Elara Caring Xxi

The agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff.

The agency failed to ensure: The initiation and review of a PIP through their QAPI Program for 06/09/22 to 02/21/23 and; PIP documentation included baseline and goal percentages to measure performance for a designated project from 02/23/23 to 04/05/23 for all patients and employees.

The agency failed to ensure individualized patient POCs included SN catheter treatment/interventions or last changed/treatment due date for three (Patients #6, 7 and #12) of 13 patients.

The agency failed to ensure physician ordered wound site care and dressing materials for one (Patient #1) of 13 patients.

The agency failed to ensure care was coordinated between the agency and physician for one (Patient #5) of 13 patients.

The agency failed to ensure: 1. SN conducted visit frequency as ordered on the POC for three (Patients #3, 7 and #8) of 13 patients and; 2. SN conducted wound site care ordered on the POCs for one (Patient #7) of 13 patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure skilled professional service visit note documentation was completed within 24 hours (agency timeline requirements) for two (Patients #2 and #6) of 13 patients.

The agency failed to ensure a completed transfer/discharge summary was provided for three (Patients #10, 12 and #13) of 13 patients.

The agency failed to ensure SN frequencies were followed as ordered on the POC for two (Pt #5 and 8) of 10 patients.

The agency failed to ensure a comprehensive infection control program was conducted for all patients and employees.

The agency failed to develop PIPs.

The agency failed to ensure skilled nursing services were provided in accordance with the POC frequency for one (Pt #4) of eight patients.

The agency failed to ensure HHA visits were made in accordance with the ordered frequency for one (Pt 2) of four patients with HHA services.

The agency failed to ensure a home health aide supervisory visit was completed every 14 days for one (Pt #3) of four patients with home health aide services.