Five Star Home Health Care Inc

The agency failed to maintain a Quality Assurance Performance Improvement (QAPI) program which measured, analyzed, and tracked quality indicators demonstrating improvement in outcomes and quality of care during 2018. Findings include: The agency was unable to provide evidence of a QAPI program for…

The agency failed to analyze data collected to implement preventative actions and make systemic improvement in Home Health Agency (HHA) operations.

The agency failed to develop a quality assessment and performance improvement (QAPI) program that tracked adverse patient events, analyzed their causes, and implemented preventive actions.

The agency failed to initiate and document Performance Improvement Projects (PIP) that would reflect the scope and complexity of services and demonstrate progress toward identified measurable goals.

The agency failed to safeguard the patient's personal health information (PHI), to prevent the risk of loss of PHI information or unauthorized access of the PHI information.

The agency failed to complete a comprehensive assessment within five calendar days from the start of care (SOC) date for 8 of 13 sampled patients (Patient (P)1, P3, P7, P8, P9, P11, P12, and P13 for whom this information was provided.

The agency failed to complete a medication profile for 10 of 13 sampled patients.

The agency failed to provide 2 of 5 sampled patients, (Patient (P)3 and P5) with current medication lists and instructions that were understandable to the patients.