Fidelity Home Health Care, LLC

Procedures and staff interview the agency failed to document the risk assessment used to identify all potential hazards, failed to train staff, and failed to test the agency's emergency plan at least annually.

Deficiencies cited at 484.60 (a) (1) G572, 484.60 (a) (2) G574, and 484.60 (b) (1) G580. Findings are: G 572 Based on review of clinical records, policies, and procedures and staff interview, the agency failed to update the physician of changes needed to the plan of care for 5 of 10 patient records…

Deficiencies cited at 484.65(a)(1),(2) G642, and 484.65(b)(1),(2),(3), G644, 484.65(c), G646, and 484.65(d)(1),(2), G658 Findings are: G642 Based on review of policies and procedures, the agency's Quality Assurance Binder review, and staff interview, the agency failed to measure, analyze and track…

Deficiencies cited at 484.80(a)(i-iv) G754, 484.80(c)(1)(2)(3) G768, 484.80(d) G774, 484.80(d)(2) G778, 484.80(g)(2) G800, 484.80(h)(1)(i) G808, 484.80(h)(1)(iii) G812 Findings are: G754 Based on review of clinical records, personnel files, policies and procedures, and staff interview the agency…

Deficiencies cited at 484.105(b)(1)(ii) G948 Findings are: Based on review of clinical records, personnel files, the agency's Position (Job) Description for the Home Health Administrator, policies, and procedures and staff interviews the agency Administrator failed to organize and direct the…

The agency failed to complete a facility and community based risk assessment that used an all- hazards approach to ensure the agency's Emergency Preparedness Policy and Procedures was developed to include facility and community specific risks and failed to include the assessment in the agency's…

The agency failed to provide a training program of the agency's emergency plan for the agency's contracted staff or for the agency's 26 of 26 existing staff employed directly by the agency (Staff A, B, C, D, E, F, G, H, I J, K, L, R, S, T, U, V, W, X, Y, Z.

E0039 Based on review of the agency's policies and procedures and staff interview, the agency failed to participate in a full-scale exercise that is a community-based or a facility-based exercise, failed to conduct a second full-scale exercise that is a community-based or a facility-based exercise…

The agency failed to update the physician of changes needed to the plan of care for 5 of 10 patient records reviewed (Patient 2, 4, 5, 9, and 10).

The agency failed to measure, analyze and track quality indicators to assess the agency's processes, services and quality of care.

The agency failed to identify opportunities for improvement for 2 of 2 records reviewed (Patient 2 and 5) when a problem was identified during the QAPI process.

G646 Based on review of policy and procedures, the agency's Quality Assurance Program and staff interview, the Home Health Agency's performance improvement (PI) activities failed to focus, consider, and identify areas for improvement as required at: 1. G648 which requires the PI activities to focus…

G658 Based on review of policies and procedures, the agency's Quality Assurance Binder, and staff interview, the agency failed to conduct performance improvement projects and failed to document the projects, the reasons for the projects, and the measureable progress achieved on these projects.

The agency failed to complete a written and/or skills competency evaluation for 11 of 13 Home Health Aide (HHA) personnel records reviewed (Staff-F, G, J, K, R, S, T, Y, AA, BB, and FF).

The agency failed to ensure that the agency's Home Health Aides (HHA) received 12 hours of in-services annually for 11 of 13 HHA files reviewed (Staff- E, F, G, H, J, R, S, T, AA, BB and FF) who had been employed by the agency 1 year or longer.

The agency failed to provide all services as outlined in the plan of care for 3 of 10 patient records reviewed (Patient 5, 9, and 10).

The agency failed to document the investigation of a complaint for 2 of 2 complaints filed by 2 patients or the patient's representative (Patient 2 and 3).

The agency failed to include Home Health Aide (HHA) services, frequency and duration of visits on the plan of care for 4 of 8 (Patient 3, 7, 9, and 10) patient records reviewed who were receiving HHA services from the agency.

The agency failed to provide Physical Therapy (PT), Occupational Therapy (OT), Skilled Nurse (SN), and Home Health Aide (HHA) services only as ordered by the physician for 4 of 10 patient records reviewed (Patient 3, 7, 9, and 10).

Staff interview the agency failed to ensure 4 of 21 unlicensed staff (Staff L, W, Z, and CC) were qualified Home Health Aides (HHA) prior to providing HHA services to 4 of 8 patients (Patients 7, 8, 9, and 10) who received HHA services.

The agency failed to maintain documentation that the agency's Home Health Aides (HHA) received 12 hours of in-services annually for 11 of 13 HHA files reviewed (Staff- E, F, G, H, J, R, S, T, AA, BB and FF) who had been employed by the agency 1 year or longer.

The agency failed to ensure that Home Health Aides (HHA) were providing services as ordered by a physician for 4 of 8 patient records reviewed (Patient 3, 7, 9, and 10) who were received both skilled services and HHA services.

The agency failed to conduct an on-site visit every 14 days for each patient who received skilled services and home health aide (HHA) services to ensure the patient's plan of care was followed for 3 of 8 patient records reviewed (Patient 2, 9, and 10) who received both HHA and skilled services.

The agency failed to conduct an annual on-site visit to observe and assess the home health aide (HHA) during the provision of home health aide services for 11 of 13 HHA files reviewed (Staff-E, F, G, H, J, R, S, T, AA, BB and FF) who had been employed by the agency one year or longer.

G948 Based on review of clinical records, personnel files, the agency's Position (Job) Description for the Home Health Administrator, policies, and procedures and staff interviews the agency Administrator failed to organize and direct the day-to-day functions of the agency to ensure compliance with…

Deficiencies cited at 484.60 (a) (1) G572, 484.60 (a) (2) G574, 484.484.60 (a) (3) G576, and 484.60 (b) (1) G580. Findings are: G572 Based on record review, policy and procedure review, and patient and staff interview, the agency failed to update the physician of changes needed to the plan of care…

Deficiencies cited at 484.80( c) (1) G768, 484.80(d) G774, 484.80(d)(2) G778, 484.80(h) (1)(i) G808 and 484.80 (h) (1)(iii) G812. Findings are: G768 Based on personnel record review and staff interview the agency failed to complete a written and/or skills competency evaluation for 2 of 7 Home…

The agency failed to update the physician of changes needed to the plan of care for 4 of 4 patient records reviewed (Patient 1, 2, 3, and 4).

The agency failed to complete a written and/or skills competency evaluation for 2 of 7 Home Health Aide (HHA) personnel records reviewed (HHA-C and D).

The agency failed to ensure that the agency's Home Health Aides (HHA) received 12 hours of in-services annually for 6 of 6 HHA files reviewed (HHA- A, B, C, F, G, and P) who were employed by the agency 1 year or longer.

Agency nurses failed to authenticate, date and time their visit note entries for 1 of 4 patient records reviewed (Patient 4).

The agency failed to provide the written notice of patient rights and responsibilities for 2 of 4 patient records reviewed (Patient 1 and 2).

The agency failed to provide verbal notice of the patient rights and responsibilities for 2 of 4 patient records reviewed (Patient 1 and 2).

The agency failed to provide all services outlined in the plan of care for 3 of 4 patient records reviewed (Patient 1, 3, and 4).

The agency failed to include all medications the patient was taking on the patient's plan of care for 1 of 4 patient records reviewed (Patient 3).

The agency failed to include verbal orders for Physical Therapy (PT) Services on the plan of care for 1 of 1 patient records reviewed (Patient 3) who was receiving Physical Therapy services.

The agency failed to follow the physician ordered treatment as directed on the plan of care for 1 of 4 patient records reviewed (Patient 2).

The agency failed to maintain documentation that the agency's Home Health Aides (HHA) received 12 hours of in-services annually for 6 of 6 HHA files reviewed (HHA-A, B, C, F, G, and P) who were employed by the agency 1 year or longer.

The agency failed to conduct an on-site visit every 14 days for each patient who received skilled services and home health aide (HHA) services to ensure the patient's plan of care was followed for 2 of 2 patient records reviewed (Patient 3 and 4) who recieved both HHA and skilled services.

The agency failed to conduct an annual on-site visit to observe and assess the home health aide (HHA) during the provision of home health aide services for 6 of 6 HHA files reviewed (HHA-A, B, C, F, G and P) who had been employed by the agency one year or longer.

The clinical manager failed to ensure the plan of care was updated to reflect the patient needs and services for 3 of 4 patient records reviewed (Patient 2, 3, 4).

The agency failed to have all clinical notes included in the clinical record for 1 of 4 patients records reviewed (Patient 3).

The agency failed to provide a transfer summary to the receiving facility once the agency became aware of the unplanned transfer and failed to complete a discharge summary and send the summary to the patients primary physician for 1 of 1 patient records reviewed (Patient 4) who had a transfer and…