Caring Choice Network

The home health 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, resulting in the potential for inappropriate, unprepared…

The agency failed to ensure the plan of care included all safety measures to prevent injury in 5 of 7 records (P-1, 3, 4, 5, 6) from a total of 7 records reviewed.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 2 of 7 (MR's #1 and 3) records reviewed, resulting in incomplete clinical information to aid in determining the needs of this patient and for measuring the patient's progress toward…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required in 7 of 7 sampled records reviewed (MR's #1, 2, 3, 4, 5, 6 and 7), resulting in the potential for…

The Agency failed to ensure a discharge summary was complete, that provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 2 (MR# 3 and 4), of 2 closed records, from a total of 7 records reviewed…

The Agency failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document their efforts in contacting these officials to engage in…

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, objective baseline data for future assessments, and ascertained the patient's immediate care…

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

The agency failed to ensure their Quality Assessment and Performance Improvement (QAPI) program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care in 2018, resulting in the potential for poor patient outcomes for the…

The Agency failed to include a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document their efforts in contacting these officials to engage in…

The Agency (HHA) failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment for 8 of 8 records (MR #1, 2, 3, 4, 5, 6, 7, and 8) for Emergency Preparedness from a total of 8 sampled records reviewed, resulting in the potential for negative patient…

The agency failed to implement in the Emergency Preparedness policy the use of volunteers and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, and regional emergency preparedness staff and other sources of assistance, resulting in the lack of essential information in the event of an actual…

The facility failed to ensure the emergency preparedness communication plan included a means for sharing information about the facility's occupancy, needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, resulting in the lack of…

The agency failed to conduct exercises to annually test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the agency's response to and…

The agency failed to ensure the patient's family or guardian was notified of their right to exercise the patient's rights in one of two records reviewed in which the patient had diagnoses of dementia or a cognitive impairment and signed their own consents (MR#3) of a total sample of 8 records…

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that included an assessment summary, accurately reflected the patient's current health status, past medical history, history of events leading to home care, objective baseline data for future assessments, required dates…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 8 of 8 records reviewed (M.R.#s 1, 2, 3, 4, 5, 6, 7, and 8), resulting in the potential for a plan of care not meeting the patient's needs.

The agency failed to ensure their Quality Assessment and Performance Improvement (QAPI) program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care in 2018, resulting in the potential for poor patient outcomes for the…

The Home Health Agency (HHA) failed to develop a Performance Improvement Plan/activities, as part of the agency's Quality Assessment Performance Improvement (QAPI) program to track the adverse patient events, analyze the cause, and implement preventive actions/interventions, resulting in the…

The Home Health Agency (HHA) failed to develop a QAPI Quality Assessment Performance Improvement (QAPI) program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2017 and 2018, resulting in the…

The Governing Body failed to be responsible for ensuring the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, resulting in the potential to adversely affect the quality of care for the…

The agency failed to ensure home health aide (HHa) skills were evaluated by observing the aide's performance of the tasks with a patient prior to performing services as an HHa for the agency for 1 of 1 aides (HHa#1), from a total sample of 1 aide personnel files reviewed, resulting in the potential…

The Agency (HHA) failed to ensure that all entries in the medical record were legible in three of eight records in which Skilled Nursing (SN) services were provided from a total sample of 8 sampled records reviewed (MR#s 1, 2, and 3), and failed to authenticate the records with signatures and…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy, failed to document the findings of the drug regime review, and failed to ensure the physician was notified of the findings in 1 record…

The registered nurse failed to document on the comprehensive assessment the primary caregivers' willingness, ability, their availability and scheduled hours and days to provide care for patients in 3 of 8 records reviewed (MR#s 1, 2, and 3) for a potential of an unavailable caregiver to provide…

The agency failed to document the patient's representative (if any) in the comprehensive assessment in 3 of 8 records reviewed (MR#s 1, 2, and 3) of a total sample of 8 records reviewed, resulting in lack of contact information to communicate the needs of the patient if needed.

The agency failed to ensure the plan of care (POC) was individualized to the specific needs of the patient and included safety precautions in 2 of 3 records reviewed with a diagnosis of diabetes (MR#s 4 and 7) and one record (MR#3) that was not individualized to the patient's specific needs from a…

The agency failed to ensure the skilled nurse performed complete assessments and re-assessments of the patient's health status including objective measurements and location of edema/fluid retention, in 2 of 8 records reviewed (MR#s 2 and 3) in which nursing services were provided.

The agency failed to ensure that skilled services were administered in accordance with the physician's orders and the plan of care (POC) in 3 (MR#s 2, 3 and 4) of 8 sampled patient records reviewed for skilled services, resulting in the potential for decline in physical functioning, unidentified…

The Agency (HHA) failed to ensure the discharge summary was complete, detailed the course of care provided with responses, and provided the patient's current health status at the time of discharge and progress toward goals in 1 (MR# 3) of 3 closed/discharged records, from a total of 8 records…