Health Care Solutions Services, Inc

The agency failed to ensure the emergency preparedness plan included a documented facility-based and community-based risk assessment, utilizing an all-hazards approach.

The agency failed to ensure the emergency preparedness plan included a process for cooperation and collaboration with tribal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

The agency failed to ensure the emergency preparedness policies and procedures were reviewed and updated at least every 2 years.

The agency failed to ensure the emergency preparedness plan included the procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric…

The agency failed to ensure the emergency preparedness plan included the procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency.

The agency failed to ensure the emergency preparedness program included a communication plan which was reviewed and updated at least every 2 years.

The agency failed to ensure their emergency preparedness plan included a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care.

The agency failed to ensure the emergency preparedness plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

The agency failed to ensure the OASIS data were transmitted within 30 days of completing the asessments.

The agency failed to complete the initial comprehensive assessment in a timely manner consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care for four of eight sampled patients (Patients 1, 2, 3, and 5).

The agency failed to ensure the completion of the updated comprehensive assessment within the last 5 days of every 60 days for one of eight sampled patients (Patient 1).

The agency failed to ensure the POC included the required components for two of eight sampled patients (Patients 1 and 2).

The agency failed to ensure effective communication with the patient’s physician for one of eight sampled patients (Patient 3).

The agency failed to ensure an interdisciplinary case conference to discuss and coordinate care for one of eight sample Patients (Patient 1) was completed.

The agency failed to ensure patient and caregiver education was provided for one of eight sampled patients (Patient 1).

The agency failed to ensure the skilled professionals consistently completed the clinical records for three of eight sampled patients (Patients 1, 4, and 5).

The agency failed to ensure the RN's supervisory oversight of a licensed vocational nurse for one of eight sampled patients (Patient 1).

The agency's Administrator failed to be responsible for the day-to-day operations related to the following: - The annual tuberculosis screening test for PT 1 was not available in the personnel file records. - The performance evaluation was not completed for Patient 1 as per the agency's P&P. - The…

The agency failed to ensure the emergency preparedness plan was updated at least every two years.

The agency failed to ensure their comprehensive emergency preparedness program was facility based and community-based risk assessment, utilizing an all-hazards approach.

The agency failed to ensure their comprehensive emergency preparedness program addressed the patient population, including the plans to continue operations.

The agency failed to ensure their emergency preparedness plan included a process for cooperation and collaboration with the local, tribal, regional, state, and federal emergency preparedness officials.

The agency failed to ensure their comprehensive emergency preparedness program based on the risk assessment was updated at least every two years.

The agency failed to ensure the emergency preparedness plan included procedures to inform the state and local emergency officials about the patients in need of evacuation from their residences due to an emergency situation.

The agency failed to ensure the emergency preparedness plan included procedures to follow up with the on-duty staff and patients, to determine the services needed and procedures to inform the state and local officials of any on-duty staff or patients they are unable to contact.

The agency failed to ensure the emergency preparedness plan included a system of medication documentation that preserves, protects, and secures the patient information, and maintains availability of the records.

The agency failed to ensure the emergency preparedness plan addressed the use of the volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

The agency failed to ensure the emergency preparedness communication plan was updated at least every two years, creating the increased risk of not addressing the care needs of the patients during the emergency events.

The agency failed to ensure the emergency preparedness plan included the updated name and contact information of the staff, entities provided services under agreement, patients' physician, and volunteers.

The agency failed to ensure the emergency preparedness plan included the contact's name and information for the federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance.

The agency failed to ensure the emergency preparedness plan included the method for sharing the information and medical documentation for the HHA's patients with other health providers to maintain the continuity of care, creating the increased risk of not providing appropriate, consistent, and…

The agency failed to ensure the emergency preparedness training and testing program were updated at least every two years, creating the increased risk of not addressing the care needs of the patients during emergency events.

The agency failed to ensure initial training in the emergency preparedness program was provided to all new staff, existing staff, volunteers, and contracted individuals providing services under arrangement and the documentation of all the emergency preparedness training was maintained.

The agency failed to ensure the POC was revised for one of seven sampled patients (Patient 5), creating the risk of not providing the necessary care and services to this patient.

The agency failed to implement and maintain the infection control program including the surveillance, identification, prevention, and control, creating the risk of the spread of infections.

The agency failed to ensure CHHA 1 completed at least 12 hours of in-service training as required by the regulations.

The agency failed to ensure the CHHA followed the written assignment as prepared by the RN for two of seven sampled patients (Patients 2 and 7), creating the risk of not providing the necessary care and services to these patients.

The agency’s Governing Body failed to ensure overall management and operation responsibility related to Professional Advisory Committee meetings, creating the risk for not identifying potential problems, establishing, and implementing action plan.

The agency failed to ensure the complaints for one of seven sampled patients (Patient 3) and three nonsampled patients (Patients A, B, and C) were thoroughly investigated, creating the risk not providing quality of care and services to these patients.

The agency failed to ensure the resolution of the complaints were provided in writing for one of seven sampled patients (Patient 3) and three nonsampled patients (Patients A, B, and C), creating the risk of violating the patient's rights and not addressing the grievances for the patients.

The agency failed to ensure the initial comprehensive assessments were completed accurately and consistently with the patients’ immediate needs for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7).

The agency failed to ensure the medication profiles were updated to reflect the current medications, include all the medication side effects, actual or potential drug interactions, and duplicate drug therapy for three of seven sampled patients (Patients 3, 4, and 6).

The agency failed to ensure the updated comprehensive assessments were completed accurately and consistently with the patients’ immediate needs for five of seven sampled patients (Patients 1, 2, 4, 5, and 6).

The agency failed to ensure the comprehensive assessment was completed at discharge for two of seven sampled patients (Patients 6 and 7), creating the risk of not updating the patient's status for these patients.\ #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical…

The agency failed to coordinate the care to meet the patients' care needs for two of seven sampled patients (Patients 2 and 6), creating the risk of not providing the necessary care and services to these patients. #. Review of Patient 6's closed clinical record was initiated on 8/3/23. The clinical…

The agency failed to assess the patient or PCG’s competency related to wound care management for one of seven sampled patients (Patient 1).

The agency failed to provide the written instructions outlining the visit schedules and treatments for two of seven sampled patients (Patients 3 and 4).

The agency failed to provide the written instructions outlining the treatments to be administered by the agency personnel for one of seven sampled patients (Patient 5).

The agency failed to ensure the SN provided care and services in accordance with the POC for one of seven sampled patients (Patient 2), creating the risk of not providing appropriate, consistent, and quality care to this patient.

The agency failed to ensure the agency's skilled staff prepared accurate and complete clinical notes for five of seven sampled patients (Patients 1, 2, 4, 6, and 7).

The agency failed to ensure the responsibility for the day-to-day operations by not implementing the agency's P&P as evidenced by: * The agency failed to ensure the wounds were measured for depth and at least weekly as per the agency's P&P for three of seven sampled patients (Patients 1, 5, and 6).…

The agency failed to ensure the discharge and transfer summaries were completed and sent to the the patients' physicians timely for two of seven sampled patients (Patients 6 and 7).

The agency failed to ensure the emergency plan was reviewed and updated at least annually, creating the risk of not providing the necessary care and services to the patients during the disaster events.

The agency failed to ensure the risk assessment was accurate.

The agency failed to ensure the emergency plan in the comprehensive assessment was accurate for four of seven sampled patients (Patients 4, 5, 6, and 7), creating the risk of not providing the necessary care and services for these patients.

The agency failed to ensure the emergency preparedness P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The agency failed to maintain the emergency communication plan that included contact information for other sources of assistance for two of seven patients (Patients 5 and 7).

The agency failed to ensure the initial comprehensive assessments were completed for two of seven patients (Patients 2 and 7), creating the risk of not identifying and addressing the care needs timely for these patients.

The agency failed to ensure the patients received care and services as written in the POC for six of seven sampled patients (Patients 1, 2, 3, 4, 5, and 6), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to ensure the clinical records were accurate for five of seven sampled patients (Patients 2, 3, 5, 6, and 7), creating the risk of substandard care provided to these patients as their clinical information was not complete.

The agency failed to ensure the complaint process was completed as per the agency's P&P for one sampled patients (Patient 3) and three nonsampled patients (Patients A, B, and C), creating the risk of violating the patient's rights and not addressing the grievances for these patients.

The agency failed to ensure the review of the medications included all of the patient's current medications to identify any potential adverse effects and drug reactions for two of seven sampled patients (Patients 4 and 7).

The agency's RN failed to complete the updated comprehensive assessments within the last 5 days of every 60 days for one of seven sampled patients (Patient 6), creating the increased risk of not addressing the care needs for these patients.

The facility failed to ensure the POC included specific information related to wound care for one of seven sampled patients (Patient 3), creating the risk of not addressing the care needs for this patient.

The agency failed to ensure the verbal order was put in writing for one of seven sampled patients (Patient 5), creating the risk of not providing appropriate, consistent, and quality care to this patient.

The agency failed to ensure the SN coordinated care with the physician for two of seven sampled patients (Patients 1 and 7), creating the risk of not providing the necessary care and services to these patients.

The agency failed to provide the written instructions outlining the SN visit schedule for one of seven sampled patients (Patient 7), creating the risk of not providing the necessary information to this patient.

The agency failed to ensure the skilled professional staff provided care and services as written in the POC for six of seven sampled patients (Patients 1, 2, 3, 4, 5, and 6), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to ensure the SN had completed and accurately prepared the clinical notes for one of seven sampled patients (Patient 3), creating the increased risk of substandard healthcare outcomes to this patient.

The agency failed to ensure the agency's RN provided supervision to the SN to ensure quality of care and services provided for two of seven sampled patients (Patients 5 and 6), creating the risk of a substandard healthcare outcome to these patients.

The agency failed to ensure the CHHA provided care and services in accordance with the POC for two of seven sampled patients (Patients 1 and 4), creating the risk of not providing necessary care and services to this patient.

The agency failed to ensure the supervisory visits for the patients who received CHHA services were conducted every 14 days to two of the seven sampled patients (Patients 1 and 4), creating the increased risk of providing substandard healthcare to these patients.

The agency's Administrator failed to be responsible for the day-to-day operations as the agency's P&P addressing the employee's TB screening was not implemented for two employees (CHHAs 1 and 2), creating the increased risk of having unqualified staff provided care to these patients.

The agency failed to ensure the transfer summary was sent to the physician within two business days of becoming aware of the unplanned transfer for one of seven sampled patients (Patient 4), creating the risk of the physician not knowing the patient's condition to anticipate the patient's care…