Green Country Home Care, Inc

The agency failed to ensure the governing body provided oversight of the agency's Quality Assessment and Performance Improvement Program for all patients and staff.

The agency failed to maintain a patient centered Emergency Preparedness Program for all current patients and employees.

The agency failed to update the Communication Plan for the Emergency Preparedness Program for all current patients and employees.

The agency failed to ensure emergency drills were completed at least bi-annually for all current patients and all employees.

The agency failed to document/create a PIP for 2024 through their QAPI Program for all employees and 38 current patients.

The agency failed to ensure the QAPI program was approved by the governing body for all current patients and all employees.

The agency failed to ensure two (Staff E and F) of two CHHAs had a competency evaluation.

The agency failed to ensure CHHA completion of 12 hours of annual training for two (Staff E and F) of two CHHAs.

The agency failed to ensure the governing body provided oversight of the agency's Quality Assessment and Performance Improvement Program for all patients and staff.

The agency failed to ensure the correct wound care orders for one (Pt #2) of seven patients.

The agency failed to ensure a skilled nurse completed clinical notes for one (Pt. #3) of seven patients.

The governing body failed to ensure professional direction was provided in the agency's daily functions by an appointed administrator for all patients and staff.

The governing body failed to ensure a pre-designated person was available to provide continuity to the agency, in the absence of the administrator, for all employees and patients.

The agency failed to ensure evidence of a patient centered QAPI Program for 87 patients and all employees.

The agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 87 patients and all employees.

The agency failed to ensure an Emergency Preparedness Communication Plan included required staff contact information for the agency for 87 patients and all employees.

The agency failed to ensure an emergency preparedness disaster table-top exercise, drill, or participation in a community-based drill or declaration was conducted for calendar year 2020 and no agency after action response to community-based drill participation in calendar year 2021 for 87 patients…

The agency failed to ensure evidence of a patient centered QAPI Program for 87 patients and all employees.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 87 patients and all employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for 87 patients and all employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for 87 patients and all employees.

The agency failed to ensure: 1. The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for 87 patients and all employees and; 2. The Infection…

The agency failed to ensure an advance beneficiary notice was provided prior to being discharged from the agency to one (Patient #6) of seven patients.

The agency failed to ensure PT visits were conducted as ordered by the physician for one (Patient #2) of seven patients.

The agency failed to ensure a transfer/discharge summary was provided for two (Patients #5 and #7) of seven patients.