First Choice Home Health Services Inc

The home health agency failed to establish and maintain an emergency preparedness plan.

The home health agency failed to ensure: the OASIS information was complete and was an accurate representation of the patient's current condition in 5 of 8 clinical records reviewed.

The home health agency failed to ensure: all the patients' medical and nursing needs were met in 4 of 8 clinical records (#3, #4, #5, #7) in 2 of 3 records where physical therapy was ordered and not provided (#3 #4, #7). 2 of 2 record where occupational therapy was ordered and not provided (#4…

The home health agency failed to develop, implement and maintain a quality assessment and performance improvement plan [QAPI]. There failed to be evidence of a program to show the agency was working to improve the health, safety and quality of care of their patients.

The home health agency failed to ensure: accepted standards of practice to prevent the transmission of infections and communicable disease were followed (see tag 682); the agency maintained an agency wide surveillance, identification, prevention, control, and investigation of infections and…

The home health agency failed to ensure: employees had a competency evaluation prior to patient care (see tag 768); home health aides received 12 hours of in-service training during each 12 month period of employment (see tag 774); the registered nurse provided a complete and appropriate care plan…

The administrator failed to ensure: there was proper organization and management, and optimal care was provided to patients.

The agency failed to ensure: clinical records evidenced all interventions, treatments, services, and responses to the interventions.

The agency failed to ensure the accuracy of OASIS [Outcome and Assessment Information Set] [a standardized assessment used in home health] data in 5 of 8 clinical records reviewed.

The home health agency failed to ensure the plan of care was established by the physician and was individualized to include patient-specific measurable outcomes and goals in 8 of 8 clinical records reviewed.

The home health agency governing body failed to ensure there was an ongoing quality assessment and performance improvement program [QAPI]. The findings include: Clinical record review of an agency binder label QAPI evidenced a document titled Quality Improvement Committee Minute dated 4/3/2019…

The home health agency failed to follow accepted standards of practice, regarding Covid-19 precautions and including the use of standard precautions, to prevent the transmission of infections and communicable diseases in 2 of 3 patients with home visits.

The home health agency failed to maintain an agency wide surveillance program, for the identification, prevention, control, and investigation of infections and communicable diseases.

The home health agency failed to ensure staff was provided with education on infection control in 9 of 9 employee files reviewed.

The home health agency failed to ensure employees had a competency evaluation prior to patient contact in 3 of 3 HHA [Home Health Aide] personnel records reviewed, out of a total of 8 personnel records reviewed.

The home health agency failed ensure their home health aide received 12 hours of in-service training during each 12 month period of employment in 1 of 1 HHA [home health aide] personnel records reviewed with a year of service out of a total of 8 personnel filed reviewed.

The agency failed to ensure the registered nurse provided a complete and appropriate care plan for the home health aide [HHA] in 2 of 2 clinical records reviewed receiving HHA services (#1,#6), out of a total sample of 8 clinical records reviewed.

The agency failed to ensure all clinical record entries were legible, clear, complete, and appropriately authenticated in 8 of 8 clinical records reviewed.

The home health agency failed to ensure patients received all services documented in the plan of care in 3 of 8 records reviewed.

The home health agency failed provide the patient with written notice prior to agency termination, in regards to insurance non-coverage in 1 of 1 discharge with insurance coverage denial, out of a total of 8 clinical records reviewed.

The agency failed to ensure patients were advised of the state toll free home health telephone hotline, its contact information, and that its purpose is to receive complaints or questions about home health agencies in 2 of 3 patients with home visits, out of a total sample of 8 clinical records…

The agency failed to ensure communication with the physician, as well as document interventions attempted to obtain patient participation in the plan of care, when the patient declined services in 1 of 3 discharge records reviewed, out of a total of 8 records reviewed (#2).

The home health agency failed to ensure a resolution was made for a complaint of inconsistent services in 1 of 2 complaints reviewed (person N) The findings include: An undated agency policy titled "home Care bill of Rights/Grievance Procedure" stated "Policy Patients will be informed of their…

The home health agency failed to ensure complaints and their resolutions were documented in 2 of 2 patient complaints (person N , person O) The findings include: 1. An undated agency document titled "Home Care Bill of Rights/Grievance Procedure" stated "Policy Patients will be informed of their…

The agency failed to ensure the comprehensive assessment was individualized and reflected the patient's current status in 4 of 8 clinical records reviewed.

The home health agency failed to identify patient centered goals, strengths and care preferences in 4 of 8 clinical records reviewed.

The home health agency failed to ensure medications were reviewed and all medications taken by the patient were added to the plan of care in 2 of 5 active records reviewed.

The home health agency failed to ensure the plan of care included medication indications for as needed medications, services, and frequency and duration of services in 6 of 8 clinical records reviewed.

The agency failed to ensure drugs, services and treatments were administered only as ordered by the physician in 2 of 8 clinical records reviewed.

Based in clinical record review and interview the agency failed to ensure verbal orders were signed by the physician in 3 out of 8 clinical records reviewed (#3, #4, #7) The findings include: 1. An undated agency policy titled "Plan of Care" stated, "Policy Home care services are furnished under…

The home health agency failed to ensure the plan of care was reviewed and revised by the physician in 2 of 2 records in which a patient was on services longer than 60 days or as frequently as the patient's condition or needs required, out of a total of 8 clinical records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition in 1 of 3 discharged records reviewed, out of a total sample of 8 clinical records reviewed.

The agency failed to integrate services to ensure coordination of care provided by all disciplines in 4 of 4 patients receiving services from other healthcare agencies, out of a total of 8 clinical records reviewed.

The home health agency failed to ensure the written visit schedule was provided to patients in 3 of 3 home visit patients observed (#1, #5, #6) The findings include: 1. Clinical record review on 12/7/2020, of patient #5's home folder provided by the agency, failed to evidence a written visit…

The home health agency failed to ensure the patient was given a written medication schedule and instructions in 3 of 3 home visits conducted.

The agency failed to ensure all skilled professional staff was participating in the home health agencies QAPI [Quality Assessment and Performance Improvement] program.

The home health agency failed to ensure staff participated in in-service training in 8 of 8 records reviewed.

The agency failed to ensure nursing supervisory visits were made every 14 days in the homes of 4 of 4 clinical records reviewed receiving HHA [home health aide] services (#1, #3, #5, #6), out of a total sample of 8 clinical records reviewed.

The agency failed to ensure the supervising registered nurse ensured home health aide care was complete, safe, effective, and followed the patient's plan of care in 1 of 1 home visit conducted with a home health aide, out of a total of 3 home visits.

The administrator failed to ensure the day-to-day operations of the home health agency.

The administrator failed to ensure the clinical manager was available during normal operating hours.

The agency failed to ensure there was a qualified alternate administrator to run the day to day operations in the absence of the administrator.

The agency failed to ensure there was a qualified staff member, to be at the agency, at all times during normal business hours The findings include: An undated agency policy titled "Administrator Backup" stated, "Policy When the Administrator is not available, a designated qualified alternate will…

The agency failed to ensure the patient's clinical records evidenced all interventions, treatments, services, and responses to those interventions in 4 of 8 clinical records reviewed.

The agency failed to ensure a discharge summary was sent to the primary care provider in 3 of 3 discharged clinical records reviewed, out of a total sample of 8 clinical records reviewed.