Community Hc, LLC

The registered nurse (RN) failed to ensure the comprehensive assessment contained the patient's current health status (See Tag G528); failed to evidence the patient's continuing need for home care (See Tag G532); failed to ensure the comprehensive assessment included individualized medical…

The agency failed to meet the needs of the patient for 1 of 10 records reviewed (#2); failed to ensure the Registered Nurse followed the plan of care (See Tag G572); the agency failed to ensure accurate and complete information on the plan of care (See Tag G574); failed to ensure the plan of care…

The agency failed to ensure a thorough quality assessment and performance improvement (QAPI) plan was developed, implemented, evaluated, and approved by the governing body.

The agency failed to ensure all staff followed infection control policies (See G682); failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infections and communicable diseases (See G684); failed to ensure all staff received…

The Registered Nurse (RN) failed to conduct a complete physical assessment during home visits (See Tag G706); the skilled nurse (SN) failed to follow the plan of care (POC) (See Tag G710); the SN failed to provide education to patients and/or their caregivers as ordered per the plan of care (See…

The agency failed to ensure all home health aides (HHA) successfully completed an entire competency program by verifying skills on a patient or pseudo-patient (See Tag G768); all HHA's received at least 12 hours of in-service training yearly (See Tag G774); failed to ensure HHA care plans contained…

The governing body failed to manage the operation of the agency by reviewing/creating budgets, operational plans, quality assessment and performance improvement program, adoption of policies and revisions, bylaws, and the capital expenditure plan (See Tag G942); the administrator failed to be…

The agency failed to ensure that OASIS (outcome and assessment information set) submissions were completed in a timely fashion, (prior to COVID-19 the expectation was within 30 days of completing the assessment).

The agency failed to ensure outcome and assessment information set (OASIS) data accurately reflected the patient's status, without conflicting information, at the time of the assessment for 8 of 10 records reviewed.

The agency failed to have a policy on comprehensive assessments and the registered nurse failed to ensure comprehensive assessments were updated for 3 of 3 patients with observed home visits (#1, 2, 3).

The agency failed to ensure all necessary medical information was sent during a discharge or transfer in 1 of 2 records reviewed, in a sample of 10 (#4).

The agency failed to ensure the Registered Nurse followed the plan of care for 2 of 2 skilled nurse home visits (#1, 2), and failed to have a plan of care policy.

The agency failed to ensure all staff followed infection control policies and standard precautions for 2 of 3 home visits observed (#1, 2).

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infections and communicable diseases, as part of their Quality Assessment and Performance Improvement (QAPI) program.

The home health agency failed to ensure all staff and patients received infection control education in relation to daily self-monitoring for COVID-19 and failed to ensure all staff received and implemented infection control education related to performing pre-visit screening of the patient for…

The agency failed to ensure all home health aides (HHA) successfully completed an entire competency program by verifying skills on a patient or pseudo-patient for 2 of 9 HHA employee records reviewed (Employees I, M).

The agency failed to ensure all Home Health Aides (HHAs) received at least 12 hours of in-service training yearly, which affected all agency HHA's.

The registered nurse (RN) failed to ensure that home health aide (HHA) care plans contained patient-specific tasks to be performed by the home health aide for 9 of 9 patients reviewed who received HHA services (#1, 2, 3, 4, 5, 6, 7, 9, 10).

The governing body failed to manage the operation of the agency by reviewing/creating budgets, operational plans, quality assessment and performance improvement (QAPI) program, adoption of policies and revisions, bylaws, and the capital expenditure plan.

The agency failed to ensure confidentiality of clinical records.

The agency failed to investigate and document complaints for 3 of 3 patient complaints reviewed (#4, 11, 12).

The comprehensive assessment failed to contain all information about the current health status for 1 of 10 records reviewed (#3).

The agency failed to ensure the comprehensive assessment contained the patient's continuing need for home care in 2 of 3 home visits observed (#1, 3).

Based record review and interview, the home health agency failed to ensure they had a comprehensive assessment policy and that agency comprehensive assessments included individualized medical, nursing, rehabilitative, social, and discharge planning needs for 10 of 10 records reviewed (#1, 2, 3, 4…

The registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications, drug interactions were identified, and the medication list was maintained for 10 of 10 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10).

The agency failed to have a policy on comprehensive assessments, and the registered nurse (RN) failed to identify availability/schedules of caregiver assistance for 10 of 10 records reviewed with primary caregivers (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10).

The agency failed to evidence all medication, durable medical equipment (DME), diagnoses, and safety measures were listed on the plan of care for 3 of 3 patients with home visit observations (#1, 2, 3), and the agency failed to have a plan of care policy in place.

The agency failed to ensure the plan of care was revised for 1 of 2 records reviewed of hospitalized patients (#1), and the agency failed to have a plan of care policy.

The agency failed to ensure their patients were properly educated according to their patient-specific needs for 2 of 2 skilled nurse observations (#1, 2).

The agency failed to ensure all patients were provided with a copy of written instructions outlining visits, including frequency of visits by the home health personnel for 3 of 3 home visits observed (#1, 2, 3).

The agency failed to ensure a medication list was provided to the patient for 3 of 3 home visits observed (#1, 2, 3).

The agency failed to provide written instructions outlining treatments and therapy that would be administered by agency staff to the patient for 3 of 3 home visits observed (#1, 2, 3).

The agency failed to ensure all patients were provided with a copy of written instructions outlining name and contact information of the home health Clinical Manager for 3 of 3 home visit observations (#1, 2, 3).

The Registered Nurse (RN) failed to conduct a complete physical assessment for 2 of 2 skilled nurse visit observations (#1, 2), in a total of 3 home visit observations.

The skilled nurse (SN) failed to follow the plan of care (POC) for 2 of 2 skilled nurse observations (#1, 2).

The skilled nurse (SN) failed to provide education to patients and/or their caregivers as ordered per the plan of care for 2 of 2 skilled nursing observations (#1, 2).

The skilled nurse (SN) failed to communicate with the doctor related to patient's plan of care for 2 of 2 skilled nurse observations (#1, 2).

The agency failed to include all skilled professionals as part of their quality assessment and performance improvement (QAPI) program.

The agency failed to ensure a skilled nurse (SN) was responsible for home health agency in-services.

The agency failed to ensure nursing services by the Licensed Practical Nurse (LPN) were provided under the supervision of a Registered Nurse (RN).

The agency failed to ensure home health aides provided services that were ordered by the physician and were included in the plan of care, for 7 of 9 records reviewed, that had Home Health Aide services (#1, 2, 3, 4, 6, 7, 9).

The administrator failed to be responsible for the day-to-day functions of the agency.

The clinical manager failed to assure patient needs were continuously assessed for 2 of 10 records reviewed (#1, 2).

The clinical manager failed to ensure the patient's plans of care were updated for 1 of 2 patients with hospitalizations (#1).

The agency failed to protect the privacy and security of health information for all required confidential clinical records (See G438); failed to ensure their policies were followed by not involving the physician and the patient in the discharge planning process, failed to document all measures…

The agency failed to complete initial assessments for 20 of 20 records reviewed (See G 512); failed to complete the initial assessment within 48 hours of referral, within 48 hours of the patient's return home, or on the physician-ordered start of care date for 6 of 20 records reviewed (See G 514)…

The agency failed to ensure all visits were provided as ordered on the plan of care (See G 572); failed to ensure plans of care contained accurate start of care dates, measurable goals, clear instruction for nursing freqencies and duties, all DME (durable medical equipment), medications, and…

The agency failed to ensure an ongoing quality assurance and performance improvement (QAPI) program been maintained (See G 642); failed to ensure on-going QAPI data had been collected and evaluated to establish quality of patient care and improve agency performance (See G 644); failed to initiate a…

The agency failed to ensure all staff followed infection control policies and procedures (See G682) and failed to ensure that the registered Nurse (RN) provided infection control education to patient and/or caregivers (See G 686).

The skilled nurse failed to ensure that nurses performed a complete physical assessment per professional standards, failed to ensure patients were assessed after injuries reported, and failed to ensure assessment and measurement of wounds (# 1) in a sample of 20. (See G 706); failed to ensure care…

The agency failed to ensure all home health aides (HHA) received manual and / or electric hoyer lift competency evaluation prior to providing care to patients with a hoyer lift for (See G 768); failed to ensure all home health aide (HHA) skills competency evaluations for manual and / or electric…

The Governing Body failed to ensure the agency maintained an ongoing quality improvement program and annual evaluation of the agency performance for 2015, 2016, and 2017 (See G 942); failed to ensure responsibility for the day-to-day operations of the agency and failed to ensure the 24 hour call…

The agency failed to ensure that the record contained all appropriate and accurate documentation for 4 of 20 records reviewed (See G 1012); failed to document goals and progress toward goals for 8 of 20 records reviewed (See G 1016); failed to ensure discharge summaries were completed for 5 of 11…

The agency failed to ensure Outcome Assessment Information Set (OASIS) data had been transmitted to the state agency within 30 days and submit OASIS documentation at all for 2 of 20 records reviewed.

The agency failed to complete initial assessments for 20 of 20 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20).

The agency failed to ensure all visits were provided as ordered on the plan of care for 14 of 20 clinical records reviewed.

The agency failed to ensure an ongoing quality assurance and performance improvement (QAPI) program had been maintained prior to January 13, 2018 for 1 of 1 agency.

The agency failed to ensure on-going quality assessment and performance improvement (QAPI) data had been collected and evaluated to establish quality of patient care and agency performance for 1 of 1 agency.

The Governing Body failed to ensure the agency maintained an ongoing quality improvement program (QAPI) for 2015, 2016, and 2017 for 1 of 1 agency.

The agency failed to ensure all staff followed infection control policies and procedures for 5 of 5 home visit observations.

The agency failed to ensure that the registered Nurse (RN) provided infection control education to patient and/or caregivers for 1 of 1 home visit with the RN.

The agency failed to ensure all home health aides (HHA) received manual and / or electric hoyer lift competency evaluation prior to providing care to patients with a hoyer lift for 2 of 9 home health aide personnel records reviewed.

The agency failed to ensure the home health aide (HHA) care plans were updated and reviewed for 1 of 20 clinical records reviewed of patients receiving HHA services.

The Governing Body failed to ensure the agency maintained an ongoing quality improvement program (QAPI) and annual evaluation of the agency performance for 2015, 2016, and 2017 for 1 of 1 agency.

The Governing Body failed to ensure that an annual operating budget and capital expenditure plan had been provided for the 2016, 2017 and 2018 year for 1 of 1 agency.

The agency failed to ensure staff did not produce documentation of visits while patients were not home or were out of town for 1 of 20 clinical records reviewed (# 12) and failed to protect the privacy and security of health information for all required confidential clinical records for 10 of 20…

The agency failed to protect the privacy and security of health information for all required confidential clinical records for 10 of 20 records reviewed.

The agency failed to ensure their policies were followed by not involving the physician and the patient in the discharge planning process, failed to document all measures taken by the agency to resolve problems, advise the patient and his / her physician in advance of a discharge that was being…

The agency failed to ensure all staff appropriately furnished care and followed incident reporting policies for 2 of 20 records reviewed (#8 and 20).

The agency failed to complete the initial assessment within 48 hours of referral, within 48 hours of the patient's return home, or on the physician-ordered start of care date for 6 of 20 records reviewed.

The agency failed to ensure the nurses accurately documented patient health status at recertification assessments for 1 of 9 active records reviewed.

The agency failed to ensure the nurses performed medication interaction reviews and updated the medication profiles for 2 of 9 active records reviewed (# 2 and 3) in a sample of 20. Findings include 1. The agency policy dated 12/2017, titled "Medications," Policy #73 stated "Policy: ... The…

The agency failed to ensure the recertification visits were completed within the last 5 days of the certification periods for 2 of 9 active records reviewed.

The agency failed to ensure plans of care contained accurate start of care dates, measurable goals, clear instruction for nursing freqencies and duties, all DME (durable medical equipment), medications, and diagnoses for services being provided for 12 of 20 clinical records reviewed.

The agency failed to ensure changes in visit frequencies and treatments to be provided were ordered by a physician for 2 of 20 clinical records reviewed.

The agency failed to ensure physician orders were written and authenticated in a timely manner for 2 of 20 clinical records reviewed.

The agency failed to ensure the appropriate physician was provided with a patient's plan of care every 60 days in 1 out of 20 records reviewed.

The agency failed to ensure that the home health agency staff promptly alerted physicians with any changes in condition for 3 of 20 records reviewed (#8, 13, 17).

The agency failed to ensure the revised plans of care accurately reflected the patients current needs for 1 of 9 active clinical records reviewed.

The agency failed to ensure services not provided by the agency were referred to an appropriate provider for 3 of 9 active records reviewed (# 1, 5, and 12) and failed to ensure coordination of care were provided by all disciplines for 2 out of 9 active records reviewed (#5 and 12) in a sample of…

The agency failed to ensure that coordination of care was completed between all staff, patient family, and/or the physician for 1 of 20 records reviewed (#8).

The agency failed to initiate a QAPI [Quality Assurance and Performance Improvement] plan to track incidents.

The skilled nurse failed to ensure that nurses performed a complete physical assessment per professional standards for 2 of 3 skilled nurse (SN) home visits (#4, 5); failed to ensure patients were assessed after injuries reported in 4 out of 4 incident reports reviewed (#13, 17, and 20) and failed…

The skilled nurse (SN) failed to ensure care and services were provided per the physician ordered plan of care for 10 of 20 records (#1, 2, 3, 4, 5, 6, 12, 14, 15, and 19) Findings include: 1. The agency policy dated 12/2017, titled "Services Provided by Discipline," Policy #59 stated "Procedure…

The Skilled Nurse (SN) failed to accurately identify, document and measured wounds consistently for 3 of 3 wound care records reviewed (#1, 2 and 6) and failed to ensure nurse documentation was consistent for suprapubic catheter changes for 1 of 9 active records reviewed.

The LPN (licensed practical nurse) failed to notify the physician of a patient's change in condition in 1 out of 20 records reviewed.

The agency failed to ensure all skilled professional staff participated in the agency's quality assurance and performance improvement (QAPI) program for 1 of 1 agency.

The LPN failed to inform the Case Manager of a patient's change in condition and the Registered Nurse failed to follow up with the LPN to ensure the physician was notified, orders obtained for a urine sample, and urine sample obtained in 1 out of 20 records reviewed.

The agency failed to ensure all home health aide (HHA) skills competency evaluations for manual and / or electric hoyer lifts were determined by direct observation for 2 of 9 HHA files reviewed.

The agency failed to ensure that the home health aide (HHA) followed the home health aide care plans for 7 of 20 records reviewed.

The agency failed to ensure home health aide (HHA) supervisory visits were completed no less frequently every 14 days for 4 of 20 clinical records reviewed of patients receiving skilled nursing (SN) services and HHA services.

The administrator failed to ensure responsibility for the day-to-day operations of the agency and failed to ensure the 24 hour call system contained identifying agency information on the voicemail for 1 of 1 agency.

The administrator failed to ensure the agency followed their policy to retained documentation of qualifications or the assistant director of nursing (ADON) and failed to ensure the competency of home health aides (HHA) prior to providing services to patients (D, M, N and former employee file CC)…

The clinical manager failed to ensure the coordination of care for 6 of 20 clinical records reviewed.

The agency failed to ensure that nurses performed a complete physical assessment per professional standards for 2 of 3 skilled nurse home visits.

The agency failed to ensure that the record contained all appropriate and accurate documentation for 4 of 20 records reviewed (#3, 5, 11, and 18).

The agency failed to document goals and progress toward goals for 8 of 20 records reviewed (#3, 4, 5, 6, 7, 8, 12, and 20).

The agency failed to ensure discharge summaries were completed for 5 of 11 discharge records reviewed.