Bethlehem Home Health Care, Inc

Emergency Preparedness (EP) Plan, and interview, the home health agency (HHA) failed to establish an emergency preparedness program to meet the federal, state, and local emergency preparedness program requirements.

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information.

The agency failed to ensure that a complete and accurate patient specific comprehensive assessment was completed for each patient.

The agency failed to meet the requirements of 484.58 Condition of Participation: Discharge Planning, when the agency: - Failed to implement an effective discharge planning process (G562); and - Failed to document/send all necessary medical information to the receiving facility or health care…

The agency failed to: -Ensure each patient received an individualized plan of care which included a description of the patient's risk for emergency department visits and hospital re-admissions and goals identified by the patient (G574); - Ensure drugs, services, and treatments administered only as…

The agency failed to: - Ensure there was evidence that the agency is measuring, analyzing, and tracking quality indicators (G642); - Ensure the agency used data collected to monitor the effectiveness and safety of the services and quality of care and identifying opportunities for improvement…

The agency failed to maintain and document a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of communicable diseases.

The agency failed to meet the requirements for this condition of participation when the agency failed to: - Ensure development and evaluation of the plan or care in partnership with the patient, representative (if any), and caregiver(s) (G708); - Ensure patient and caregiver education (G714); -…

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to ensure a governing body, administrative, and clinical manager oversight to patients resulting in twelve…

The agency failed to: - Ensure a complete discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency within 5 business days of the patient's…

The agency failed to ensure HHA (home health agency) staff meet the required following standards: - The Administrator: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; (ii) Has experience in health service administration, with at least 1 year of supervisory or…

The agency failed to review and update their Emergency Preparedness Plan every two years.

The agency failed to develop emergency preparedness policies and procedures.

The agency failed to ensure each patient had an individualized emergency plan documented as part of the patient's comprehensive assessment in four (Records/Patients #2, #3, #4, and #5) of five cases reviewed.

The agency failed to update emergency preparedness procedure regarding how the agency will follow up with on-duty staff and patients to determine services that are needed and the process for informing State and local officials of any on-duty staff or patients that the agency is unable to contact.

The agency failed to develop an emergency preparedness system of documentation that preserved patient information, protected confidentiality, and secured and maintained the availability of records.

The agency failed to ensure a policy for emergency staffing strategies was developed for the agency's Emergency Preparedness (EP) plan.

The agency failed to develop a comprehensive communication plan that included names and contact information of staff, physicians, and other service provider to be accessed during an emergency.

The agency failed to develop an emergency preparedness communication plan that includes primary and alternate means of communicating with agency staff, and Federal, State, tribal, regional, and local emergency management agencies.

The agency failed to develop an emergency preparedness communication plan that includes a means of providing information about the agency's needs; and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center/designee.

The agency failed to maintain a comprehensive emergency preparedness plan that provides a training and testing program that is reviewed and updated at least every two years.

The agency failed to ensure staff were provided annual Emergency Preparedness (EP) training in five (Employee #1, #2, #3, #4 and #5) of five employee files reviewed.

The agency failed to conduct exercises to test the emergency plan annually and analyze the agency's response to and maintain documentation of all drills, table top exercises, and emergency events, and revise the agency's emergency plan as needed.

The agency failed to ensure that each completed OASIS (Outcome and Assessment Information Set-a required set of assessment data submitted to Medicare and Medicaid Services) assessment was encoded and electronically transmitted within the required 30 days of completion of each patient's…

The agency failed to ensure patients received effective discharge planning in two (Records/Patients #3 and #5) of three discharge records reviewed.

The agency failed to ensure a discharge summary that included all necessary information pertaining to the patient's current course of illness and treatment, post-discharge goals of care and treatment preferences was sent to the patient's health care practitioner to ensure the safe and effective…

The agency failed to provide evidence that the agency was measuring, analyzing, and tracking quality indicators.

The agency failed to provide evidence that collection of quality data was on going to: - Monitor the effectiveness and safety of the services and quality of care; and - Identify opportunities for improvement.

The agency failed to provide evidence that the performance improvement activities were focused on high risk, high volume, or problems-prone areas This deficient practice has the potential to affect the quality of care and safety of all agency patients.

The agency failed to provide evidence of performance improvement activities to track adverse patient events, analyze their causes, and implement preventative actions.

The agency failed to provide evidence that the governing body was responsible for ensuring the agency had an ongoing program for quality improvement and patient safety.

The agency failed to maintain a coordinated agency-wide infection control program that included infection control education for five (Employee #1, #2, #3, #4, and #5) of five employee files reviewed.

The agency failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. This deficient practice has the potential to affect the quality of care to all patients served by the agency.

The agency failed to demonstrate and ensure the governing body had assumed effective oversight responsibility for the operation of the agency.

The agency failed to ensure all documented entries included appropriate authentication that included, the time the plans of care were completed, the plan of care signed by the nurse, plans of care dated by the physician, and time the visits were completed in, but not limited to, two…

The agency failed to ensure that clinical record information was safeguarded against loss or unauthorized use.

The agency failed to show the HHA (home health agency) administrator meets the required following standards: - Is a licensed physician, a registered nurse, or holds an undergraduate degree; and - Has experience in health service administration, with at least 1 year of supervisory or administrative…

The agency failed to show the Physical Therapist had an updated, current license, by the state in which the Physical Therapist is practicing.

The agency failed to update the written notice of patient rights to include the rights of the patient and representative (if any) regarding contact information for the home health agency administrator to receive complaints.

The agency failed to update the written notice of patient rights to include the patient has the right to participate in, be informed about, and consent or refuse care, with respect to completion of all assessments, care to be furnished based on the comprehensive assessment, and expected outcomes.

The agency failed to include the patient has the right to receive all services outlined in the plan of care.

The agency failed to ensure the patient was advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program, the charges of services that may not be covered.

The agency failed to include the patient has the right to receive proper written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care.

The agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week) in the admission folder.

The agency failed to update the written notice of patient rights to include the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides.This deficient practice has the potential to affect all patients served by the agency.

The agency failed to provide written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the agency can no longer meet the patient's needs.

The agency failed to provide written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient or payer can no longer pay for the services.

The agency failed to provide written notice of patient rights to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician and agency agree that the outcomes and goals have been achieved and the patient no longer…

The agency failed to provide written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged.

The agency failed to include that the agency policy for discharge for cause: - Determines that the patient's or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the ability of the agency to operate effectively is…

The agency failed to provide written notice of patient rights to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered.

The agency failed to provide written notice of patient rights to include the agency must make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other person’s in the patient’s home, or situation.

The agency failed to provide written notice of patient rights to include that if the patient is being considered for discharge for cause, the agency must provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care after…

The agency failed to provide written notice of patient rights to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause.

The agency failed to provide written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies.

The agency failed to provide written notice of patient rights to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency ceases to operate.

The agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in four (Records/Patients #1, #3, #4 and #5) of five full records reviewed.

The agency failed to ensure the patient's current health status was assessed and documented in two (Patients/Records #1 and #3) of five records reviewed.

The agency failed to ensure the patient’s medical, nursing, rehabilitation, social, and discharge planning needs were met in three (Records/Patients #1, #3, and #5) of five records reviewed.

The agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in, but not limited to, two (Records/Patients #1 and #2) of two home visit observations.

The agency failed to ensure the comprehensive assessment was updated at discharge that included a summary of the patient’s progress in meeting the care plan goals, in two (Records/Patients #3 and #5) of three discharge records reviewed.

The agency failed to ensure the plan of care (POC) included all of the required elements in, but not limited to, one (Record/Patient #2) of two home visit observations.

The agency failed to ensure staff obtained physician signed plans of care for orders and treatments and verbal or telephone orders in a timely manner which affected two (Records/Patients #4 and #5) of three discharge records reviewed.

The agency failed to ensure that a revised plan of care reflected current information from the patient’s updated and contained information concerning the patient’s progress toward goals, in one (Record/Patient #3) of three discharge records reviewed.

The agency failed to provide the patient/caregiver with a copy of written instructions outlining the patient's medication schedule/ instruction, including the medication's name, dosage, and frequency in one (Record/Patient #2) of two home visit observations.

The agency failed to provide the patient/ caregiver with a copy of written instructions of any treatments being administered by the agency in one (Record/Patient #1) of two home visit observations.

The agency failed to provide in writing the name and contact information of the clinical manager in one (Record/Patient #2) of two home visit observations.

The agency failed to provide evidence of any performance improvement activities that were focused on high risk, high volume, or problems-prone areas.

The agency failed to ensure that skilled professional developed and evaluated the plan of care in partnership with the patient, in two (Records/Patients #3 and #5) of three discharge records reviewed.

The agency failed to ensure that skilled professional services prepared appropriate and timely clinical notes in three (Records/Patients #1, #3, and #5) of five full records reviewed.

The agency failed to ensure staff were provided with agency in-service training in five (Employee #1, #2, #3, #4 and #5) of five employee files reviewed.

The agency was found out of compliance in twelve Conditions of Participation: Reporting OASIS information, patient rights, comprehensive assessment of patients, discharge planning, care planning, coordination of services and quality of care, quality assessment and performance improvement (QAPI)…

The agency failed to ensure an administrator was appointed by and reported directly to the governing body.

The administrator failed to ensure the agency developed personnel policies and provided adequate in-service training to five staff (Employees E1, E2, E3, E4 and E5) of five employee files reviewed.

The agency failed to ensure a qualified, pre-designated person who is authorized in writing by the administrator and the governing body assumes the same responsibilities and obligations as the administrator when the administrator is not available.

The agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge in three (Records/Patients #3, #4, and #5) of three discharge records reviewed.

The agency failed to ensure that OASIS (Outcome and Assessment Information Set, the data collection tool used to collect and report performance data by home health agencies to the Centers for Medicare & Medicaid Services (CMS)) was accurately collected and reported, when the agency failed to: -…

The agency failed to ensure that a complete and accurate patient specific comprehensive assessment was completed for each patient.

The agency failed to: - Include all required items on the individualized plan of care (G574); - Ensure conformance with physician orders (G578); - Include the time verbal orders were received from physicians (G584); - Ensure the individualized plan of care was reviewed and revised by the physician…

The agency failed to: - Ensure that there was evidence that the agency is measuring, analyzing, and tracking quality indicators (G642); - Ensure that the agency used data collected to monitor the effectiveness, safety of services, quality of care and identified opportunities for improvement (G644)…

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of communicable diseases that is an integral part of the agency Quality Assessment and Performance Improvement (QAPI) program (G684).

The agency failed to meet the requirements for the Condition of Participation: Organization and Administration of Services when the agency failed to: - Assume responsibility for all day-to-day operations (G948); - Ensure the availability of a clinical manager during all operating hours (G950); and…

The agency failed to: - Ensure the clinical record contained accurate assessments (G1012); and - Ensure clinical record information was safeguarded against loss or unauthorized use (G1028).

The agency failed to conduct an annual full scale exercise (either community - based or individual, facility - based) to test its emergency preparedness plan.

The agency failed to ensure that each completed OASIS (Outcome and Assessment Information Set-a required set of assessment data submitted to Medicare and Medicaid Services) assessment was encoded and electronically transmitted within the required 30 days of completion of each patient's…

The agency failed to ensure that encoded OASIS (Outcome and Assessment Information Set) data accurately reflected the patient's status in two (Records/Patients #4 and #5) of five applicable cases.

The agency failed to develop a complete/ accurate plan of care (POC) including current physician orders and/or conformance to physician orders for three (Records/Patients #2, #3 and #5) of five records reviewed.

Staff interview the agency failed to provide the patient with written information regarding visit schedules and frequency of visits for all disciplines, patient medication schedule/ instructions, treatments to be administered, other pertinent instruction related to the patient's care and…

The agency failed to provide evidence that quality indicators were measured, analyzed, and tracked as part of an on-going quality assessment and performance improvement (QAPI) program.

The agency failed to provide evidence that the frequency and detail of the quality data collection was approved by the agency's governing body, and that the collection of quality data was ongoing to: - Monitor the effectiveness and safety of services and quality of care; and - Identify…

The agency failed to show that the QAPI committee had conducted at least one performance improvement project (PIP) to reflect the scope, complexity and past performance of the agency's services/ operations with measurable progress achieved.

The agency failed to provide evidence that the governing body was responsible for ensuring an ongoing program for quality improvement and patient safety.

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of infectious and communicable diseases that was part of the agency's quality assessment and performance improvement (QAPI) program.

The agency failed to complete both the written Missouri Home Health Aide Competency Evaluation and basic skills evaluation in one (Employee #1) of one home health aide personnel file reviewed.

The agency failed to ensure that clinical record information was safeguarded against loss or unauthorized use.

The agency failed to ensure that patients or their legal representatives had access to the patient's clinical records within 4 business days in one (Record/Patient #1) of one applicable record.

The agency failed to ensure that a registered nurse (RN) conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of the referral in two (Records/Patients #3 and #5) of five records reviewed.

The agency failed to ensure that the registered nurse (RN) performed an accurate and complete review/ update of all medications the patient was currently using in three (Records/Patients #2, #4, and #5) of five records reviewed.

The agency failed to develop a revised plan of care (POC) to be reviewed by the physician at least once every 60 days in two (Records/Patients #2 and #3) of two applicable patient records reviewed.

The agency failed to develop a complete/ accurate plan of care (POC) in, three (Records/Patients #2, #3 and #5) of five records reviewed.

The agency failed to develop a complete/ accurate plan of care (POC) including current physician orders and/or conformance to physician orders for three (Records/Patients #2, #3 and #5) of five records reviewed.

Staff interview the agency failed to ensure that the plan of care (POC) was reviewed at least every 60 days for one (Record/Patient #5) of five records reviewed.

The agency failed to provide the patient/ caregiver with a copy of written instruction outlining the visit schedule, including the frequency of visits in two (Records/Patients #2 and #3) of three home visit observations.

The agency failed to provide the patient/caregiver with a copy of written instructions outlining the patient's medication schedule/ instruction, including the medication's name, dosage, and frequency in two (Records/Patients #2 and #3) of three home visit observations.

The agency failed to provide the patient/ caregiver with a copy of written instructions of any treatments being administered by the agency in two (Records/Patients # 2 and #3) of three home visit observations.

The agency failed to provide in writing the name and contact information of the clinical manager in one (Record/Patient # 2) of three home visit observations.

The agency failed to provide evidence of any performance improvement activities that were focused on high risk, high volume, or problem-prone areas.

Therapy contract review and interview the agency failed to ensure that physical therapy assistant (PTA) services were provided under the supervision of the physical therapist (PT) in one (Record/Patient #5) of one applicable records reviewed.

The agency failed to ensure that the registered nurse (RN) or other appropriate skilled professional completed home health aide (HHA) supervisory visits within the required time frame for one (Record/Patient #5) of one applicable record where HHA services were ordered.

The agency administrator failed to effectively assume responsibility for the overall operations, including supervisory and administrative functions of the provider #26-7605 when the administrator failed to: - Ensure that a clinical manager was available during all working hours; and - Ensure that…

The agency failed to ensure that a clinical manager (CM, supervising nurse) was available during all operating hours.

The agency failed to develop a revised plan of care to be reviewed by the physician at least once every 60 days in three (Records/Patients #1, #2 and #3) of three patient records reviewed.

The agency failed to ensure that the clinical record contained accurate assessments of the patient in two (Records/Patients # 4 and #5) of five patients reviewed.

The agency failed to ensure that contracted staff completed infection control education before staff was allowed to perform their duties initially upon hire in one applicable case (Employee E 2).

The agency failed to ensure that the registered nurse (RN) prepared a complete home health aide (HHA) assignment in one (Record/Patient #1) of two patients receiving HHA services.

The agency failed to ensure that the registered nurse (RN) performed an accurate and complete review/update of all medications the patient was currently using in, but not limited to, two (Records/Patients #3 and #5) of five cases reviewed.

The agency failed to ensure that a complete plan of care (POC) was developed in, but not limited to, three (Records/Patients #1, #3, and #4) of five cases.

The agency failed to notify the physician of changes in the patient's condition to determine if changes in the plan of care (POC) were needed in, but not limited to, two (Records/Patients # 2 and #4) of five cases reviewed.

The agency failed to provide the patient with a copy of written instructions outlining the patient's medication schedule/instructions, to include the names, dosages, frequency and which medications would be administered by agency personnel in, but not limited to, two (Records/Patients #2 and #3) of…

The agency failed to ensure that the registered nurse (RN) followed the plan of care in, but not limited to, one (Record/Patient #3) of five records reviewed related to patient assessments.

The agency failed to ensure that contracted occupational therapy staff completed agency inservice training/education in one applicable case (Employee E 2).

The agency failed to ensure that the home health aide (HHA) documented/provided care as directed on the aide assignment sheet in one (Record/Patient #5) of two applicable records.

The agency failed to ensure the accuracy of home health aide (HHA) supervisory visits documented by the registered nurse (RN) in one (Record/Patient #5) of two applicable cases.

The agency failed to ensure that contracted staff had a criminal background check performed in one (Employee E2) of three employee files reviewed.