Care Home Health Agency, LLC

The Agency failed to develop an emergency preparedness plan that must be reviewed, and updated at least every 2 years (See E 0004); failed to develop an emergency preparedness plan that was based on both a facility and community-based all-hazards risk assessment (See E 0006); failed to develop and…

The Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every two years, resulting in Agency personnel not having updated and approved emergency procedures in the event of an actual emergency or disaster.

The Agency failed to develop an Emergency Preparedness Plan that was based on both a facility and community-based all-hazards risk assessment, resulting in the potential to negatively affect the health and safety of all future patients that will be serviced by this Agency in the event of an…

The Agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws, and must be reviewed and updated at least every 2 years, resulting in the Agency's inability to ensure the coordination of patient care in the event of an actual…

The Agency's Emergency Preparedness Plan failed to ensure all staff including contracted staff, received initial emergency preparedness (EP) training for 5 (Staff A, C, D, E, and F) of 6 personnel files reviewed, and failed to ensure EP training was provided at least every two years for 4 (Staff A…

The Governing Body failed to ensure the agency had an ongoing and functioning Quality Assessment and Performance Improvement (QAPI) program, resulting in the potential to adversely affect the quality of care for all patients serviced by this agency.

The agency failed to ensure annual infection control education was provided to all staff employed or contracted by the agency, resulting in the lack of knowledge and training regarding current infection prevention/treatment practices in the home setting.

The agency failed to ensure that 1 (P-3) of 7 records reviewed, were included in the planning of their care, including the disciplines that will furnish the care and the frequency of visits, resulting in the lack of participation in planning, the potential for missed visits, and unmet care needs.

The Agency failed to ensure the measurable outcomes and goals instituted in the plan of care (POC) had been achieved and failed to ensure blood oxygen safety parameters were obtained and assessed before discharging the patient from home care in 1 (P-7) of 7 closed records reviewed in total…

The agency failed to ensure the initial assessment visit was completed within 48 hours of the referral in 2 (P-3, P-4) of 7 records reviewed, resulting in a delay in determining the immediate care and support needs for these patients.

The Agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission, including the events that led to the need for home care referral for 2 (P-4, P-7) of 7 records reviewed in total, resulting in incomplete clinical information…

The agency failed to perform a comprehensive drug review in 7 records (P-1, 2, 3, 4, 5, 6, and 7) from a total of 7 records reviewed, resulting in the potential for harmful medication effects for the agency's patients.

The Agency failed to ensure the goals on the Plan of Care (POC) were measurable in 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, and failed to incorporate safety parameters in which to notify the physician regarding clinical results that would be considered potentially dangerous, resulting in…

The agency failed to ensure treatments were provided in accordance with a physician's order in 1 (P-4) of 7 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure speech language pathology (SLP) services were provided as ordered by the physician in the plan of care (POC) for 1 of 7 (P-1) records reviewed, resulting in the potential for physical decline and negative patient outcomes.

The agency failed to ensure skilled nursing communicated assessment findings with the physician for 2 (P-3, P-4) of 7 records reviewed, resulting in the potential for poor patient outcomes.

The agency failed to have all agency staff, participate in agency sponsored in-services, resulting in the potential for poor patient outcomes.

The Agency failed to provide evidence of a discharge summary in the medical record which would be sent to the physician within 5 business days of the patient's discharge for 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 closed records reviewed out of a total sample of 7 records, resulting in the…

The Agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to…

The agency failed to ensure that the Home Health Agency was functioning under the supervision of an Administrator who was present and responsible for all day-to-day operations (G948); the Administrator failed to ensure the Clinical Manager was available during all operating hours (G950); failed to…

The Agency failed to ensure that the home health agency was functioning under the supervision of an Administrator who was present and responsible for all day-to-day operations resulting in the potential for unmet patient care needs for all patients currently serviced by this agency.

The Administrator failed to ensure the Clinical Manager was available at all times during operating hours, resulting in the lack of clinical supervision and oversight, and the potential for unmet care needs for all patients serviced by this agency.

The Agency failed to ensure a qualified alternate, was available and authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions and unmet patient care needs for all patients serviced by…