Care Plus Homehealth Care Inc

The agency failed to ensure the patients received the frequency of services as ordered by physician for 1 of 2 active clinical records reviewed with only HHA services.

The agency failed to ensure infection control practices were upheld for hand hygiene practices for 1 of 1 home visit with a HHA (HHA 1) providing care.

The agency failed to ensure the POC was individualized, included all DME and supplies, medication route and indication, hospitalization and emergency room risk, and instructions for a timely discharge for 4 of 7 active clinical records reviewed.

The agency failed to ensure they received orders from the physician to provide services before the physician signed the POC for 1 of 2 active clinical records reviewed with patients receiving HHA services.

The agency failed to ensure the physician was notified of the patient going to the hospital for 1 of 1 active clinical records reviewed with a patient going to the hospital.

The agency failed to ensure the HHA performed tasks within their scope for 1 of 1 home visit with a HHA.

The agency failed to ensure infection control practices were upheld according to the agency's policy, as observed by Registered Nurse (RN) #1 during 1 of 3 home visits for hand hygiene and the Agency for the proper disposal of biohazardous waste.

The agency failed to ensure all employee COVID vaccination records and all patient clinical records were stored safely as noted over 2 of 2 survey days.

The agency failed to ensure the privacy of patient and employee records as noted over 2 of 2 survey days.

The agency failed to ensure all medications were listed on the plan of care for 1 of 1 active patients receiving an intravenous infusion.

The agency failed to ensure the plan of care included all medications and treatments for 1 of 1 patients receiving intravenous therapy.

The agency failed to provide the agency’s Clinical Manager’s name and contact information to the patients in 3 of 3 patients with home visits (Patients: #1, 2, and 3) with the potential to affect all patients receiving services from this agency.

The agency failed to ensure patient education was comprehensive for 1 of 1 active patients receiving an intravenous (IV) infusion.

The agency failed to show measurable improvement in health outcomes, patient safety, quality of care and failed to measure, analyze, and track quality indicators of adverse patient events.

The agency failed to obtain and utilize quantity indicator data derived from OASIS [outcome and assessment information set], and additional related patient data to monitor safety and effectiveness and quality of services provided for 1 of 1 agency.

The agency failed to identify and implement for QAPI [quality assurance and performance improvement] and PIP [performance improvement program] program for high risk, high volume or problem-prone patient areas for 1 of 1 agency.

The agency failed to ensure a program for quality assessment and performance was implemented, maintained and evaluated for the agency effectiveness by the governing body for 1 of 1 agency.

The agency failed to ensure all staff followed infection control policies for 2 of 2 home visits observed (#3, 5 ).

The agency failed to show measurable improvement in health outcomes, patient safety, quality of care and failed to measure, analyze, and track quality indicators of adverse patient events.

The registered nurse failed to identify patient safety measures following back surgery for the assigned Home Health Aides (HHA) for 1 of 1 aide care plans reviewed for safety measures following back surgery (#7).

The agency failed to ensure that Governing Body documentation contained bylaw reviews, budget approvals, and quality assessment and performance improvement (QAPI) data for 1 of 1 agency.

The registered nurse (RN) failed to complete the recertification assessment including date and time within the last 5 days of the certification period for 1 of 8 records reviewed (#5).

The registered nurse (RN) failed to identify patient strengths, goals and care preferences and the patient's progress toward those goals for 6 of 8 records reviewed.

The registered nurse (RN) failed to ensure the comprehensive assessment contained an accurate review of medications for 4 of 8 records reviewed (#1, 2, 3, 4).

The registered nurse failed to identify availability of caregiver assistance for 1 of 8 records reviewed (#3).

The registered nurse (RN) failed to accurately complete the plan of care (POC) to ensure all diagnoses were accurate and included for 1 of 8 records reviewed (#1 ) all diet orders were identified for 1 of 8 records reviewed (#1), all treatments regarding catheter care for 1 of 1 records reviewed…

The agency failed to ensure that a medication list was put into layman's terms that were easy for the patient to understand for 2 of 2 home visits conducted (#3, 5).

The agency failed to identify and focus the QAPI [quality assurance and performance improvement] and PIP [performance improvement program] programs on high risk, high volume or problem-prone patient areas for 1 of 1 agency.

The home health aide (HHA) failed to follow the assigned HHA care plan for 1 of 8 records reviewed (#7).

The agency failed to ensure the appointments of administrative staff were appointed by the Governing Body in writing for 1 of 1 agency.