Fni Healthcare, Inc

The agency failed to maintain documentation of evidence of the staff’s ability to demonstrate knowledge of agency’s emergency preparedness plan.

The agency failed to ensure each patient received home health services as ordered by the physician in the patient's individualized plan of care for five (5) of seven (7) clinical records in the survey sample (Clinical records #1, #2, #3, #5 and #6).

The agency failed to ensure patients were notified of the disciplines that would furnish care and/or the purposed visit frequency in advance of providing care for five (5) of seven (7) clinical records reviewed in the survey sample (Clinical records #1, #2, #4, #5, and #6).

The agency failed to ensure patient discharge summaries were sent to the physician within five (5) business days of discharge as required for two (2) of two (2) discharge records in the survey sample (Clinical records #3 and #4).

The agency failed to ensure and document that patients were allowed to participate in their care (see G434); patients failed to receive all services ordered in the plan of care (see G436); failed to inform patients of their financial liability for payment (see G440); failed to provide patients with…

The agency failed to provide safe care as ordered by a physician.

The agency failed to implement, evaluate and maintain an effective, ongoing HHA (Home Health Agency)-wide, data driven QAPI (Quality Assurance Performance Improvement) program (refer to G642); The agency failed to focus on high risk, high volume, or problem-prone areas (refer to G648); The agency…

The agency failed to develop and implement an emergency preparedness plan (EPP) that contained all the required elements of the regulations and was reviewed annually.

The agency failed to ensure an up to date all hazards risk assessment had been completed for the agency.

The agency failed to develop and maintain an emergency preparedness plan (EPP) that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency…

The agency's emergency's preparedness policy and procedures failed to include procedures to inform State and local emergency preparedness officials about home health patients in need of evacuation from their residences.

The agency's emergency's preparedness policy and procedures failed to include the procedures to follow up with on-duty staff and patients.

The agency's emergency's preparedness policy and procedures failed to include a policy for medical documents.

The agency's emergency preparedness policies and procedures failed to include a policy and procedure for the use of volunteers in an emergency or other professionals for emergency staffing needs.

The agency's emergency preparedness policies and procedures failed to contain a current communication plan that included contact information for federal, state, tribal, and regional emergency preparedness (EP) staff.

The agency's Emergency Preparedness Plan (EPP) failed to identify their primary and alternate means for communicating with Federal, State, tribal, regional, and local emergency management agencies.

The agency's emergency's preparedness policy (EPP) failed to include methods for sharing medical documentation for patients with other health providers to maintain continuity of care.

The agency failed to provide initial and ongoing training to staff, provide training at least annually, demonstrate staff knowledge and maintain documentation of all emergency preparedness training.

The agency failed to ensure the OASIS data accurately reflected the patient's status at the time of assessment for five (5) of ten (10) patients whose records were reviewed in the survey sample and or had a home visit.

The agency's staff failed to follow the plan of care for six (6) of ten (10) patients whose records were reviewed in the survey sample (Clinical records #1, 3- 6, and 9).

The agency's staff failed to follow physicians orders for wound care for one (1) of one (1) patient in the survey sample receiving wound care and had a home visit conducted (Clinical record #6 ).

The agency failed to maintain a quality assessment/process improvement program (QAPI) with a defined scope of the program and show of measurable improvement indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The agency failed to document the quality improvement projects undertaken, the reasons for conducting the projects, and the measurable progress achieved on the projects.

The agency's governing body failed to ensure an ongoing program for quality improvement and patient safety is defined, implemented and maintained; all improvement actions are evaluated for effectiveness and with clear expectations including any findings of fraud or waste appropriately addressed.

The Administrator failed to provide organization, and overall administrative duties related to the agency's ongoing functions to include maintaining an ongoing liaison among the governing body, and the staff.

The agency failed to ensure the patient was free from neglect by anyone furnishing services on behalf of the HHA (Home Health Agency).

The agency failed to ensure patients were informed at the time of admission of the disciplines that would provide care and the frequency of proposed visits for ten (10) of ten (10) patients whose records were reviewed in the survey sample (Clinical records #1-10).

The agency failed to ensure each patient was advised in advance of providing care the extent to which payment for HHA (home health agency) services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, the charges for services that may not…

The agency failed to provide a Home Health Change of Care Notice (HHCCN) to Medicare patients in advance of reducing/discontinuing services for one (1) of two (2) clinical records reviewed in the survey sample for which a HHCCN was applicable (Clinical record: #3) The findings: Clinical records…

The agency failed to provide the names, addresses, and telephone numbers of the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center; and the Quality Improvement Organization for where the patient resides for eight (8) of eight (8)…

The agency failed to document each complaint with a documented investigation and or resolution of the complaint for 13 of 41 complaints reviewed from 12/30/2018 to 05/17/2019. The findings: Forty-one complaints were reviewed in the agency on 05/28/2019. The complaint log revealed an incomplete…

The agency failed to ensure each patient's medication profile contained a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions…

The agency failed to ensure the patient's individualized plan of care included a description of the patient's durable medical equipment and supplies, the risk for emergency department visits and hospital re-admissions, measurable outcomes and/or goals, and patient stated goals for ten (10) of ten…

The agency staff failed to follow physicians orders for wound care for six (6) of six (6) patients whose records were reviewed in the survey sample and receiving wound care (Clinical records #1, 2, 3, 6, 9 and 10).

The agency's staff failed to promptly alert the physician to changes in the patient's condition or needs that may require an alteration in the plan of care for two (2) of ten (10) patients whose records were reviewed in the survey sample and or had a home visit (Clinical records #1 and 6).

The agency's staff failed to communicate with the patient's physician for two (2) of ten (10) patients whose records were reviewed in the survey sample and had a home visit (Clinical records #1 and #6).

The agency's professional staff failed to ensure that each patient and his or her caregivers receive ongoing education and training provided as appropriate, regarding the care and services identified in the Plan of Care for one (1) of ten (10) patients whose records were reviewed in the survey…

The agency failed to maintain a quality assessment/process improvement program (QAPI) that focused on high risk, high volume areas.

The agency failed to maintain a quality assessment/process improvement program (QAPI) that focused on high risk, high volume areas and which the agency considered the incidence, prevalence and severity of problems in those areas.

The agency failed to ensure corrective action was taken on identified problems that directly or potentially threaten the health and safety of patients.

The agency failed to take actions aimed at performance improvement, and measure its success and track performance to ensure that improvements are sustained.

The agency staff failed to ensure all clinical notes and physician orders were in the clinical record for three (3) of ten (10) patients whose records were reviewed in the survey sample (Clinical records #2, 5, and 9).

The agency failed to send the patient's transfer summary and/or a discharge summary to the primary care physician within 5 business days of discharge or within 2 days of transfer for three (3) discharged patients and two (2) transferred patients whose records were reviewed in the survey sample…