Humble Home Health Care 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 updated direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services, (G642); failed to ensure that the collected data was used to monitor the effectiveness and safety of services provided with opportunities for…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of infections, and failed to ensure the infection control program was an integral part of the agency's Quality Assessment Performance Improvement (QAPI) program (G684); and, failed…

The Agency failed to adequately assess and monitor the needs of the patient in 4 (P-3, P-4, P-5, P-7) of 7 sampled patient records reviewed (see G704); failed to ensure services were provided in accordance with the Physician's orders for 3 (P-1, 6, 7) of 3 patient reviewed, who were ordered to…

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

The agency failed to ensure its Emergency Preparedness policies and procedures were reviewed and updated at least every 2 years, resulting in the potential for poor patient outcomes during a disaster if staff are ill-prepared.

The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently…

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency's emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster.

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 services were provided in accordance with the Physician ordered visit frequency for 4 (P-2, P-3, P-6, P-7) of 7 sampled records reviewed, resulting in the potential for decline in physical health and unmet care needs.

The Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all patients currently serviced…

The agency failed to ensure that the collected data was used to monitor the effectiveness and safety of services provided with opportunities for improvement; and failed to ensure the Governing Body approved the program's frequency and detail of data collection, resulting in the potential for poor…

The agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of…

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented its quality improvement projects, the reasons for conducting these projects with measurable progress achieved for calendar years 2023 and 2024, resulting in the Agency's inability to improve in…

The Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, addressed priorities for improved quality of care and patient safety and was evaluated for…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of infections, and failed to ensure the infection control program was an integral part of the agency's Quality Assessment Performance Improvement (QAPI) program, resulting in the…

The Agency failed to provide documented evidence that infection control education was provided to all staff employed by the agency, including contracted staff, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by this agency.

The Agency failed to adequately assess and monitor the needs of the patient in 4 (P-3, P-4, P-5, P-7) of 7 sampled patient records reviewed, resulting in a potentially poor patient outcomes.

The agency failed to ensure the home health aide had clear, written patient care instructions regarding visit frequency in 1 (P-6) of 3 records reviewed with home health aide services from a total of 7 records reviewed, resulting in the potential for unmet care needs.

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 for all patients serviced by this agency.

The agency failed to ensure the patient was allowed the right to participate and be informed about changes in services provided in 3 (P-3, P-4, P-7) of 7 records reviewed, resulting in the potential for unmet care needs and a violation of patient rights.

The agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral, and failed to ensure a registered nurse conducted the initial assessment to determine the patients immediate care needs and home care eligibility in 4 (P-1, P-2, P-6, P-7) of 7…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 2…

The agency failed to conduct a review of the patient’s medications in 1 (P-6) of 7 records reviewed; and failed to ensure the medication profile contained new/updated medications in 2 (P-6, 7) of 7 records reviewed, resulting in the potential to miss harmful medication reactions.

The agency failed to ensure the plan of care (POC) included allergies for 2 (P-3, P-4) of 7 records reviewed; failed to ensure the plan of care included patient specific parameters to meet the needs of the patient for 3 (P-3, P-4, P-6) of 7 records reviewed; and failed to ensure the plan of care…

The agency failed to ensure visit were provided only as ordered by the physician for 1 (P-3) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services.

The agency failed to ensure the Physician was promptly notified of 1 (P-2) of 1 patient who experienced a significant change in condition, and failed to promptly notify the Physician concerning a heart rate outside of vital sign parameters for 1 (P-3) patient, from a total of 7 sampled records…

The agency failed to ensure coordination of care between all disciplines in 1 (P-7) of 7 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure services were provided in accordance with the Physician's orders for 3 (P-1, 6, 7) of 3 patients reviewed, who were ordered to receive Skilled Nursing, Physical therapy, Occupational Therapy and Home Health Aide services, from a total of 7 sampled records reviewed…

The agency failed to ensure the clinical record was complete and included detailed wound measurements for 1 (P-5) of 7 records reviewed, resulting in lack of continuity of care, undocumented health concerns and potential poor outcomes.

The agency failed to establish a written agreement with the contracted agency or organization from which contracted Home Health Aide services were provided, resulting in the potential for the rendering of unauthorized unsafe care and services, and unmet care needs.

The agency failed to ensure the written contract for services included language that ensured the home health agency retained overall responsibility for all services provided, and failed to specify how supervision would occur for 3 (Contract #1, Contract #2, Contract #3) of 3 contracts reviewed…

The agency failed to ensure the clinical record contained an accurate representation of all interventions and assessments in 2 (P-6, 7) of 7 records reviewed, resulting in the potential for an unclear picture of the patient’s treatment and an incomplete medical record.