Diversity Home Care Services, LLC

The Agency failed to develop an emergency preparedness plan that had been updated as per this requirement and included the agency's current and correct address and personnel, 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 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 for all patients currently serviced…

The Skilled disciplines failed to implement appropriate seizure precautions for 1 (P-2) of 1 patient diagnosed with seizures and failed to utilize professional standards of practice during the provision of care and services for 1 (P-3) of 1 patient observed during a Physical Therapy home visit…

The Agency failed to develop an emergency preparedness plan that had been updated as per this requirement and included the agency's current and correct address and personnel, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency 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 all patients currently serviced…

The Agency failed to provide evidence of initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate…

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.

The agency failed to ensure the comprehensive assessment had been updated to reflect 1 (P-3) of 1 patient observed during a home visit who sustained a fall with injury, from a total of 7 sampled records reviewed, resulting in the potential for the patient not receiving care and services based on…

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators 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 for all patients currently serviced…

The agency failed to ensure that the collected data was used to monitor the effectiveness and safety of services provided with opportunities for improvement; and failed to ensure the Governing Body approved the program's frequency and detail of data collection, resulting in the potential for poor…

The agency failed to track and analyze adverse events in order to implement preventative actions, which had the potential to negatively affect all 116 patients serviced by the agency in the past 12 months, resulting in the potential for failing to prevent future adverse events.

The Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, addressed priorities for improved quality of care and patient safety and was evaluated for…

The Agency failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care and services for 1 (P-2)) of 1 patient observed during a home health aide visit, from a total of 7 sampled records reviewed, resulting in the potential for the development and…

The Skilled disciplines failed to implement appropriate seizure precautions for 1 (P-2) of 1 patient diagnosed with seizures and failed to utilize professional standards of practice during the provision of care and services for 1 (P-3) of 1 patient observed during a Physical Therapy home visit…

The Agency failed to ensure Skilled Nursing 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 (P#'s 1, 2) of 2 records reviewed in which Home Health Aide services were ordered, from a total of…

The agency failed to ensure that 3 (P's #1, 2, 3) of 3 patients observed during home visits, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, from a total of 7…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to provide documented evidence of the drug regime review: failed to ensure the Registered Nurse provided oversight of the review process, and failed to ensure the…

The Agency failed to ensure the Physician was promptly notified of the patient's change in condition for 1 (P-1) patient who experienced significant weight loss and 1 (P-3) patient who experienced a fall with injury, from a total of 7 sampled records reviewed, resulting in the potential for…

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 Registered Nurse performed baseline assessments and re-assessments of the patient's health status and needs in 1 (P-1) record of a patient with a diagnosis of Heart Failure, from a total of 7 sampled records reviewed, resulting in the potential for unidentified…

The Agency failed to ensure the clinical record was completed and included detailed Skilled Nursing notes for 1 (P's #3) record with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for lack of continuity of care, undocumented, unidentified health…