Family Care Home Health, Inc

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events from 05/12/23 to 01/28/25 for all patients and employees.

The agency failed to ensure utilization of quality indicator data for the QAPI program; to improve program effectiveness, quality of patient care, and overall program improvement for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program for calendar year 2023 for all patients and employees.

The agency failed to ensure the Infection Control Program surveillance data was included in QAPI program activities for all patients and employees.

The agency failed to ensure governing body oversite of the agency’s program evaluation for calendar year 2024 and operating budget, and capital expenditure plan for calendar years 2023 for all patients and employees.

The agency failed to ensure a SOC assessment was conducted within 48 hours of referral for two (Patients #2 and #6) of seven patients.

The agency failed to ensure individualized patient POC included: 1. Updated physician orders for each 60-day certification period for four (Patient #1, 2, 3 and #4) of seven patients; 2. Specific SN frequency and duration for each 60-day certification period for one (Patient #2) of seven 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 clinical visit note documentation was complete and accurate for two (Patients #3 and #4) of seven patients.

The agency failed to ensure completed transfer/discharge summaries were provided to receiving service providers for three (Patients #1, 6 and #7) of seven patients.

The agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 16 patients and all employees.

The agency failed to ensure the Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for all patients and staff.

The agency failed to ensure individualized patient plans of care were developed for two (Patient’s #2 and #3) of seven.

The agency failed to ensure: SN and HHA visits were conducted with physician orders as directed per individualized POC’s on two (Patient’s #2 and #3) of seven patients and; SN visits were conducted after discharge from agency services with continued physician orders on one (Patient #6) of seven…

The agency failed to notify the physician of a change in health condition for one (Patient #1) of seven patients.

The agency failed to ensure SN: 1. Conducted ankle measurement monitoring for one (Patient #4) of seven patients and; 2. Conducted weight monitoring for one (Patient #5) of seven patients.

The agency failed to ensure: Skilled nurse clinical notes were completed for two (Patients #1 and #5) of seven patients; andHHA visit note was completed for one Patient #5) of seven patients.

The agency failed to ensure a completed transfer/discharge summary was provided for one (Patient #7) of seven patients.