Excel Home Health

The agency failed to ensure the Quality Assurance and Performance Improvement (QAPI- data-driven, proactive approach to improve quality of care and services) program was fully developed, implemented, and maintained when the documents were undated, lacked signatures of the participant attendance…

The agency failed to ensure hand hygiene (keeping hands clean) was performed prior to accessing the clinical supply bag for one of three home visits observed (Patient 2).

The facility failed to develop a written comprehensive Quality Assessment and Performance Improvement (QAPI) plan.As a result, the agency could not ensure that QAPI programs were being monitored, analyzed, and processed to maintain or achieve the organization's performance improvement efforts.

The agency failed to ensure the plan of care was implemented for 2 of 9 sampled patients (2, 4) when: 1. The skilled nurse did not assess the patient for edema and did not review the medication profile (2); and, 2. A Physical Therapist (PT) did not assess Patient 4's vital signs during home visits.

The agency failed to ensure patient clinical records were adequately safeguarded for 3 of 9 sampled patients (4, 5, 7), when patients' clinical records were stored in an employee's vehicle unattended.

The agency failed to ensure an initial assessment was conducted within 48 hours of the referral date for 1 of 9 sampled patients (3).

The agency failed to review all current medications for 2 of 9 sampled patients (2, 7).