Comprehensive Home Health Care Agency

This did not occur.

Alternate administrator was not completed.

The agency’s Emergency Preparedness Plan (EPP) the agency leadership did not develop and maintain required facility-based and community-based risks assessments for 2020, 2021, 2022, 2023 or 2024. Failure of the agency to complete up-to-date risk assessments places patients and staff at risk for…

Findings Included: On 9/17/2024, during the review of the agency’s EPP, what services the agency would provide and how the facility plans to continue operations were not addressed.

The agency’s Administrator this did not occur.

The agency failed to provide and maintain documentation of training (initial and continued) in emergency preparedness policies and procedures for all staff newly hired and existing staff.

The administrator did not provide any documentation used by the facility to support the exercise.

The agency failed to transmit completed OASIS assessments to the CMS system within 30 days as required by regulation 484.45(a).

The agency did not establish or implement any quality assessment and performance improvement (QAPI) project(s) 4 out of 4 years.

The agency's administrative failed to assess and document a competency and skills assessment for the home health aide prior to providing patient care.

Failure to provide in-service training places patients and staff at risk for unsafe and adverse outcomes.

Failure to comply with regulations places patients at risk for inadequate health care.

The agency's governing body failed to develop an Emergency Preparedness Program (EPP), Policies/Procedures, or an appropriate Plan.

The agency's governing body failed to develop an appropriate performance improvement program.

The agency's staff did not maintain accurate or complete clinical records for 4 out of 7 records reviewed.

The agency's governing body failed to develop Emergency Preparedness Policies/Procedures.

The (RN) failed to follow the appropriate "bag technique" during 3 out of 3 home visits.

The agency's administrator, it was determined that the agency's home health aide had not received in-service training(s) in accordance with the federal requirements and the agency's policies.

The RN failed to perform a complete head-to-toe assessment during 3 out of 3 skilled nursing home visits.

The RN did not complete medication reconciliation during 3 out of 3 home visits.

The agency's registered nurse (RN) failed to follow the physician's orders, this placed the patient at risk for adverse health care outcomes.

The patient care plan was not updated.

The agency's administration failed to maintain an interdisciplinary (IDT) review of the patient's.

The agency's administration failed to provide required training to its home aide staff.

The agency's administration failed to provide required training to its staff.

Findings include: 1. The listed telephone number for the agency was not in service.

The administrator was absent from the agency and there was no designee in place.

Findings include: 1. The listed telephone number for the agency was not in service.