East West Health Services

The agency (HHA) failed to develop and maintain an emergency preparedness program that must be reviewed, and updated at least annually (See E0004); failed to address the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of…

The Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators for calendar years 2021 and 2022, 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 patient records were complete contained all pertinent documentation to provide care for and ascertain the needs of the patients in 3 (P#'s 10, 3, 5) records, plus an additional 38 unsampled records identified as incomplete, from a total of 10 sampled records reviewed…

The agency failed to review and update the emergency preparedness plan at least annually.

The facility failed to address patient population, identify types of services the agency would provide in an emergency and 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…

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's Emergency Preparedness (EP) plan, policies, and procedures, failed to address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs…

The agency failed to develop and maintain an Emergency Preparedness (EP) communication plan and ensure the communication plan was reviewed and updated at least annually.

The agency failed to provide initial training in emergency preparedness (EP) policies and procedures to all new staff, including contract employees and volunteers, and failed to maintain documentation of training, resulting in the potential for inappropriate, unprepared responses to emergencies and…

The Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators for calendar years 2021 and 2022, 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 for calendar years 2021 and 2022, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2021 and 2022 calendar years, resulting in the Agency's inability…

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 and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the…

The Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of its Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated…

The Agency failed to ensure the Physical Therapist prepared clear written patient care instructions for the home health aide regarding client needs prior to the provision of care in 1 (P-4) of 1 record in which Home Health Aide services were ordered, from a total of 10 sampled records reviewed…

The agency failed to ensure that 2 (P's #1, 2 ) of 2 patient's observed during home visits, from a total of 10 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, the…

The Agency failed to ensure that 1 (P-4) patient observed during a home visit, was informed both verbally and in writing of any/all charges that could affect the provision of health care services, prior to the provision of care, from a total of 10 sampled records reviewed, resulting in the…

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (P-3) of 3 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered…

The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 2 (P's #1, 2) of 2 records in which start of care services was delayed, from a total of 10 sampled records reviewed, resulting in delay in needed care and services and the…

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 conducted the drug review process in 1 (P-4) of 10 sampled records…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the individualized needs of the patient for 3 (P's #7, 9, 1) records, from a total of 10 sampled records reviewed, resulting…

The Agency failed to ensure the Physician was promptly notified of the patient's change in condition for 1 (P-3) patient who experienced elevated blood pressure readings, from a total of 10 sampled records reviewed, resulting in the potential for unidentified, unaddressed health concerns and unmet…

The agency failed to ensure services were provided as ordered by the Physician and in accordance with the plan of care for 1 (P-1) patient who required Medical Social Work services, from a total of 10 sampled records reviewed, resulting in lack of community resources and the potential for unmet…

The Agency failed to ensure the Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the potential for lack of oversight of patient needs.

The Agency failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The agency failed to ensure patient records were complete contained all pertinent documentation to provide care for and ascertain the needs of the patients in 3 (P#'s 10, 3, 5) records, plus an additional 38 unsampled records identified as incomplete, from a total of 10 sampled records reviewed…

The agency failed to ensure the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 4 (P's #6, 7, 10, 2) records in which the patient was…

The administrator failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for all services to be provided by contracted staff.

The agency failed to ensure a plan of care was developed for review and revision by the physician at least every 60 days for 1 of 1 (MR#6) record reviewed in which the patient was recertified for an additional episode of care, resulting in the potential for overlooked patient needs and the…

The agency failed to ensure physical therapy developed plans of care that included visit frequencies and durations for 1 of 7 (MR#6) records reviewed in which physical therapy services were provided, resulting in the potential for decline in physical functioning and unmet care needs for this one…

The agency failed to document actual blood sugar results for a Diabetes Type 2 patient and notify the physician of elevated blood sugar levels in 1 record, from a total of 7 sampled records reviewed (MR's #2), resulting in the physician not having a clear and concise clinical picture of the…

The agency failed to ensure the clinical record was complete and included physical therapy clinical notes for 1 of 7 (MR#6) records reviewed in which physical therapy services were provided, resulting in the potential for unidentified health concerns and unmet patient needs.

The agency failed to ensure the clinical record was complete and included a plan of care, skilled nursing, and home health aide clinical notes for 1 of 10 (MR#6) records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient's health status and progress…