Great Lake Home Care, LLC

The Administrator failed to ensure that Federal and State agencies were notified of the Agency's change of address, resulting in the potential for the Agency to be operating out of compliance with Federal requirements.

The Agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs.

The Agency failed to ensure the clinical record was authenticated for accuracy and correctness by appropriate staff entities in 1 of 8 records (MR#7) from a total sample of 8 records, resulting in having inaccurate information documented in the medical record.

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on a past medical history that included dates of onset, exacerbations, treatments, and outcomes, history of events leading to current home care needs that…

The Agency failed to ensure that a Registered Nurse performed a comprehensive review of all medications in 2 of 2 record (MRs #5 & 8) following a resumption of care after hospitalization, from a total of 8 sampled records, resulting in the potential for harmful medication effects for all 28…

The Administrator failed to be responsible for all day-to-day operations of the Home Health Agency, resulting in a lack of supervision of the clinical staff and daily operations.

The Agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes in 6 of 8 records reviewed (MR#s 1, 2, 4, 5, 7, and 8) out of a total sample of 8 records reviewed, resulting in difficulty determining the patient's progress toward the achievement of…

The agency failed to ensure a transfer summary was sent to the physician/receiving facility within 2 business days of the patient's transfer for 2 of 3 (MR#'s 6, and 8) records in which the patient was transferred to an inpatient facility out of a total of 8 records reviewed, resulting in the…

The agency failed to ensure the Plan of Care (POC) included measurable and individualized goals and outcomes to determine progress towards goals throughout the certification period in 2 of 10 records reviewed (MR#s 1 and 5).

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program, (refer to G 0642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, (refer to G0644); failed to initiate any…

The agency failed to ensure actions were taken to communicate patient's needs to the physician resulting in the patient being hospitalized due to hyperglycemia (elevated blood glucose level) in 1 of 1 records reviewed in which there was serious harm to a patient (MR#2) (See G706).

The agency failed to maintain compliance with this condition of participation.

The agency failed to maintain compliance with this condition of participation. the agency failed to ensure the clinical record included all clinical notes and physician orders for 3 of 10 records reviewed (MR# 2, 7 and 8) (See G1012); failed to ensure the clinical record contained interventions to…

The agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 6 of 10 records reviewed (MR #1, 5, 6, 7, 8 and 9) for Emergency Preparedness out of a total sample of 10 records reviewed, resulting in the potential for negative patient…

The Agency failed to implement in the Emergency Preparedness policy the use of volunteers and other emergency staffing strategies, and the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, resulting in the…

The Agency (HHA failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the following required subject areas (1) Names and contact information for the following: (iii) Patients' physicians, (iv) Other [facilities]…

The Agency failed to ensure the communication plan included a method for sharing information and medical documentation for patients under the Agency's care with other providers to maintain continuity of care, resulting in the potential to affect the Agency's ability to provide pertinent patient…

The agency failed to ensure the Plan of Care (POC) included measurable and individualized goals and outcomes in two of ten records reviewed (MR#s 1 and 5) resulting in a potential for failure to measure progress toward achievement of desired outcomes.

The agency failed to ensure skilled professional services were provided as ordered by the physician for 2 of 10 records reviewed (MR#s 1 and 7) , resulting in the potential for poor outcomes for these patients.

The Agency (HHA) failed to analyze its quality indicators to assess processes of care and services, resulting in the inability to determine the scope of services provided.

The agency failed to monitor data for the Quality Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the governing body approved the QAPI…

Executive Responsibilities For Qapi

The agency failed to ensure that 3 of 3 home health aides (HHa #1, #3 and #4) received the required 12 hours of annual in-service training, resulting in a lack of educational opportunities pertinent to patient care and the potential for substandard care.

The agency failed to ensure the registered nurse (RN) prepared clear written patient care instructions for the home health aide (HHa) regarding patient needs prior to providing care for 4 of 5 patients (MR# 5, 7, 8 and 9) in which HHa services were provided, resulting in the potential for the…

The agency failed to ensure that all entries in the medical record were authenticated by a signature, date and title for 2 of 10 records reviewed (MR#7 and 8), resulting in a lack of validation as to the correctness of the entries in the medical record.

The agency failed to ensure the plan of care (POC) included all pertinent interventions, treatments, and measurable outcomes and goals specific to the needs of the patient for 7 of 10 records reviewed (MR#s 1, 2, 4, 5, 7, 8, and 9), resulting in patients not receiving care specific to their…

The agency failed to ensure that care and services were provided only in accordance with physician's orders for 1 of 2 records reviewed (MR# 7) in which the patient was recertified for an additional episode of care; and in 1 of 2 records reviewed (MR# 1) in which occupational therapy services were…

The agency failed to ensure the plan of care was reviewed and revised by the physician at least every 60 days for 1 of 2 records reviewed (MR# 7) in which the patient was recertified for an additional episode of care, resulting in the potential for overlooked patient needs and the provision of…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 of 7 records reviewed (MR#2) in which the patient had uncontrolled blood glucose levels, from a total sample of 10 records reviewed, resulting in a poor patient outcome of hospitalization.

The Home Health Agency (HHA) failed to develop a QAPI (Quality Assessment Performance Improvement) program that focused on high risk, high volume or problem-prone areas of the agency, to monitor the agency's improvement in these areas resulting in the agency's inability to improve in patient care…

The agency failed to ensure the skilled nurse performed complete assessments and re-assessments of the patient's health status including, blood glucose monitoring in 1 of 10 records reviewed (MR# 2), in which nursing services were provided out of a total sample of 10 records reviewed, which…

The agency failed to ensure that Skilled Nursing (SN), Home Health Aide (HHa), and Physical Therapy (PT) services were administered in accordance with the physician's orders and the plan of care (POC) in 3 of 10 records reviewed (MR# 4, 7, 8), from a total sample of 10 records reviewed, resulting…

The agency failed to ensure the skilled professionals prepared clinical notes for 1 of 10 records reviewed (MR#7), from a total sample of 10 records reviewed, resulting in the physician not having a complete clinical picture of the patient's health status and progress toward goals during the period…

The agency failed to ensure the Skilled Nurse (SN) coordinated services with the physician in 3 of 10 records reviewed (MR# 2, 4, 7) with unreported significant patient condition changes from a total of 10 records reviewed, resulting in the potential for unidentified, untreated health concerns and…

The registered nurse failed to supervise the services provided by the Licensed Practical Nurse (LPN) every 30 days for 4 of 6 records reviewed with LPN services (MR# 2, 4, 8, and 9) out of a total of 10 record review with nursing services, resulting in failure of the LPN to provide services as…

The qualified therapists failed to supervise the services that were provided by the therapy assistants for 2 of 5 records reviewed (MR# 1 and 10) with physical therapy assistant services were provided, out of a total of 9 records with therapy services, for a potential for unmet therapy needs.

The agency failed to ensure the home health aide (HHa) provided services as ordered in the plan of care for 2 of 5 patients (MR# 7 and 10) in which HHa services were provided, resulting in the patient not receiving services as ordered.

The agency failed to ensure the registered nurse completed an on-site supervisory visit to the patient's home at least every 14 days to supervise the services that were provided by the home health aide (HHa) for 4 of 5 records reviewed (MR# 7, 8, 9, and 10) in which aide services had been…

The agency failed to ensure the clinical record included all clinical notes and physician orders for 4 of 10 records reviewed (MR# 2, 7, 8 and 9), resulting in an incomplete clinical record that fails to communicate a clear and concise clinical picture of the patient's health status and progress…

The agency failed to ensure the clinical record contained interventions to reduce high blood glucose levels for 1 of 1 record reviewed (MR#2) in which the patient had uncontrolled blood glucose levels resulting in hospitalization.

The Home Health Agency (HHA) failed to ensure the discharge summaries were complete and provided the patient's current health status at the time of discharge, status of problems identified throughout the course of care, and a summary of care or services provided in 5 of 5 records reviewed in which…