Excellence Home Health Provider, Inc

The agency failed to ensure the emergency preparedness plan included the process for collaboration with the Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

The agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency's occupancy and its ability to provide assistance to the authority having the jurisdiction, the Incident Command Center, or designee.

The HHA failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets, creating the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the agency.

The agency failed to measure, analyze, and track quality indicators to assess the processes of care as part of the QAPI program.

The agency failed to utilize the quality indicator data in the design of its program.

The agency failed to ensure the PI activities focused on high risk, high volume, and problem-prone areas.

The hospice failed to document the measurable progress achieved on the 2023 and 2024 PI project.

The agency failed to maintain an infection control program related to the disposal of syringes for one of 12 sampled patients (Patient 9), creating the risk of the spread of infections.

The agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and investigation of infections.

The agency failed to ensure the written patient care instructions for the CHHA was developed by the RN who was responsible for the supervision of the CHHA for one of 12 patients (Patient 3).

The agency failed to authenticate the entries made in the clinical records for two of 12 patients (Patients 3 and 10).

The agency failed to ensure the grievance was investigated thoroughly and the resolution was communicated in writing as per the agency's P&P.

The agency failed to ensure the initial assessment visits were conducted within 48 hours of referral for two of 12 sampled patients (Patients 2 and 10).

The agency failed to ensure the review of medications included all of the patients' current medications to identify any potential adverse effects and drug reactions for three of 12 sampled patients (Patients 10, 11, and 12).

The agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for four of 12 sampled patients (Patients 3, 5, 7, and 10).

The agency failed to ensure the update comprehensive assessment was completed within 48 hours of the patient's return to home from the acute care hospital for two of 12 sampled patients (Patients 5 and 8).

The agency failed to ensure the discharge assessments were completed for one of 12 sampled patients (Patient 1).

The agency failed to ensure the POC was completed timely and included the required elements in the POC for five of 12 sampled patients (Patients 2, 5, 6, 8, and 10).

The agency failed to ensure the SN provided wound treatment in accordance with the physician's order for one of 12 sampled patients (Patient 7).

The agency failed to ensure the coordination of care for four of 12 sampled patients (Patients 4, 5, 7, and 11).

The agency failed to provide the written instructions outlining the SN visit schedule for three of 12 sampled patients (Patients 10, 11, and 12).

The agency failed to ensure the patients received care and services as per the written POCs for seven of 12 sampled patients (Patients 1, 4, 5, 7, 8, 9, and 10).

The agency failed to ensure the clinical records were complete and accurate for eight of twelve sampled patients (Patients 1, 2, 3, 4, 7, 8, 10, and 12), creating the risk of substandard care provided to these patients as their clinical information were not accurate and complete.

The agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of 12 sampled patients (Patient 10), creating the risk of substandard health outcomes to this patient.

The Administrator failed to ensure the HHA employed a qualified personnel (RN 2).

The agency failed to ensure the rehabilitation services were provided timely as per the contract agreement for two of the 12 sampled patients (Patient 8 and 12).

The agency failed to ensure the implementation of the P&Ps related to wound photography for four of 12 sampled patients (Patient 1, 4, 7, 8 and 10); and employee TB screening for one of five employees (RN 2).

The agency failed to provide completed discharge summaries within five days from the date of discharge for three of three discharged patients (Patient 1, 2, and 3).

The agency failed to ensure the emergency preparedness plan was reviewed and updated every two years, creating the increased risk of not addressing the care needs for the patients of the agency during the emergency events.

The agency failed to ensure the emergency preparedness plan included the strategies addressing the emergency events identified by the risk assessment, creating the increased risk of not addressing the care needs for the patients during the emergency events.

The agency failed to ensure the emergency preparedness plan included the updated information addressing the patient population and type of services to be provided in an emergency, creating the risk of not providing appropriate, consistent, and quality care to the patients.

The agency failed to ensure the emergency preparedness P&P was reviewed and updated every two years, creating the increased risk of not addressing the care needs for the patients during the emergency events.

The agency failed to ensure the emergency preparedness P&P addressed the procedures to inform the State and local emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency situation based on the patient's medical and psychiatric condition…

The agency failed to ensure the emergency preparedness P&P addressed the procedures to inform the State and local officials of any on-duty staff or patients that they were unable to contact.

The agency failed to ensure the emergency preparedness P&P addressed a system of medical documentation that protected confidentiality of the patient information, and secured and maintained availability of records.

The agency failed to ensure the emergency preparedness communication plan was reviewed and updated every two years, creating the increased risk of not addressing the care needs for the patients during the emergency events.

The agency failed to ensure the emergency preparedness communication plan included the updated name and contact information of the staff, entities provided services under agreement, patients' physician, and volunteers.

The agency failed to ensure the emergency preparedness communication plan included the information related to the alternate means for communicating with staff, federal, state, regional and local emergency management agencies, creating the risk of not being able to communicate to meet the patient…

The agency failed to ensure the emergency preparedness communication plan included the method for sharing information and medical documentation for the HHA's patients with other health providers to maintain the continuity of care, creating the increased risk of not providing appropriate…

The agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.

The agency failed to ensure the emergency preparedness training and testing program was reviewed and updated every two years, creating the increased risk of not addressing the care needs for the patients during the emergency events.

The agency failed to ensure the initial training in the emergency preparedness program was provided to contracted individuals providing services under arrangement.

The agency failed to ensure the HHA had conducted exercises to test the emergency plan annually.

The agency failed to ensure the patients received care and services as per the written POCs for six of 10 sampled patients (Patients 2, 4, 5, 7, 8, and 10), creating the risk of not providing appropriate, consistent, and quality of care to these patients.

The agency failed to revise and update the POC for one of 10 sampled patients (Patient 4), creating the risk for not providing necessary care and services to meet the care needs for these patients.

The agency failed to ensure infection control practices were implemented for one of 10 sampled patients (Patient 7).

The agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, control, and investigation of infections, creating the risk of spread of infections.

The agency failed to ensure the written agreements for the contracted rehabilitation companies (Companies 1 and 2) providing PT, OT, and ST services included the rights and responsibilities of the agency or contracted provider in the patient admission process.

The agency failed to ensure the CLIA waiver certificate was current when conducting the blood glucose testing for one of 10 sampled resident (Patient 2) and one nonsampled resident (Patient A ), creating the risk of not meeting the regulatory standards related to laboratory testing.

The agency failed to ensure the clinical record was completed for one of 10 sampled patient (Patient 4), creating the risk of not appropriately authenticating the contents of the patient's clinical record.

The agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for seven of 10 sampled patients (Patients 1, 3, 4, 5, 7, 8, and 10), creating the risk of not…

The agency failed to ensure the medication profiles were updated for seven of 10 sampled patients (Patients 2, 4, 5, 6, 7, 8, and 10), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients.

The agency failed to ensure the update comprehensive assessment was completed within 48 hours of the patient's return to home from the hospital for one of 10 sampled patients (Patient 4), creating the risk of not providing the necessary care and services timely to meet the care needs for these…

The agency failed to ensure the comprehensive assessment was completed at discharge for one of 10 sampled patients (Patient 3), creating the risk of not updating the patient's status for this patient.

The agency failed to communicate with the physician to meet the patients' care needs for two of 10 sampled patients (Patients 4 and 7), creating the risk of not providing the necessary care and services to these patients.

The agency failed to ensure the effective coordination for three of 10 sampled patients (Patients 1, 5, and 8), creating the risk of not providing necessary care and services to these patients.

The agency failed to provide the written instructions outlining the SN visit schedule for three of 10 sampled patients (Patients 4, 5, and 7), creating the risk of not providing the necessary information to these patients.

The agency failed to provide the name and information of the clinical manager for two of 10 sampled patients (Patients 5 and 7), creating the risk of not providing the necessary information to these patients.

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for two of 10 sampled patients (Patients 4 and 9).

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for seven of 10 sampled patients (Patients 3, 4, 6, 7, 8, 9, and 10), creating the increased risk of substandard healthcare outcomes to these patients.

The agency failed to ensure the agency's RN provided the onsite supervision for the CHHA no less frequently than every 14 days to ensure quality of care and services provided for two of 10 sampled patients (Patients 2 and10 ), creating the risk of substandard health outcomes to these patients.

The agency's Administrator failed to be responsible for the day to day operations related the P&P development and implementation, and maintain the current CLIA certificate of waiver.

The agency failed to ensure the discharge summary for three of 10 sampled patients (Patients 1, 2, and 3) were completed.