Good Journey Home Health, LLC

The agency failed to ensure a patient centered QAPI Program for all patients and employees.

The agency failed to ensure an emergency preparedness disaster tabletop exercises or disaster drill were conducted for calendar years 2022 and 2023 for all patients and current staff members.

The agency failed to ensure SN frequencies were followed as ordered for two (Patients #2 and 4) of thirteen patients.

The agency failed to ensure a patient centered QAPI Program for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for all patients and employees.

The agency failed to ensure an individualized patient POC included the frequency and duration of visits to be made for seven (Patients #2, 3, 5, 8, 9, 11, and 12) of thirteen patients.

The agency failed to ensure SN obtained an order for oxygen administration for one (Patient #6) of thirteen patients.

The hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 80 patients and all employees.

The agency failed to ensure SN frequencies were followed as ordered for one (Pt #4) of seven patients.

The agency failed to ensure quality indicators were analyzed for 80 current patients, patients on services during calendar years 2019 and 2020, and all employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for 80 patients and all employees.

The agency failed to ensure governing body oversight of the agency's budget, QAPI Program and policies and procedures for all agency patients and staff employed by the agency during 2020. A review of administrative records for calendar year of 2020 showed no review and approval of: 1) annual…

The agency failed to ensure the initial assessment was performed within 48 hours of the referral for one (Pt #2) of seven patients.

The agency failed to ensure: 1. wound care was ordered for one (Pt #3) of seven patients; 2. an OT evaluation was ordered for one (Pt #6) of seven patients; 3. a PT evaluation was ordered for one (Pt #6) of seven patients.

The agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements was sustained for all patients and employees.

The agency failed to revise a plan of care to meet patient needs for one (Patient #3) of ten patients.

The agency failed to ensure patients had access to their current POC for three (Pt #3, 4 and 5) of ten patients.

The agency failed to specify the visit frequency for one (Pt #4) of ten patients.

The agency failed to ensure wound care was provided as ordered by a physician for one (Pts #4) of 10 patients.

The agency failed to ensure visits were completed in accordance with the plan of care for one (Pts #4 and 5) of ten patients.

The agency failed to ensure an RN supervisory visit was made every two weeks for one (Pt #5) of six patients who received CHHA services.

The agency failed to complete a discharge and or transfer for two (Pt #1 and 6) of ten patients.