Carebridge Home Health

The agency failed to develop and maintain an emergency preparedness program that includes an emergency plan, policies, procedures, communication plan, training, and testing.

The agency failed to maintain compliance with this condition of participation.

The agency failed to maintain compliance with this condition of participation.

The agency failed to maintain compliance with this condition of participation.

The agency failed to develop and maintain an emergency preparedness plan based on both an agency-based and community-based risk assessment, resulting in a lack of direction and duties for agency personnel in the event of an actual emergency or disaster.

The agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan.

The agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws, resulting in the facility's inability to ensure the coordination of patient care in the event of an actual emergency.

The agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan.

The Agency failed to ensure that the skilled nurse notify the physician of blood pressure findings that fell outside the parameters ordered in the patient’s plan of care in 1 (MR# 1) of 4 records reviewed with diagnoses of high blood pressure, and failed to ensure the skilled nurse followed…

The agency failed to develop, implement, evaluate, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2019 through 2022. Resulting in no documented evidence of the agency's efforts to monitor agency processes and improve patient outcomes for the 23…

The agency failed to collect and utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program, resulting in the potential for poor quality outcomes for the 23 patients admitted to the agency in the past 12 months.

The agency failed to ensure to conduct performance improvement projects from 2019 through 2022, resulting in no coordinated efforts to improve patient outcomes for the 23 patients admitted to the agency in the past 12 months.

The governing body failed to ensure the agency developed, implemented, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2019 through 2022. Resulting in a lack of oversight by the governing body to ensure patient safety and quality of care…

The agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program in 2019 through 2022, resulting in the potential…

The agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the agency contracting for all patient services.

The Agency failed to ensure patients received contact information for the Agency Administrator including the Administrator's name in order to receive complaints potentially affecting the ability to voice complaints for all 23 patients serviced by the Agency in the past 12 months.

The Agency failed to provide patients with the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the areas in which the patients reside: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability…

The agency failed to ensure the initial assessment visit was conducted on the date ordered by the physician for 1 of 1 (MR#4) records reviewed with a specific date ordered by the physician and failed to ensure the initial assessment visit was conducted within 48 hours of referral for 4 of 6 (MR# 2…

The Agency failed to ensure the comprehensive assessment included a review of all medications prescribed to the patient and include those medications in the medication reconciliation in its entirety for possible adverse effects or drug interactions in 4 (MR#’s 1, 3, 5, and 6) of 7 sample records…

The Agency failed to ensure the plan of care included all treatments, individualized, patient-specific, measurable outcomes and goals in 4 of 7 (MR# 2, 3, 4, and 6) records reviewed, resulting in a lack of patient inclusion in care planning and potential for unmet patient care needs.

The Agency failed to ensure that skilled nursing and physical therapy followed the visit frequency ordered by the physician as indicated in the patient plan of care in 3 (MR# 1, 5, and 6) of 7 sample records reviewed, resulting in the potential for physical decline and unmet patient care needs.

The Agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 7 (MR# 1, 2, 3, 4, 5, 6, and 7) of 7 discharge records reviewed; resulting in a lack of information to ensure continuity of care for the 46 patients discharged from the agency…

The agency failed to update its Emergency Preparedness plan to include plans to address the global pandemic (COVID-19), resulting in staff being ill-prepared to address the crisis and the potential for poor patient outcomes for patients serviced from 1/1/2020 to 6/4/2020. Findings include: On…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening visitors and all 18 staff employed by this agency, resulting in the potential development and spread of a contagious viral…

The Agency failed to provide documented evidence that COVID-19 infection control education was provided to all 18 staff employed by the agency staff, resulting in the potential for the development and spread of the COVID-19 infection to staff and all patients serviced by this agency from 1/1/2020…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 6 records (MR's #1, 2, 3, 4, 5, 6), from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for…

The agency failed to ensure the plan of care was patient specific and individualized to the patient's identified needs, covered all pertinent interventions with reportable parameters for 4 of 7 records reviewed (MR#'s 4, 5, 1, 2), resulting in patients not receiving care specific to their needs and…

The Agency failed to ensure the physician was promptly notified of the patient's elevated blood pressure or pain for 2 patient's (MR #1, and 6) with a diagnosis of hypertensive heart disease with heart failure and low back pain, of a total of 7 records, resulting in untreated health issues and the…

The Agency failed to ensure the clinical record was complete and included a discharge summary and comprehensive assessment that accurately captured the status of the patient at the time of discharge for 3 records (MR's #1, #2, #6) and failed to include a transfer summary for 1 of 1 patient (MR #2)…