Community Home Health Care

The agency's administrator failed to demonstrate responsibility for all day-to-day operations of the home health agency concerning a change of address and ensuring the required paperwork was appropriately completed per Federal requirements, resulting in the agency's continuance of operating at an…

The agency failed to ensure the registered nurse conducted an initial assessment within 48 hours of the physician referral in 1 (P-2) of 7 records reviewed (see G514); failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for…

The agency failed to ensure the plan of care included all required elements to provide quality and safety in patient care in 2 (P-4, and P-7) of 7 records reviewed (see G574); failed to ensure the plan of care included all patient care orders for 1 (P-6) of 7 records reviewed (see G576); failed to…

The agency failed to provide evidence of its efforts to measure, track, and analyze its quality indicators in order to assess processes of care and services for 2023, 2024 and 2025 (See G0642); failed to utilize quality indicator data including measures derived from the Outcome and Assessment…

The agency failed to ensure the registered nurse developed a plan of care with the patient in 1 (P-1) of 7 records reviewed, (See G0708); failed to ensure the patient received services as ordered by the physician or allowed practitioner as indicated in the plan of care for 3 (P-4, P-6 and P-7) of 7…

The Administrator failed to demonstrate responsibility for all day-to-day operations of the home health agency including ensuring the address change of the agency was properly completed as needed according to Federal requirements resulting in the agency operation which was outside of Federal…

The agency failed to ensure staff received on-going Emergency Preparedness (EP) training every 2 years in 1 (CM-1) of 5 employee records reviewed; and failed to ensure staff received initial EP training in 2 (CM-1 and RN-1) of 3 employee records reviewed who were hired since 2022, resulting in the…

The agency failed to ensure Emergency Preparedness (EP) drills were performed to test the agency’s EP program annually in 2 (2023 and 2024) of 2 years reviewed, resulting in the potential for an unprepared staff response in the event of an emergency.

The agency failed to provide evidence of its efforts to measure, track, and analyze its quality indicators in order to assess processes of care and services for 2023, 2024 and 2025, resulting in the inability of the agency to determine the scope of services provided by the agency, and the potential…

The agency failed to utilize quality indicator data including measures derived from the Outcome and Assessment Information Set (OASIS), and other relevant data to monitor the effectiveness and safety of services; quality of care; and identify opportunities for improvement in the design of its…

The agency failed to develop a 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 2023, 2024 and 2025, resulting in the agency's inability to…

The agency failed to provide documented evidence of the initial infection control education for 1 (CM-1) of 7 agency employees, and the ongoing infection control education for 7 (ADM; CM-1; CM-2; RN-1; RN-2; PT-1; and CNA-1) of 7 current employees, including those with clinical (direct patient…

The agency failed to ensure that one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs.

The agency failed to ensure all entries into the clinical record were appropriately authenticated and signed in 1 (P-1) of 7 records reviewed resulting in incomplete entries which were not reviewed or approved by the author.

The agency failed to ensure patients were provided with the name and contact information for the agency administrator for 7 of 7 patients serviced by the agency in the last 12 months, resulting in the potential for patients being unaware of who to contact regarding any complaints.

The agency failed to ensure the patient was informed of and consented to care in 3 (P-1, P-4, and P-7) of 7 records reviewed, resulting in the potential for a violation of patient rights.

The agency failed to ensure the patient received written notice in advance of the agency terminating on-going care in 1 (P-7) of 7 record reviews, resulting in the potential for a violation of patient rights.

The agency failed to ensure the registered nurse conducted an initial assessment within 48 hours of the physician referral in 1 (P-2) of 7 records reviewed resulting in a delay in assessment of immediate care and support needs of the patient and the potential for a poor patient outcome.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-6 and P-7) of 7 records reviewed, resulting in incomplete clinical information used to determine the needs of these patients and used to assist in…

The agency failed to ensure the comprehensive assessment included the patient’s medical equipment, rehabilitation, and discharge planning needs in 1 (P-4) of 7 records reviewed resulting in a lack of information to determine the needs of the patient.

The agency failed to ensure the comprehensive assessment included the patient’s primary caregiver and their willingness and ability to provide care in 1 (P-7) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the plan of care included all required elements to provide quality and safety in patient care in 2 (P-4, and P-7) of 7 records reviewed resulting in a lack of critical information to ensure the needs of the patient are met and potentially resulting in poor patient…

The agency failed to ensure the plan of care included all patient care orders for 1 (P-6) of 7 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure all services and treatments were administered only as ordered by a physician who establishes and reviews the plan of care in 2 (P-1 and P-7) of 7 records reviewed resulting in care provided without the direction of the physician and potentially resulting in poor patient…

The agency failed to ensure patients were provided with the name and contact information for the agency clinical manager for 7 of 7 patients serviced by the agency in the last 12 months, resulting in the potential for patients being unaware of who to contact regarding any issues.

The agency failed to ensure the registered nurse developed a plan of care with the patient in 1 (P-1) of 7 records reviewed resulting in home care services being provided without a plan of care and the potential for unmet care needs.

The agency failed to ensure the patient received services as ordered by the physician or allowed practitioner as indicated in the plan of care for 3 (P-4, P-6 and P-7) of 7 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure skilled professionals prepared clinical notes in 2 (P-1 and P-7) of 7 records reviewed, resulting in the potential for poor patient outcomes.

The agency failed to ensure skilled professionals participated in agency-sponsored in-service training for 5 of 5 (CM-1, CM-2, RN-1, RN-2, and PT-1) employed skilled professionals, resulting in the potential for a lack of staff education and training.

The Administrator failed to demonstrate responsibility for all day-to-day operations of the home health agency including ensuring the address change of the agency was properly completed as needed according to Federal requirements resulting in the agency operating outside of Federal reporting…

The administrator failed to ensure the agency employed qualified personnel in 1 (CM-1) of 4 clinical employee records reviewed, resulting in the potential for unqualified staff and poor patient outcomes.

The agency failed to ensure the administrator or pre-designated alternate administrator was available during all operating hours, resulting in the potential for a lack of oversight for the agency.

The agency failed to ensure the clinical record included all interventions, treatments, and services provided for 2 (P-5 and P-6), resulting in an incomplete and inaccurate medical record.

The agency failed to ensure completed discharge summaries were sent to the primary care practitioner or other health care professional responsible for caring for the patient after discharge within 5 days in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 discharged records reviewed, resulting in a…