of patients’ progress in meeting care plan goals in two (2) of two (2) closed clinical records for discharged patients (Patients #9 and 10).