Family Care Home Health Agency

The agency failed to transmit Outcome and Assessment Information Set (OASIS) records to the Centers for Medicare and Medicaid (CMS) internet Quality Improvement and Evaluation System (iQIES) timely for 11 of 15 quarters since the last recertification survey in July 2022. The deficient practice…

The agency failed to ensure influenza and pneumonia vaccination status and needs were assessed for 7 of 7 sampled patients in accordance with the agency's vaccination policy (Patient 1, 2, 3, 4, 5, 6, 7).

The home health agency (HHA) failed to conduct annual exercises to test the emergency plan.

The home health agency (HHA) failed to ensure the agency's COVID-19 vaccination policy contained all the required content, failed to ensure two staff members (Home Health Aide (HHA)2 and Registered Nurse (RN)1) of 15 staff member’s personnel files reviewed were fully vaccinated or had been granted…

The Home Health Agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based electronic medical record (EMR).

The home health agency (HHA) failed to ensure staff performed the initial comprehensive assessment within 48 hours of the referral or discharge from the hospital for one (Patient (P) 5) of seven patient records reviewed.

The home health agency (HHA) failed to ensure: 1. Verbal orders were signed in accordance with agency policy for three (Patient (P) 1, P2, P4) of seven patient records reviewed and 2. A tracking system was developed for tracking verbal orders that were sent to physicians for signature in accordance…

The home health agency failed to provide the patient with a copy of the medication list for three of three patients (Patient (P)1, P2, P3) observed during home visits.

The facility failed to ensure 18 of 35 staff members received emergency preparedness training annually.

The facility failed to participate in a full-scale community-based exercise or an individually facility-based tabletop exercise, on an annual basis, as part of the facility's Emergency Operations Plan (EOP).

The home health agency (HHA) was not in compliance with rules regarding safeguarding personal health information and failure to protect patient information from risk of loss or unauthorized use.

The facility failed to ensure that there was a process in place to analyze and track incidents related to patient falls, as well as, ensure an incident report was completed when a patient experienced a fall, for 2 of 8 patients reviewed (Patient (P)3 and P5).

The facility failed to ensure there was an adequate process in place for tracking and trending infections, and failed to distinguish between a new urinary tract infection (UTI) and an ongoing recurring urinary infection for 2 of 8 patients reviewed (Patient's (P)1 and P4).