Caring Home Health Agency, LLC

The agency failed to ensure the administrator’s name and contact information related to complaint and grievance procedures for the agency was a part of the admission packet information for all patients.

The agency failed to ensure a recertification (updated comprehensive [OASIS]) assessment was completed for six (Patients #1, 2, 3, 4, 5 and #9) of nine patients.

The agency failed to ensure development, implementation and update of individualized patient POCs by the designated administrator/clinical manager (Staff B) for the agency for seven (Patients #1, 2, 3, 4, 5, 6 and #9) of nine patients and all employees.

The agency failed to ensure development of an episodic Plan of Care after a comprehensive OASIS assessment for seven (Patients #1, 2, 3, 4, 5, 6 and #9) of nine patients.

The agency failed to ensure evidence of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure its infection control program included surveillance monitoring and reporting and was included in QAPI program activities for all patients and staff.

The agency failed to ensure governing body oversite of management and operations of the agency for provisions of care and services, patient safety, budget planning, allocation of resources, QAPI program planning and annual agency program evaluation for calendar years 2022 and 2023 for all patients…

The agency failed to ensure a facility and community-based risk assessment (All Hazards Risk Assessment) was developed and implemented for all patients and employees.

The agency failed to ensure development, implementation and maintenance of processes and contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees.

The agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff and contracted service providers contact information for the agency for all patients and staff.

The agency failed to ensure: 1. An emergency preparedness testing and training program was developed, implemented and reviewed/updated at least annually for all patients and employees and; 2. An after action report was documented after each drill, exercise or plan activation event for all patients…

The agency failed to ensure development, implementation and update of individualized patient POCs by the designated administrator/clinical manager (Staff B) for the agency for seven (Patients #1, 2, 3, 4, 5, 6 and #9) of nine patients and all employees.

The agency failed to ensure a transfer/discharge summary was completed at the time of patient transfer/discharge for three (Patients #3, 7 and #8) of nine patients.

The agency failed to ensure development of an episodic certification Plan of Care for seven (Patients #1, 2, 3, 4, 5, 6 and #9) of nine patients.

The agency failed to ensure evidence of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure utilization of OASIS quality indicator source data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI Program activities that included self-monitoring efforts and opportunities that tracked adverse events, analyzed causes and implemented actions to identify problems to improve care, services and operations for all patients and…

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities which included sources of data, analysis of data and implementation of actions which tracked efforts toward improvement of care and services for all patients and employees.

The agency failed to ensure its infection control program included surveillance monitoring and reporting; and was included in QAPI program activities for all patients and staff.

The agency failed to show infection control education was: 1. Included in QAPI activities; 2. Showed interventions to reduce future infections; and 3. Provided and/or maintained infection control education for all patients and employees.

The agency failed to ensure governing body oversite of management and operations of the agency for provisions of care and services, patient safety, budget planning, allocation of resources, QAPI program planning and annual agency program evaluation for calendar years 2022 and 2023 for all patients…

The agency failed to ensure governing body fiscal planning and oversite of an operating budget and capital expenditure plan for calendar years 2022 and 2023 for all patients and employees.

The agency failed to ensure the administrator’s name and contact information related to complaint and grievance procedures for the agency was a part of the admission packet information for all patients.

The agency failed to ensure patients’ rights to have completed assessments, participate in the establishment and revision of a plan of care and be informed of disciplines to provide services with expected frequencies of visits for seven (Patients #1, 2, 3, 4, 5, 6 and #9) of nine patients.

The agency failed to ensure OSDH complaint hotline contact information was included as a part of the agency’s grievance and complaint procedures for all patients.

The agency failed to ensure a recertification (updated comprehensive [OASIS]) assessment was completed for six (Patients #1, 2, 3, 4, 5 and #9) of nine patients.

The agency failed to ensure a discharge oasis was completed by the agency for one (Patients #8) of nine patients.

The agency failed to ensure an individualized patient POC included weight reporting parameters for one (Patient #2) of nine patients.

The agency failed to ensure resumption of care SN visit was ordered by the physician for one (Patient #3) of nine patients.

The agency failed to ensure timely notification and physician opportunity to review and revise individualized POCs every 60 days for eight (Patients #1, 2, 3, 4, 5, 6, 8 and #9) of nine patients.

The agency failed to ensure a designation of the clinical manager and/or supervising RN contact information for the agency was included in patient information packet for all patients and employees.

The agency failed to ensure SN conducted visit frequency as ordered on the POC for nine (Patients #1, 2, 3, 4, 5, 6, 7, 8 and #9) of nine patients.

The agency failed to ensure governing body appointment of an administrator for the agency effecting all patients and employees.

The agency failed to ensure development, implementation and update of individualized patient POCs by the designated administrator/clinical manager (Staff B) for the agency for seven (Patients #1, 2, 3, 4, 5, 6 and #9) of nine patients and all employees.

The agency failed to ensure an all hazard risk assessment identified the agency and completion date for 45 patients and all staff members.

The agency failed to ensure an Emergency Preparedness Communication Plan included required contact information related to the patients and staff members of the agency which had the potential to cause increased havoc during an emergency situation for all agency patients and staff.

The agency failed to ensure emergency preparedness disaster table top exercises and drills were conducted for fiscal years 2019 and 2020 for all patients and staff members.

The agency failed to notify the physician of: 1. a missed PT visit for one (Patient #1) and; 2. missed SN visits for four (Pt's #2, 3, 5 and #6) of seven patients.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 45 patients and all employees.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for 45 patients and all employees.

The agency failed to ensure a comprehensive infection control program for 45 patients and all employees.

The agency failed to show infection control education was: 1) included in QAPI activities; 2) showed interventions to reduce future infections; and 3) provided and/or maintained for all patients and employees.

The agency failed to ensure required home health aide annual in-service training hours were completed for one (Staff E) of five personnel records reviewed.

The agency failed to ensure governing body oversite of: 1. patient centered QAPI Program and; 2. operating budget and allocation of resources for calendar years 2019 and 2020 for all patients and staff.

The agency failed to ensure notice of non-medicare coverage was provided prior to discharge from agency services for one (#2) of seven patients.

The agency failed to ensure medication embedded wound care supplies were included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for one (Patient #6) of seven patients.

The agency failed to ensure: 1. an occupational therapy evaluation was conducted for one (Patient #1) and; 2. a physical therapy evaluation was conducted for one (Patient #3) of seven patients.

The agency failed to ensure: 1. skilled nurse clinical visit notes were completed for three (Pt's #3, 5 and #6) and; 2. home health aide clinical visit notes were completed for one (Patient #6) of seven patients.

The agency failed to ensure governing body appointment of the administrator for calendar year's 2019 and 2020. Findings: A review of administrative records for calendar year's 2019 and 2020 showed no documentation the governing body appointed the administrator for the agency.

The agency failed to ensure discharge summaries were sent to the physician after patient discharge from the agency for two (Patient #1 and #2) of seven.

The agency failed to coordinate drills, potentially affecting all agency patients and employees.

The agency failed to develop a patient centered Quality Assurance Program.

The agency failed to ensure the utilization of Quality Assurance data to improve program effectiveness, quality of patient care and overall program improvement.

The agency failed to ensure the governing body provided oversight of agency operations and programs.

The agency failed to ensure staff developed an individualized plan of care to include equipment required for one (Patient #1) of seven patients.

The agency failed to ensure physicians were notified of missed visits for three (Pts #1, 3 and 7) of seven patients.