Best Home Health Care, Inc

The agency did not have a community based All Hazards Risk Assessment.

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2024 for all patients and employees.

Findings: A review of QAPI and Infection Control Program records showed no infection control program surveillance monitoring and reporting as a part of QAPI program for calendar years 2024 and 2025. On 01/15/26 at 11:30 a.m., Staff A stated the infection control monitoring was not included in the…

Agency services.

The agency failed to ensure an initial evaluation/SOC assessment was conducted within 48 hours of referral for three (Patients #1, 2 and #3) of 11 patients.

The agency failed to ensure an individualized patient POC included a last conducted or next date a skilled intervention was due for one (Patient #11) of 11 patients.

The agency failed to ensure physician orders for physical therapy interventions and goals were a part of the patient’s plan of care for two (Patients #5 and #8) of 11 patients.

The agency failed to ensure care was coordinated with the medical provider for one (Patient #6) of 11 patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure transfer/discharge summaries were provided to receiving service providers for two (Patients #4 and #8) of 11 patients.

The agency failed to show utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to show conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure an advance notice of discharge was provided prior to being discharged from the agency for one (Patient #6) of seven patients.

The agency failed to ensure individualized patient POC included: 1. Vitamin B12 intramuscular injection treatment intervention due date for one (Patient #1) of seven and; 2. Pain reporting parameters for physician notification for one (Patient #3) of seven.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure a completed transfer/discharge summary was provided to a receiving service provider for one (Patients #7) of seven patients.

The agency failed to ensure physician notification of a missed physical therapy visit for one (Patient #4) of ten patients.

The agency failed to ensure their infection control program included infection surveillance activities and interventions to reduce future infections and promote learning throughout the agency for all employees and 92 current patients.

The agency failed to ensure governing body oversight of the program, the agency budget and the QAPI program for calendar year 2019 for all employees and 92 employees.

The agency failed to ensure medication regimen changes were updated on the medication profile for two (Patients #1 and 7) of ten patients.

The agency failed to notify the physician of changes in health conditions for three (Patients #2, 5, and #6) of ten patients.

The agency failed to ensure a physical therapy evaluation was provided as ordered on the POC for one (Patient #5) of ten patients.

The agency failed to: 1) develop policies, procedures and a resolution process for patient problems or situations; 2) allow patient/family opportunity to resolve the problem prior to discharge; 3) document efforts to resolve the problem for one (Pt #3) of four patients.