Ethical Home Health Care

The agency failed to ensure that the Condition of Participation: G 700 484.75: Skilled professional services was in compliance when: Based on observation, interview, and record review, the agency failed to provide services ordered by the physician and indicated in the plan of care for two of seven…

The agency failed to ensure the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance when: Based on observation, interview, and record review, the Governing Body (GB) failed to operate and manage the agency from January 1, 2023, to February 28…

The agency failed to ensure all staff were knowledgeable on the agency’s Emergency Preparedness Program (EPP) and all contracted staff were trained on the EPP, for the 2022, 2023 and 2024 years reviewed, in a universe of 19 patients.

The agency failed to use quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency’s services, from January 1, 2023, to February 29, 2024, in…

The agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had…

The agency failed to ensure its staff followed the agency’s policy and procedure and professionally accepted infection control practices for two of seven sampled patients (Patients 1 and 2) when a Licensed Vocational Nurse (LVN 1) did not follow clean bag technique (a set of procedures to follow to…

The Governing Body (GB) failed to operate and manage the agency from January 1, 2023, to February 28, 2024, in a universe of 19 patients when: 1. A current California Department of Public Health (CDPH) Laboratory Registration was not provided.

The agency failed to ensure a review of all medications the patients were taking was conducted for three of seven sampled patients (Patients 1, 2, and 3) when: 1. For Patient 1: the Medication Profile (MP-a current list of all medications prescribed for a specific patient), indicated the wrong…

The agency failed to provide services ordered by the physician and indicated in the plan of care for two of seven sampled patients (Patients 1 and 2) when: 1a.

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to document a community/facility-based risk assessment (community/facility-based…

The agency failed to ensure the Condition of Participation: G 640 484.65 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to identify quality indicators (a measurable element of the agency's practice that…

The agency failed to ensure that the Condition of Participation: G 680 484.70: Infection prevention and control was in compliance when: Based on interview and record review, the agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment…

The agency failed to document a community/facility-based risk assessment (community/facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; patient population; facility type and potential surrounding community assets [i.e. rural area versus a…

The agency failed to provide for the continuity of operations during an emergency when a succession of authority plan (a plan indicating who will take control in the absence or inability of another) was not in place for seven of seven patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop a policy and procedure to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for seven of seven sampled patients (Patients 1, 2, 3…

The agency failed to develop a procedure to create individual patient emergency preparedness plans based on and included in the patients' comprehensive assessments for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7).

The agency failed to implement procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness staff, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications (phone service, including cellular phone and internet) failure during a disaster or emergency, for seven of seven sampled patients…

The agency failed to develop a procedure for: sharing information and medical documentation for the agency's patients with other health providers, releasing patient information in the event of an evacuation, or providing information about the general condition and location of the agency's patients…

The agency failed to develop a procedure to provide information about the agency's occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop a procedure to provide training to all staff, as well as contracted staff, every two years, on the emergency preparedness policy and procedure titled, "Emergency and Disaster Preparedness Plan Policy," dated 11/11/97, for seven of seven sampled patients (Patients 1, 2…

The agency failed to develop policy and procedures for conducting full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency…

The agency failed to identify quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) to measure, analyze and track in order to assess the agency's processes of care, services, and operations, for seven of seven sampled patients…

The agency failed to use quality indicator (a measurable element of the agency's practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency's services.

The agency failed to document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken…

The agency's Governing Body (GB) failed to ensure a Quality Assessment and Performance Improvement (QAPI) Program was implemented, maintained and evaluated for effectiveness, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment Performance Improvement (QAPI) program in order to identify infection trends (analysis of a pattern), develop action plans and improve disease prevention for seven of seven sampled…