Carepine Home Health, LLC

The agency failed to provide the patient or their representative with the required discharge and transfer policies upon admission for seven (7) of seven (7) CR reviewed.

The agency failed to utilize data to monitor the effectiveness and safety of services and quality of care and/or identify opportunities for improvement.

The agency failed to conduct TB testing per agency policy for three (3) of five (5) PF reviewed (PF #1, 2, and 4).

The agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for five (5) of seven (7) CR reviewed (CR#1, 2, 3, 4, and 5).

The agency failed to document physician notification and/or obtain a verbal order to amend frequencies for missed visits for four (4) of seven (7) CR reviewed.

The governing body failed to assume full legal authority and responsibility for the agency's overall management and operation, and the provision of all home health services by not having an on-site full-time administrator, alternate administrator, and clinical manager at this location.

The agency failed to follow its policy to develop and maintain an emergency preparedness plan training and testing program that was reviewed and updated at least annually.

The agency failed to provide documentation of an annual competency evaluation for four (4) of five (5) PF's reviewed, (PF #1, 3, 4, and 5); and failed to provide documentation of an annual performance evaluations for four (4) of five (5) PF's reviewed, (PF #1, 3, 4, and 5).