Diversified Home Health Care

The agency failed to ensure all entries into the clinical record were appropriately authenticated by the clinician who signed the entry in 1 (P-5) of 5 sample records reviewed resulting in duplicate assessment entries and potentially inaccurate patient information.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status based on past medical history and history of events leading to current home care needs in 2 (P-2, 3) of 5 records reviewed, resulting in incomplete and inaccurate clinical information…

The agency failed to ensure clinicians included a review of all medications during the comprehensive assessment in order to identify any potential adverse effects and drug reactions in 1 (P-5) of 5 sample records reviewed potentially resulting in unknown side effects, drug interactions, duplication…

The agency failed to ensure the plan of care included individualized, patient-specific measurable outcomes and goals in 3 (P-1, 3, 5) of 5 sample records reviewed potentially resulting in the lack of care that is specific to the patient’s individual needs and difficulty determining progress toward…

The agency failed to ensure the clinical records contained an accurate representation of all treatments and interventions provided in 2 (P-3 and P-5) of 5 records reviewed, resulting in the potential for an unclear picture of the patient’s treatment and an incomplete medical record.

The agency failed to ensure a completed discharge summary was sent to the primary care physician or other health care professional who will be responsible for providing care to the patient after discharge in 1 (P-3) of 5 discharged records reviewed, resulting in a lack of information communicated…

The Agency failed to develop an emergency preparedness plan that must be reviewed, updated, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators and show measurable improvement, in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs…

The Agency failed to ensure that the individuals who furnished Home Health Aide services on its behalf, met the competency evaluation requirements of this section by ensuring the subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section were evaluated by a…

The Agency failed to develop an emergency preparedness plan that must be reviewed, updated and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor patient and staff…

The facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of staff and the 4 patients…

The Agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of trainings, resulting in the potential for inappropriate, unprepared…

The Agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency and the…

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators and show measurable improvement, in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs…

The Agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved for the 2019 and 2021 calendar years, resulting in the Agency's inability to improve in…

Based record review and interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care, patient safety and was evaluated for effectiveness…

The Agency failed to ensure that the individuals who furnished Home Health Aide services on its behalf, met the competency evaluation requirements of this section by ensuring the subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section were evaluated by a…

The agency failed to ensure that 2 of 2 Home Health Aides, whose personnel files were reviewed, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency failed to ensure Skilled Nursing and Physical Therapy prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 2 (MR#'s 2 and 3) of 4 records in which Home Health Aide services were ordered…

The Agency failed to include full contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission, including the events that led to the need for home care referral, for 7 (MR's #1, 2, 3, 4, 5, 6, and 7) of 7 records reviewed, resulting in incomplete clinical…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review, failed to ensure the Physician was notified of potential drug interactions as appropriate, and failed to ensure…

The agency failed to ensure the plan of care included all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 3 (MR's # 1, 2 and 4) records, from a total of 7 sampled records reviewed, resulting in patients…

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The Agency failed to ensure the Home Health Aide provided care and services as ordered in the plan of care for 1 (MR #3) of 1 patients observed during an Aide home visit, from a total of 7 sampled records reviewed, resulting in the potential for the rendering of unsafe care and unmet needs.

The Agency failed to ensure the skilled discipline made an annual onsite observation visit at the patient's residence to observe the care being provided, by 1 of 2 Home Health Aides employed by this agency, whose file was reviewed, resulting in the potential for the provision of substandard care…

The agency failed to provide documented evidence that the Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority, lack of oversight of patient care and operations of the agency, and the potential for poor patient outcomes.

The Agency failed to ensure a discharge summary was completed, provided the patient's current health status at the time of discharge, assessed progress toward goals, and was forwarded to the physician within 5 days of discharge in 1 (MR's #7), of 3 closed records, 7 records reviewed, resulting in…

The facility failed to document the delegation of authority in an event of an emergency, resulting in the potential to hinder the Agency's ability to provide continued patient care for all patients receiving care.

The Home Health Agency (HHA) failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document their efforts in contacting these officials…

The agency failed to have policies and procedures for the use of volunteers and other staffing strategies in its emergency plan, resulting in no directives in the event volunteers are utilized during an actual emergency.

The agency failed to conduct a patient-specific, comprehensive assessment that documented past medical history and baseline data in 3 of 5 records reviewed (MR# 1, 3 and 4), resulting in the potential for unmet care needs.

The agency failed to insure ordered disciplines completed their start of care (SOC) assessments within the agency's expected timeframe of 48 hours for 2 of 5 records reviewed (MR# 1 and 2) out of a total sample of 5 records reviewed, resulting in the potential for unmet care needs.

The home health agency failed to advise the patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the area where the patient resides, resulting in the potential for patient needs being unmet.

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 4 of 5 records reviewed (M.R.#s 1, 2, 3 and 4), and failed to ensure POC's documented safety measures, resulting in the potential for a plan of care not meeting the patient's needs, and the…

The agency failed to ensure the written contract for services included language that ensured the home health agency retained overall responsibility for all services provided and failed to specify how supervision would occur for 1 of 1 contracts reviewed (Contract #1 and 2) that provided hourly or…