Gem Home Care Inc

The agency failed to establish and maintain a comprehensive emergency preparedness program describing the facility's comprehensive approach to meeting the health, safety, and security needs of staff and patient populations during an emergency or disaster situation.

The agency failed to implement, evaluate and maintain an effective, ongoing, Home Health Agency-wide, data-driven QAPI program.

The agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services and operations.

The agency failed to utilize quality indicator data, including measures derived from OASIS (The Outcome and Assessment Information Set), where applicable, and other relevant data, in the design of its program; failed to use the data to monitor the effectiveness and safety of services and quality of…

The agency failed to maintain documentation to demonstrate performance improvement projects conducted annually at the HHA (home health agency).

The agency's governing body failed to define and implement an ongoing QAPI (quality assessment and program improvement) program for the purpose of quality improvement and patient safety; failed to ensure the HHA's (home health agency) QAPI efforts addressed priorities for improved quality of care…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program.

See tag 1023 Based on review of clinical records (CRs) and agency policy, and an interview with the administrator, the agency failed to complete the initial assessment within 48 hours of referral, or within 48 hours of the patients return home, or on the physician ordered start of care date for…

The agency failed to complete a comprehensive assessment within five (5) calendar days after the start of care date for four (4) of seven (7) CRs reviewed.

The agency failed to complete a comprehensive assessment within five (5) days of the end of the certification period for three (3) of seven (7) CR reviewed.

The agency failed to complete an assessment upon discharge for one (1) of three (3) discharged CRs reviewed.

The agency failed ensure that a registered nurse complete an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care for four (4) of seven (7) CRs reviewed.

The agency failed to ensure medication profiles were incorporated into the CR for four (4) of seven (7) CR reviewed.

The agency failed to provide documentation that a discharge summary was sent to the primary care physician within five (5) days of discharge for one (1) of three (3) discharged CRs reviewed (CR# 3).