Ideal Home Health Services, LLC

The agency failed to ensure the plan of care was individualized and included all of the required elements to manage the care and needs of the patient (G574); failed to ensure services were administered only as ordered by the physician (G580); failed to ensure the physical therapist promptly…

The agency failed to ensure the Registered Nurse followed accepted standards of practice in assuming responsibility for the care of 1 (P-6) of 1 patient who required wound care services (G704); failed to ensure its skilled disciplines performed baseline and ongoing assessments for 1 (P-2) of 1…

The agency failed to ensure the Emergency Preparedness plan was tested per regulation requirements and according to agency policy for 2 (2023 and 2024) of 3 years reviewed, resulting in the potential for an unprepared staff response in the event of an actual emergency.

The agency failed to provide effective discharge planning for 1 (P-3) of 2 patients reviewed who had been discharged from this agency, resulting in the potential for unmet care needs.

The Agency failed to develop a Performance Improvement Project (PIP) within its QAPI (Quality Assessment Performance Improvement) program that documented the reasons for conducting these projects with measurable progress achieved for the chosen PIPs since 2024, resulting in the Agency's inability…

The agency failed to ensure staff followed accepted standards of practice for infection control for 1 (Staff-D) of 3 staff observed during home visits, resulting in the potential for spread of infection to all patients receiving services from this agency.

The Agency failed to ensure Skilled Nursing (SN) followed accepted standards of practice in assuming responsibility for the care of 1 (P-6) of 1 patient who required wound care services, and failed to ensure that SN properly assessed the patient to obtain pertinent clinical findings in 1 (P-7) of 3…

The agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care for 3 (P-1, P-3, P-5) of 4 patients in which Home Health Aide services were ordered, resulting in the…

The agency failed to ensure 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.

The agency failed to ensure the patient was informed of, consented to, or given the right to refuse care prior to the provision of treatment for 3 (P-2, P-3 and P-6) of 3 patients, resulting in the potential for a violation of patient rights.

The agency failed to ensure the Registered Nurse conducted the initial assessment within 48 hours, to establish the immediate care needs and homebound status for 1 (P-5) of 1 patient, resulting in the potential for unidentified care needs and poor patient outcomes.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status and clinical needs at the time of admission for 2 (P-3, P-6) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the patient's needs were adequately met in the home for 2 (P-2, P-3) of 2 patients who required therapy and assistance with grooming, resulting in the potential for physiological decline, low self-esteem and poor hygiene.

The agency failed to provide evidence the Physician had been notified of the untoward findings identified during the drug review for 2 (P-1, P-2) of 2 patients, resulting in the potential for unidentified effects of harmful ingestion of medications.

The agency failed to ensure the comprehensive assessment accurately reflected the primary caregivers willingness, ability, and availability to provide care for 1 (P-2) of 1 patient assessed as needing assistance with activities of daily living, resulting in the potential for poor grooming and unmet…

The agency failed to ensure the Plan of Care was individualized and included all of the required elements to manage the care and needs for 2 (P-1, P-2) of 2 patients, resulting in patients not receiving care in accordance with their identified needs.

The agency failed to ensure services were administered only as ordered by the physician in 2 (P-3 and P-4) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the Physical Therapist promptly notified the physician of a significant change in 2 (P-2 and P-4) of 2 patients reviewed with elevated blood pressure readings, resulting in the potential for unidentified, untreated health concerns and unmet patient care needs.

The agency failed to ensure services were integrated when additional needs were identified in 1 (P-3) of 7 patients reviewed, resulting in the potential for unmet care needs.

The Agency failed to ensure skilled nursing (SN) coordinated wound care interventions/treatments in 1 (P-6) of 7 patients reviewed, resulting in the potential for a poor clinical outcome.

The agency failed to ensure the Admission packet contained the Clinical Manager's full contact information, resulting in the potential for unaddressed clinical care concerns and unmet care needs.

The agency failed to ensure its skilled disciplines performed baseline and ongoing assessments for 2 (P-2 and P-3) of 2 patients, resulting in the potential for unidentified, untreated health concerns and unmet patient care needs.

The agency failed to ensure services were provided in accordance with the Plan of Care and Physician's orders for 5 (P-1, P-2, P-3, P-4, P-6) of 5 patients, resulting in the potential for decline in health and unmet care needs.

The agency failed to ensure the home health aide provided services as ordered in the plan of care for 2 (P-3, P-4) of 3 patients reviewed who received home health aide services, resulting in the potential for poor patient outcomes.

The agency failed to ensure accurate aide supervision for 1 (P-4) of 3 patients reviewed who received home health aide services, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the transfer/discharge summaries were complete in 2 (P-1, P-5) of 3 patients who were discharged/transferred from the agency's services, resulting in the potential for unidentified continuing health care concerns and unmet care needs.

The Agency failed to ensure the comprehensive assessment accurately reflected the patient's health status at the time of admission and the events that lead to the need for home care, in 3 (MR's #1, 2, 3) records, from a total of 7 sampled records reviewed, resulting in incomplete clinical…

The agency failed to ensure the plan of care included interventions, treatments, measurable outcomes, and goals for 3 of 7 (MR# 1, 4, 5) records reviewed (refer to G574); failed to ensure that all care and services were provided only as ordered by the Physician for 1 (MR #1) of 1 patient observed…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of Covid-19 which included a method of screening visitors and the screening of all staff who were granted clinical privileges, prior to the provision of care and services, resulting…

The Agency failed to ensure the Skilled disciplines prepared clear written patient care instructions for the Home Health Aide regarding client needs, and safety precautions prior to the provision of care in 3 (MR's #3, 5, 6) of 4 records in which Home Health Aide services were ordered, from a total…

The Agency failed to ensure the comprehensive assessment accurately reflected the patient's health status at the time of admission and the events that lead to the need for home care, in 3 (MR's #1, 2, 3) records, from a total of 7 sampled records reviewed, resulting in incomplete clinical…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; and failed to ensure the Physician was notified of potential drug interactions in 5 (MR's #1, 2, 3, 4, 5) of 7 sampled records reviewed, resulting in the potential for…

The Agency failed to ensure the Comprehensive Assessment was updated, accurate, and included a summary that accurately reflected the health status of the patient at the time of discharge for 1 (MR #) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in no indication of…

The agency failed to ensure the plan of care included interventions, treatments, measurable outcomes, and goals for 3 (MR# 1, 4, 5) of 7 records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine progress towards goals for these…

The Agency failed to ensure that all care and services were provided only as ordered by the Physician for 1 (MR #1) of 1 patient observed during a home visit with a left forearm injury, from a total of 7 sampled records reviewed, resulting in the potential for the provision of unsafe, substandard…

The Agency failed to ensure the Physician was promptly notified of the patient's change in condition for 1 (MR #1) of 1 patient diagnosed with heart disease, who experience significant fluctuations in weight, from a total of 7 sampled records reviewed, resulting in the potential for worsening of…

The Agency failed to provide services as ordered by the Physician and as indicated in the Plan of Care for 1 (MR #1) of 1 patient who required specialized care, from a total of 7 sampled records reviewed, resulting in the potential for decline in health and development of infection.

The agency failed to ensure the home health aide provided care in accordance with the plan of care for 2 of 4 (MR# 5, 6) patients in which aide services were provided, resulting in the provision of care that was not assigned and the potential for patient harm.

The agency failed to ensure the clinical record contained a complete visit note for 1 of 7 (MR# 5) records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient.

The Agency failed to ensure a discharge summary was completed and detailed the course of care provided, with the patient's health status at the time of discharge for 1 (MR #3) of 1 patient discharged from the agency's services and failed to ensure a transfer summary was sent to the receiving…

The agency failed to document Infection Control education related to COVID-19 resulting in the potential for contracting the COVID-19 infection.

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, measurable data to use as a baseline for future assessments…

The agency failed to ensure the registered nurse included accurate functional limitations in the home health aide care plan for 1 of 4 patients (MR# 1) in which home health aide services were provided out of a total of 7 sampled records, resulting in the potential of inappropriate care.

The agency failed to ensure that all entries in the medical record were authenticated by a signature, date and title for 3 of 7 records reviewed (MR#s 1, 2, and 5), resulting in a lack of validation as to the correctness of the entries in the medical record.

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 2 of 7 (MR# 4, 7) records reviewed, resulting in the potential for unrecognized adverse effects…

The agency failed to ensure the plan of care included measurable skilled nursing outcomes and goals for 5 of 7 (MR#s 1, 2, 3, 5, and 6) records reviewed, and failed to include functional limitations in 1 of 7 (MR#2) records, resulting in the potential for poor patient outcomes due to a lack of…

The agency failed to ensure the physician was notified of changes in the patient's condition in 3 of 7 records reviewed (MR#s 1, 2, and 5) in which the patient had increased pain or reportable weight gain, from a total sample of 7 records reviewed, resulting in the potential for poor patient…

The agency failed to ensure that blood glucose levels were monitored as ordered in the plan of care for 1 of 4 (MR# 4) records reviewed with diagnoses of diabetes, and lower extremity edema was measured for congestive heart failure patients in 2 of 3 (MR#s 1 and 2) records reviewed with diagnoses…

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 6 of 7…

The agency failed to ensure the skilled nurse performed complete assessments and re-assessments of the patient's health status including, actual weights for congestive heart failure patients, edema monitoring and blood sugars for diabetics in 4 of 7 records reviewed in which nursing services were…

The agency failed to ensure Administrative and supervisory functions were not delegated to another agency or organization, which had the potential to affect all 56 patient's admitted in the past 12 months, which resulted in the potential for failure to meet patient needs and the potential for…

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 6 of 7…

The agency failed to ensure the comprehensive assessment was updated and revised following the patient's hospitalization in 2 out of 2 records reviewed in which the patient returned to home care services following discharge from the hospital (MR #3 and 5) out of a total sample of 7 records…

The Agency (HHA) failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for…

It was noted that the agency failed to ensure the home health aide plan of care included a complete list of ordered safety precautions and baseline bowel movement dates in 4 of 4 records reviewed (MR# 1, 3, 5,) in which home health aide services were provided, out of a total sample of 7 records…

The agency failed to ensure the comprehensive assessments included an assessment of patient identified goals and care preferences in 7 of 7 records reviewed out of a total sample of 7 records (MR #1, 2, 3, 4, 5, 6 and 7), which resulted in the potential for less than optimal patient outcomes due to…

The agency failed to ensure the registered nurse performed a complete and accurate review of the medications the patient was taking at the time of the comprehensive assessments in 2 out of 3 records reviewed in which a surveyor home visit was provided (MR# 1 and 5) and in 2 of 2 resumption of care…

The agency failed to ensure the comprehensive assessment was updated and revised at the time of discharge from the agency that demonstrated the patient made any progress toward desired outcomes in 3 out of 3 records reviewed in which the patient was discharged from the agency (MR #3, 6 and 7) out…

The agency failed to ensure the plan of care included a complete and accurate list of the patient's medications in 2 out of 3 records reviewed in which a surveyor home visit was provided (MR # 1 and 5) and in 2 of 2 resumptions of care after hospital discharge (MR#3 and 5) out of a total sample of…

The agency failed to ensure the plan of care was updated and revised following the patient's hospitalization in 2 out of 2 records reviewed in which the patient returned to home care services following admission to the hospital (MR #3 and 5) out of a total sample of 7 records reviewed, which…

The agency failed to ensure the skilled nurse performed complete assessments and re-assessments of the patient's health status including, actual weights for congestive heart failure patients, edema monitoring and blood sugars for diabetics in 4 of 7 records reviewed in which nursing services were…

The agency failed to ensure that Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and home health aide (HHa) services were administered in accordance with the Physician's orders and the plan of care in 4 of 7 records with SN, PT, OT, and HHa services ordered (MR# 3, 5, 6, 7)…

The agency failed to ensure the Skilled Nurse (SN) coordinated services with the physician in 2 of 7 records reviewed (MR# 3 and 7) with unreported significant patient condition changes from a total of 7 records reviewed resulting in the potential for unidentified, untreated health concerns and…

The agency failed to ensure communication and oversight between the registered nurse (RN) and licensed practical nurse (LPN) occurred in 2 of 5 records reviewed (MR #3 and 7) in which nursing services were provided by an LPN (licensed practical nurse), out of a total sample of 7 records, resulting…

The agency failed to ensure that the discharge summary was complete, provided the patient's current health status at discharge and progress toward goals, and was forwarded to the physician in 3 of 3 closed records (MR#3, 6 and 7), from a total of 7 records reviewed, resulting in the potential for…