Grand Care Home Health Services, Inc

The agency failed to establish and maintain a comprehensive emergency preparedness program that meets the requirements of 42 CFR 485.727. This deficient practice could potentially affect all staff and patients of the agency in the event staff is not properly prepared for an emergency.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of the referral for 3 of 8 records reviewed resulting in patients not receiving care to assure a safe return home (G512); failed to conduct a patient-specific, comprehensive assessment that accurately reflected…

The Agency (HHA) failed to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided (G642); and failed to develop Performance Improvement activities, as part of the Agency's QAPI…

The Agency (HHA) failed to ensure the skilled nurse (SN) followed accepted Infection Control standards of practice during wound care for 1 of 1 patient requiring wound care treatment, from a total sample of 7 sampled records reviewed (MR #5) (G682); failed to coordinate an agency-wide program for…

The agency (HHA) failed to ensure that 1 of 2 Home Health Aides (HHa #1) employed by the Agency, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs (G774); failed to ensure that the individuals who…

The agency failed to develop and implement emergency preparedness policies and procedures for the home health agency resulting in not having direction for agency actions should a disaster occur.

The agency failed to develop and implement emergency preparedness training and testing program for the home health agency resulting in agency personnel not being trained in actions to take should a disaster occur.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of the referral for 3 of 8 records reviewed (MR#s 4, 7, 8), from a total sample of 8 records, resulting in a delay in determining the patient's immediate care and support needs.

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments to determine progress towards goals, and ascertained the…

The agency failed to ensure the plan of care included measurable and individualized goals and outcomes as required in 2 of 8 records reviewed out of a total sample of 8 records reviewed (MR#s 6 and 7).

The Agency (HHA) failed to measure, track and analyze its quality indicators in order to assess processes of care and services, resulting in the inability to improve patient care with positive outcomes.

The Agency (HHA) failed to develop Performance Improvement activities, as part of the Agency's QAPI (Quality Assessment Performance Improvement) program, to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering…

The Agency (HHA) failed to ensure the skilled nurse (SN) followed accepted Infection Control standards of practice during wound care for 1 of 1 patient requiring wound care treatment, from a total sample of 8 sampled records reviewed (MR #5), resulting in the potential for transmission of…

The Agency (HHA) failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for…

The Agency (HHA) failed to provide documented evidence that infection control education was provided to staff, resulting in the potential for the development and spread of infection.

The agency (HHA) failed to ensure that the individuals who furnished Home Health Aide (HHa) services on its behalf met the competency evaluation requirements of this section by ensuring the subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section were evaluated…

The agency (HHA) failed to ensure that 1 of 2 Home Health Aides (HHa #1) employed by the Agency, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency (HHA) failed to ensure the Registered Nurse (RN) prepared clear concise written patient care instructions for the provision of Home Health Aide (HHa) services in 2 of 3 records in which aide services were ordered, from a total of 8 records reviewed, (MR #4, 7) resulting in the potential…

The skilled nurse failed to follow agency policy as required regarding supervision of Home Health aide (HHa) services in 1 of 2 records in which home health aide services were provided (MR# 7) out of a total of 8 records reviewed.

The agency failed to ensure that the admission consent was authenticated with dates and signatures for 1 of 8 records reviewed (MR#7).

The agency failed to include contact information for the Home Health Agency Administrator including the Administrator's name, in the agency "Patient Admission/Orientation Packet," in order to facilitate the patient rights in lodging complaints.

The agency (HHA) failed to ensure that Home Health Aide (HHa) services were provided as ordered in the plan of care for 2 of 3 records with Home Health Aide services ordered, from a total of 8 sampled records reviewed (MR's # 4, 1) resulting in the potential for poor hygiene, and unmet care needs.

The agency failed to ensure patients were notified of the names, addresses and telephone numbers of the federally and stated funded entities that serve the areas in which their patients reside which affected 8 out of 8 records reviewed out of a total sample of 8 records reviewed (MR #1, 2, 3, 4, 5…

The agency failed to document the existence and resolution of registered complaints lodged by patient's, staff, or their representatives.

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, document the findings of the drug regime review, and failed to ensure the physician was notified of any potential drug interactions in 2 records, from a total of 8…

The agency failed to ensure the total plan of care was reviewed and signed by the physician at least every 60 days for 1 of 3 records reviewed (MR# 2) in which the patient had been recertified for care, from a total sample of 8 records reviewed, resulting in the inability of the agency to ensure…

The Agency (HHA) failed to ensure that Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services were administered in accordance with the Physician's orders and the plan of care in 8 of 8 records with SN, PT, and OT services ordered (MR#s 3, 5, 7, 8, 9, 10, 11, 12) from a…

The Agency (HHA) failed to ensure the skilled discipline made an annual onsite observation visit at the patient's residence to observe the care being provided, for 1 of 2 Home Health Aides (HHa #2) employed by the Agency, resulting in the potential for the provision of substandard care and unmet…

The agency failed to ensure the clinical record was complete in 1 of 8 records reviewed (MR#1) in which services were ordered, from a total of 8 sampled records, resulting in an incomplete clinical record for the patients.

The Agency (HHA) failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician in 2 of 2 closed records, from a total of 8 records reviewed (MR#s 4 and 7), resulting in the potential…