Care Essentials Home Health

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the…

The agency failed to ensure the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance when: 1. Based on interview, and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2023 and…

The agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2023 and 2024 years reviewed, in a universe of 96 patients.

The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2023 and 2024 years reviewed, in a universe of 96 patients.

The agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2023 and 2024 years reviewed, in a universe of 96 patients.

The agency failed to develop and implement a procedure to provide for emergency staffing during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients.

The agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the 2023 and 2024 years…

The agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2023 and 2024 years reviewed, in a universe of 96 patients.

The agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “boots on the…

The agency failed to transmit OASIS (Outcome and Assessment Information Set-patient-specific information used in Medicare to determine reimbursement and measure quality) data (facts collected together for analysis) from patient assessments was transmitted to CMS (Centers for Medicare and Medicaid…

The agency failed to ensure a Registered Nurse (RN) updated the comprehensive assessment for one of seven sampled patients (Patient 1) when Patient 1's right ankle surgical wound had healed and the continued need for the protective orthopedic (the branch of medicine concerned with conditions…

The agency failed to ensure upon transfer and/or discharge all necessary medical information pertaining to the patient’s current course of illness and treatment, was sent to the receiving healthcare facility and healthcare practitioner for two of seven sampled patients (Patients 6 and 7).

The agency failed to ensure each patient received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, for one of seven sampled patients (Patient 1) when Patient 1's right ankle surgical wound was enclosed in a…

The agency failed to maintain an infection control program that was integrated into the agency’s Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, from January 3, 2024, to…

The agency failed to ensure a Registered Nurse (RN) provided a Certified Home Health Aide (CHHA) written patient care instructions for one of seven sampled patients (Patient 1) when the CHHA's care plan did not contain special instructions on how to care for Patient 1's orthopedic (the branch of…

The Governing Body (GB) failed to operate and manage the agency from January 1, 2023, to February 27, 2025, in a universe of 96 patients, when: 1. The agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2023 and 2024 years reviewed, in a universe of…

The agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for four of seven sampled patients (Patients 1, 2, 5, and 6).

The agency failed to ensure the patients' individualized plans of care contained all the required elements for two of seven sampled patients (Patients 3 and 5) when: 1. For Patient 3: the Physical Therapy (PT) and Occupational Therapy (OT) visit frequencies were not in the plan of care and there…

The agency failed to obtain physician’s orders for one of seven sampled patients (Patient 1) when a Registered Nurse (RN) removed surgical staples from Patient 1’s right ankle without a physician’s order.

The agency failed to conduct an on-site Certified Home Health Aide (CHHA) supervisory visit every 14 days for two of seven sampled patients (Patients 1 and 4).

The agency failed to ensure the clinical record contained a completed discharge summary sent to the primary care practitioner within five business days of the patient’s discharge and a completed transfer summary was sent within two business days of becoming aware of a planned transfer to a…

The agency failed to ensure that the home health aide care plan was specific to the needs of the patient when a Licensed Vocational Nurse (LVN – provides patients with quality care and comfort measures under the supervision of a registered nurse), who was performing the duties of the Home Health…

The agency failed to ensure a review of the medications was conducted for patients in the home for one (1) of ten (10) sampled patients (Patient 1) For Patient 1, one (1) medication, Glimepiride, on the medication profile (MP- a current list of all medications prescribed for a specific patient)…

The agency failed to ensure that the Condition of Participation: E 0001 403.748 Establishment of the Emergency Program (EP) was in compliance as follows: 1.Based on interview and record review, the agency failed to ensure the emergency preparedness program plan was updated and reviewed every 2…

The agency failed to ensure the Condition of Participation: G510 484.55 Comprehensive Assessment of Patients was in compliance when: Based on interview and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for two of ten sampled patients…

This Condition is not met as evidenced by: The agency failed to ensure that the Condition of Participation: G640 484.65 Quality Assessment and Performance Improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to track, measure and analyze…

The agency failed to ensure the emergency preparedness program plan was updated and reviewed every 2 years.

The agency failed to have strategies for addressing emergency events identified by the risk assessment.

The agency failed to have a written emergency plan which addresses the agency's patient populations that would be at risk during an emergency event, services that the agency would be able to provide during an emergency and any plans to address services needed that cannot be provided by the agency…

The agency failed to collaborate with local, Regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts to maintain an integrated response during an emergency.

The agency failed to develop and implement emergency preparedness policies and procedures based on the emergency plan, risk assessment, and the communication plan.

The agency failed to have Individual, natural or man made disaster plans for each patient in the comprehensive patient assessment.

The agency failed to develop a policy and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process in an emergency.. This failure had the potential to place the agency's patients at risk when…

The agency failed to develop policies and procedures when 1.The agency did not have a transfer arrangement with the local health care facilities to ensure patient care is continued during an emergency.

The agency failed to develop and implement emergency preparedness policies and procedures, based on the emergency plan, risk assessment, and the communication plan that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records…

The agency failed to develop policies and procedures for 1. The use of volunteer support during an emergency from individuals with varying levels of skills and training.

The agency failed to develop policies and procedures for a written emergency communication plan that contains how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments.

The agency failed to have a communication plan with names and contact information for Staff, Entities providing services under arrangement, Patients’ physicians and Volunteers.

The agency failed to have an emergency preparedness plan which included contact information for Federal, State, tribal, regional, local emergency preparedness staff, and other sources of assistance.

The agency failed to have an emergency preparedness plan to include a Primary and alternate means for communicating with Facility staff and Federal, State, tribal, regional, and local emergency management agencies.

The agency failed to develop policies and procedures for sharing information and medical documentation for patients under the agency care with other health providers to maintain the continuity of care.

The agency failed to develop policies and procedures for providing information about the agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee during an emergency.

The agency failed to develop and maintain an emergency preparedness training and testing program.

This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency.

The agency failed to participate in a community based, full-scale exercise, conduct an annual individual, facility-based functional exercise, conduct a mock disaster drill, and conduct a tabletop exercise.

The agency failed to track, measure and analyze quality indicators (a measurable element of the agency’s practice that can be used to assess the quality of care provided) in order to assess the agency’s processes of care, services and operations for 10 of 10 sampled patients (1,2,3,4,5,6,7,8,9 and…

The agency failed to use quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data to improve the quality of the agency’s services.

The agency’s Governing Body (GB) failed to ensure opportunities for improvement addressing gaps in systems or processes by developing and implementing an improvement or corrective plan and continuously monitoring plan for effectiveness of interventions for ten of ten sampled patients…

The agency failed to provide Quality Assessment and Improvement (QAPI) program which would lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of patients for ten of ten sampled patients (Patient 1,2,3,4,5,6,7,8,9, and 10) in a…

The agency failed to conduct and document Performance Improvement Projects (PIP), the agency could not provide data giving the reasons for conducting the PIP and measurable goals to show progress achieved for ten of ten patients (Patient 1,2,3,4,5,6,7,8,9, and 10) in a universe of 84 patients . The…

The agency’s Governing Body (GB) failed to ensure a QAPI plan was implemented maintained and evaluated for effectiveness, for ten of ten patients (Patient 1,2,3,4,5,6,7,8,9, and 10) for a universe of 84 patients.

The agency failed to provide the names, addresses, and telephone numbers of federally and state-funded entities for one of 10 Sampled Patients (Patient 4) This failure resulted in Patient 4 not having the names, addresses, and telephone numbers of federally and state-funded entities available for…

The agency failed to provide skilled nursing visits for 5 days during the week of (12/27/21 to 1/2/22) in one of nine sampled patients.

The agency failed to focus on high risk, high volume, problem -prone areas, or Adverse patient events by the Quality Assessment and Performance Improvement (QAPI) program for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) in a universe of 84 patients.

The agency failed to consider incidence, prevalence, and severity of problems in areas and other events which are negative and unexpected impacting the patient’s plan of care for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) for a universe of 84 patients.

The agency failed to provide a Quality Assessment and Performance Improvement (QAPI) program which would lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of patients for ten of ten sampled patients (Patient 1,2,3,4,5,6,7,8,9…

The facility failed to implement their performance policy and procedure for a Licensed Vocational Nurse (LVN 1) when LVN 1 did not received her annual performance evaluation for 2021. This failure had the potential not to identify areas requiring performance improvements when delivering patient…

The home health agency Licensed Vocational Nurse ( LVN -responsible for rendering basic nursing care) providing the skills of the home health aide (HHA- provides basic personal care to patients) missed four SN need for care or treatment that can only be performed by a licensed nurse) visits, not…

The agency failed to provide equipments to adequately meet the needs of the patient at her place of residence when; patient was not provided with a cane, walker, and shower chair, as identified needed equipment during the initial assessment and as ordered by the physician.