Dependable Healthcare Services LLC

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure that the needs of patients admitted for treatment are met and that the patient’s individualized plan of care specifies that the care and services the s/he…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to develop, implement, evaluate and maintain an effective and ongoing Agency wide data driven Quality assessment/performance improvement (QAPI) program that is reviewed…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to assure that administrative and supervisory functions are not delegated to another Agency or organization and failed to monitor and control all services not furnished…

The agency failed to establish and maintain a comprehensive emergency preparedness program utilizing an all-hazards approach, that is reviewed and updated at least every two (2) years.

The agency’s emergency preparedness plan failed to include procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation that is reviewed and updated at least every two (2) years.

The agency’s emergency preparedness plan failed to include policies and procedure for the use of volunteers in an emergency and is reviewed and updated at least every two (2) years.

The agency’s emergency preparedness communication plan failed to include staff contact information regarding the entities providing services under arrangement, and volunteers, and is reviewed and updated at least every two (2) years.

The agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures, the communication plan and that is reviewed and updated at least every two (2) years.

The agency failed to maintain documentation of initial and ongoing emergency preparedness training, that is to be provided to all staff, individuals providing services under arrangement, and volunteers upon hire ongoing every two (2) years.

The agency failed to conduct exercises to test the emergency plan at least annually, participate in a full-scale exercise that is community based, and conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise.

This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to assist patients in realizing patent specific measurable outcomes and goals by not providing services outlined as such in the individualized plan of care for 2 patients…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to develop, implement, and maintain a Quality assessment/performance improvement (QAPI) program that demonstrates measurable improvement in indicators related to infectious…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to develop a Quality assessment/performance improvement (QAPI) program which includes data collection from quality indicator data derived from Oasis that is used to…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to develop, implement, and maintain performance improvement activities that focus on high risk, high volume, or problem-prone areas that directly or potentially threaten the…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to track unexpected and/or adverse events that have, or potentially could impact a patient’s plan of care, and have the potential to cause a decline in a patient’s condition.

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the governing body failed to ensure the Agency has developed, implemented, and maintained an ongoing Quality assessment/performance improvement (QAPI) program which prioritizes patient…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the HHA (Home Health Agency) failed to provide infection control education to Registered Nurse (RN), Staff E and Patient ID #1. Findings are as follows: 1. Review of the patient record…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to maintain responsibility for rehabilitative services rendered to patients and that are provided under contract and conduct onsite supervisory visits on behalf of Physical…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure all entries are appropriately authenticated by signature of the primary author, or entry identifier who has reviewed and approved the entry, and dated, for 1…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to develop, implement, and maintain policies and procedures specific to the way in which patient records are protected for loss, theft, or unauthorized use.

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to protect and promote patient rights to receive services outlined in their plan of care for 2 patients reviewed, ID #s 2 and 7. Findings are as follows: 1. Record review…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure comprehensive assessments accurately reflect the patient’s status and must include incorporation of the current version of the Outcome and Assessment Information…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to take actions aimed at performance improvement and failed to implement those actions and therefore, were unable to provide evidence related to the measuring and…

This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to provide services that are ordered by a physician for 2 patients reviewed, ID #s 2 and 7. Findings are as follows: 1. Record review for Patient ID #2 revealed a start of…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure that education was provided for 1 of 1 caregiver and patient who had wounds, Patient ID #1. Findings are as follows: Review of the patient record revealed…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency lacked evidence of having developed and maintained a Quality Assessment and Improvement (QAPI) program in which all skilled professional staff (direct employees and contractor…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure that all professional staff participate in educational in-service trainings sponsored by the Agency.

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to provide supervisory visits every 14 days for 1 patient receiving home health aide (HHA) services and skilled nursing services, ID #6. Findings are as follows: Record…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the HHA (Home Health Agency) failed to ensure that skilled nursing services are provided in accordance with current clinical practice guidelines and accepted professional standards of…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure that clinical records of discharged patients contain evidence of a discharge summary for 1 patient reviewed for a planned discharge, ID #5. Findings are as…

The HHA failed to meet the regulatory provisions of the Condition of Participation (CoP) requirements and remain in substantial compliance with all conditions of participation.

The HHA failed to ensure that when the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator is available to provide continuity of services.