Heritage Home Health Care Services, Inc

The Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The agency failed to ensure the Plan of Care was established, periodically reviewed, and signed timely by the physician in 3 of 7 records reviewed (P-5, 6, 7) resulting in patient's receiving services that were not reviewed and approved by the physician (G572); failed to ensure the Plan of Care…

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

The agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program in 2022 through 2024 (see G684) and failed to provide…

The Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, that had been updated at least every 2 years, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in…

The agency failed to ensure its policies and procedures were updated at least every 2 years, resulting in the potential for lack of direction and guidance in the event of an actual emergency.

The agency failed to develop an Emergency Preparedness Communication Plan that had been reviewed and updated at least every 2 years, resulting in the potential for lack of effective communication amongst staff, patients and local officials in the event of an actual event.

The facility failed to develop and maintain an emergency preparedness communication plan that had been updated at least every 2 years and included contact information for all staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and…

The agency failed to ensure its training and testing program, based on the Emergency Preparedness Plan and Risk Assessment, had been updated at least every 2 years, resulting in staff not being adequately prepared in the event of an actual disaster.

The Agency failed to provide documented evidence of initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, resulting in the potential for inappropriate, unprepared responses to…

The Agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency.

The agency failed to ensure the Plan of Care was established, periodically reviewed, and signed timely by the physician in 3 of 7 records reviewed (P-5, 6, 7) resulting in patient's receiving services that were not reviewed and approved by the physician.

The agency failed to develop, implement, evaluate, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program in 2022, 2023 and 2024. Resulting in no documented evidence of the agency's efforts to monitor agency processes and improve patient outcomes for the 24…

The agency failed to collect and utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program, resulting in the potential for poor quality outcomes for the 24 patients admitted to the agency in the past 12 months.

The agency failed to ensure to conduct performance improvement projects in 2022 through 2024, resulting in no coordinated efforts to improve patient outcomes for the 24 patients admitted to the agency in the past 12 months.

The governing body failed to ensure the agency developed, implemented, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2021 through 2024. Resulting in a lack of oversight by the governing body to ensure patient safety and quality of care…

The agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program in 2022 through 2024, resulting in the potential…

The agency failed to provide annual infection control education to staff in 2022 thru 2024, resulting in a lack of education regarding current infection prevention and treatment practices in the home setting.

The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the Agency terminating on-going care for 7 (P#'s 1, 2, 3, 4, 5, 6, 7) of 7 discharged records, resulting in the patient being denied the right to appeal the decision to end…

The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 5 (P#'s 1, 2, 3, 4, 5) of 5 records where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the…

The agency failed to ensure the Comprehensive Assessment was updated within 48 hours for 1 (P-2) patient who returned home from an inpatient hospital stay, from a total of 7 sampled patients reviewed, resulting the delay in needed services and the potential for unmet care needs.

The agency failed to ensure the Plan of Care included patient-specific measurable outcomes and goals to determine the patients progress towards achieving the goals in 5 of 7 records reviewed (P-3, 4, 5, 6, 7) resulting in lack of information of the patient's progress during the certification period.

The Agency failed to ensure that all care and services were provided only in accordance with the Physician's orders for 1 (P-2) of 1 patient admitted to the agency's services, from a total of 7 sampled records reviewed, resulting in the provision of unauthorized unsafe care and services and the…

The agency failed to ensure the Physician was promptly notified of a patient's change in condition for 1 (P-2) patient who was transferred/admitted to an inpatient facility, from a total of 7 sampled patients reviewed, resulting in the Physician not being aware of the patient's health status, lack…

The agency failed to ensure the patient was advised of the ordered discipline's visit frequency prior to the provision of care and services for 3 (P-1, 3, 4) patients ordered to receive home health services, from a total of 7 sampled records reviewed, resulting in the patient not having a say in…

The agency failed to ensure Occupational Therapy services were provided as ordered by the Physician for 2 (P#'s 1, 2) patient who required therapy services, from a total of 7 sampled records reviewed, resulting in the potential for physiological decline and unmet activity of daily living needs.

The agency failed to pre-designate a person who is authorized in writing by the administrator and the governing body to assume the same responsibilities and obligations as the administrator, resulting in no person authorized to assume the responsibilities of the administrator in their absence.

The agency failed to ensure a discharge/transfer summary was completed and sent to the receiving facility within 2 days, and sent to the physician within 5 days of the patient's discharge for 7 (P#'s 1, 2, 3, 4, 5, 6, 7) of 7 records reviewed in which the patient was either transferred, or…

The agency failed to document baseline data for 3 of 3 records reviewed (MR# 2, 6, and 7) with a diagnosis of diabetes mellitus (DM), out of a total of 7 records reviewed, resulting in the potential for unmet care needs.

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 4 of 4 records (M.R.#s 1, 4, 5 and 6) with nursing services, from a total of 7 records reviewed, resulting in the potential for a plan of care not meeting the patient's needs.

The agency failed to ensure that 2 of 2 contracts included the provision that the Home Health Agency (HHA) must maintain overall responsibility for the services provided under contract.

The agency failed to submit a discharge summary to the physician in 2 of 2 discharge records (MR #'s 1, 2), from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs.

The Agency (HHA) failed to have a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document the it's efforts in contacting these officials to engage in…

The agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 7 of 7 records reviewed for Emergency Preparedness out of a total sample of 7 records reviewed, resulting in the potential for negative patient outcomes.

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 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 develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section.

The Agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to…

The Agency (HHA) failed to provide documentation for the required annual tabletop and community based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan, resulting in the potential to affect all patients and staff, in the event staff is…

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, and ascertained the patient's immediate care needs in 4 of 7…

The Agency (HHA) failed to develop a Quality Assessment Performance Improvement (QAPI) program that is at least capable of showing measurable improvements in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 7 of 7 records reviewed (M.R.#s 1, 2, 3, 4, 5, 6, and 7), resulting in the potential for a plan of care not meeting the needs of all of its patients.

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.

The Home Health Agency (HHA) failed to develop a QAPI (Quality Assessment Performance Improvement) program that considered incidence, prevalence and severity of problems in identified areas, resulting in the inability of the agency to monitor and track improvement in identified areas of concern.

The agency failed to ensure the clinical record was complete in 2 of 7 records reviewed (MR#3 and 4) in which services were ordered, from a total of 7 sampled records, resulting in an incomplete clinical record for the patients.

The Home Health 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 discharged records, from a total of 7 records reviewed (MR #1 and 7)…