Heart Care at Home, LLC

The agency failed to ensure documentation of patient rights and responsibilities were available for review for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients.

The agency failed to ensure a comprehensive assessment (OASIS) was conducted at SOC for one (Patients #1) of seven patients.

The agency failed to ensure development of an episodic certification Plan of Care for three (Patients #1, 2 and #6) of seven patients.

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

The agency failed to ensure clinical records were maintained in their entirety and accessible for two (Patients #1 and #2) of seven patients.

The agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) was updated for the agency for all patients and employees.

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

The agency failed to ensure completion of a discharge summary for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients.

The agency failed to ensure development of a Plan of Care for three (Patients #1, 2 and #6) of seven patients.

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

The agency failed to ensure utilization of QAPI data in calendar years 2023, 2024 and 01/01/25 to 11/24/25 to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI activities included follow-up for self-monitoring for outcomes, improved care, services and operations for all patients and employees.

The agency failed to ensure a performance improvement project for the agency from 07/02/23 to 12/31/23, calendar year 2024 and 01/01/25 to 11/24/25 for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program from 09/05/24 to 12/31/24 and 01/01/25 to 11/24/25 for all patients and employees.

The agency failed to ensure the Infection Control program surveillance data was included in QAPI program activities for all patients and employees.

The agency failed to ensure documentation of patient rights and responsibilities were available for review for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients.

The agency failed to ensure patient consent for the provision of agency care and services were obtained for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients.

The agency failed to ensure advance beneficiary notice and/or HHCOC notice was provided to five (Patients #1, 2, 3, 5 and #7) of seven patients.

The agency failed to ensure a comprehensive assessment (OASIS) was conducted at SOC for one (Patients #1) of seven patients.

The agency failed to ensure a medication profile was completed for ordered medications for two (Patients #1 and #2) of seven patients.

The agency failed to ensure a discharge assessment (OASIS) was completed for four (Patients #1, 2, 6 and #7) of seven patients.

The agency failed to ensure individualized patient POC for four (Patients #3, 5, 6 and #7) of seven patients.

The agency failed to ensure a physician order for wound site care interventions as a part of the patient’s plan of care for one (Patient #2) of seven patients.

The agency failed to ensure timely notification and physician opportunity to review and revise individualized POCs every 60 days for four (Patients #3, 5, 6 and #7) of seven patients.

The agency failed to ensure: PT evaluation was conducted as ordered for one (Patient #5) of seven patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure clinical records were maintained in their entirety and accessible for two (Patients #1 and #2) of seven patients.

The agency failed to ensure clinical visit note documentation was completed for one (Patient #7) of seven patients.

The agency failed to ensure a completed transfer with discharge summary was provided to the receiving service provider for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients.

The agency failed to ensure the individualized patient POCs included: 1. Pain reporting parameters for five (Patients #1, 3, 4, 5 and #7) of seven; 2. Recurring urinary catheter change treatment due dates for one (Patient #1) of seven; 3. Wound care treatment interventions and related goals for two…

The agency failed to ensure an ongoing patient centered QAPI Program for 29 patients and all employees.

The agency failed to ensure infection control policies and procedures followed accepted standards of practice to prevent infection and disease for 29 patients and all employees.

The agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) for 29 patients and all employees.

The agency failed to ensure its Emergency Preparedness Program, including its written policies and procedures were reviewed annually for 29 patients and all employees.

The agency failed to ensure documentation of an Emergency Preparedness Communication Plan which included required information related to the agency staff contact information for 29 patients and all employees.

The agency failed to ensure documentation of an Emergency Preparedness Communication Plan which included required contact information for the emergency management resource agencies for the agency effecting 29 patients and all employees.

The agency failed to ensure documentation of an emergency preparedness testing and training education program for 29 patients and all employees.

The agency failed to ensure an emergency preparedness disaster table-top exercise and/or drill was conducted by the agency for 29 patients and all employees.

The agency failed to ensure completion of a transfer/discharge summary for three (Patients #4, 6 and #7) of seven patients.

The agency failed to ensure the individualized patient POCs included: Pain reporting parameters for five (Patients #1, 3, 4, 5 and #7) of seven;Recurring urinary catheter change treatment due dates for one (Patient #1) of seven;Wound care treatment interventions and related goals for two (Patients…

The agency failed to ensure evidence of an ongoing patient centered QAPI Program for 29 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 29 patients and all employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for 29 patients and all employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for 29 patients and all employees.

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

The agency failed to ensure infection control policies and procedures followed accepted standards of practice to prevent infection and disease for 29 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 and; 2. The infection control program was included in…

The agency failed to ensure the infection control education was: 1. Included in QAPI activities; 2. Showed interventions to reduce future infections; and 3. Provided and/or maintained for 29 patients and all employees.

The agency failed to ensure its employees either received required COVID 19 vaccination or were granted an appropriate waiver status exemption for one (Staff D) of six employees.

The agency failed to ensure a medication profile was reviewed and updated with a medication regimen change for one (Patient #3) of seven patients.

The agency failed to ensure physician orders were documented for: Occupational therapy visit frequencies for two (Patients #1 and #5) of seven;Medication regimen change for one (Patient #3) of seven and; Physical therapy visit frequency for one (Patient #6) of seven patients.

The agency failed to ensure SN performed wound care as ordered by the physician for one (Patient #7) of seven patients.

The agency failed to ensure physician notification of changes in health conditions for one (Patient #7) of seven patients.

The agency failed to ensure services were provided as ordered on the POC for: 1. SN to conduct wound site assessment every visit for one (Patient #1) of seven; 2. SN to conduct pain assessment every visit for two (Patient #3 and #5) of seven; 3. SN visit frequencies for three (Patient #3, 4 and #5)…

The agency failed to ensure documented participation of multi-discipline skilled professional staff in patient centered QAPI Program activities for 29 patients and all employees.

The agency failed to ensure a completed transfer/discharge summary was provided for three (Patients #4, 6 and #7) of seven patients.

The agency failed to develop an individualized plan of care for three (Patients #3, 4 and 5) of seven patients.

The agency failed to ensure an RN updated patient care instructions for the CHHA for care provided to one (Pts #1) of seven patients.

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

The agency failed to ensure: 1) the skilled nurse visit frequency was completed as ordered on the plan of care for two (Patient #1 and 4) of seven patients, 2) the CHHA visit frequency was completed as ordered on the plan of care for one (Patient #1) of seven patients.

The agency failed to ensure improvement activities were identified and focused on high risk problem-prone areas for 31 current patients.