In Home Healthcare, Inc

The agency failed to review and update its Emergency Plan annually, for 15 of 15 months reviewed, in a universe of 31 patients.

The agency failed to develop policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for 15 of 15 months reviewed, in a universe of 31 patients.

The agency failed to develop a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for 15 of 15 months reviewed, in a…

The agency failed to provide training to all staff, as well as contracted staff, on the agency’s Emergency Preparedness Program, for 15 of 15 months reviewed, in a universe of 31 patients.

The agency failed to ensure OASIS (Outcome and Assessment Information Set-patient-specific information used in Medicare to determine reimbursement and measure quality) data (facts collected together for analysis) from patient assessments was transmitted to CMS (Centers for Medicare and Medicaid…

The agency failed to maintain an infection control program, in a universe of 31 patients when: 1. The staff COVID 19 vaccination rate was 78.4% 2. The agency failed to track 21 staffs' vaccination status (Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, and 26) 3. The…

The agency failed to ensure patients’ rights were protected when the state toll free home health telephone hot line, its contact information, hours of operation and its purpose to receive complaints was not provided to one of three sampled patients (Patient 3).

The agency failed to ensure a review of all medications the patients were taking was conducted for three of three sampled patients (Patients 1 and 3) when: 1. For Patient 1: two medications the patient was taking were not indicated on the Medication Profile (MP-a current list of all medications…

The agency failed to follow agency policy and procedure to ensure the comprehensive assessment was updated by a discharge assessment and summary within two calendar days for one of seven sampled patients (Patients 4), when the discharge assessment and summary not completed after 29 days.

The agency failed to ensure the Condition of Participation: E 001 484.102 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to document a community/facility-based risk assessment (community/facility-based includes…

The agency failed to ensure that the Condition of Participation: G 640 484.65 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to identify quality indicators (a measurable element of the agency's practice…

The agency failed to ensure that the Condition of Participation: G 680 484.70: Infection prevention and control was in compliance when: Based on interview and record review, the agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment…

The agency failed to document a community/facility-based risk assessment (community/facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; patient population; facility type and potential surrounding community assets [i.e. rural area versus a…

The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts to maintain an integrated response during a disaster or emergency for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness staff, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to develop a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for seven of seven sampled patients…

The agency failed to develop a procedure to provide information about the agency's occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to provide training to all staff, as well as contracted staff, on the emergency preparedness policy and procedure titled, "Emergency Management Plan," dated January 2019, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to conduct a full-scale emergency preparedness exercise that was community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [e.g., joint field office, emergency operation centers, etc.] and "boots on the ground"…

The agency failed to identify quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) to measure, analyze and track in order to assess the agency's processes of care, services, and operations, for seven of seven sampled patients…

The agency failed to use quality indicator (a measurable element of the agency's practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency's services.

The agency failed to document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken…

The agency's Governing Body (GB) failed to ensure a Quality Assessment and Performance Improvement (QAPI) Program was implemented, maintained and evaluated for effectiveness, for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6 and 7).

The agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment Performance Improvement (QAPI) program in order to identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, for seven of seven sampled…

The agency failed to ensure a Registered Nurse (RN) completed a discharge OASIS (Outcome and Assessment Information Set - a data collection tool used by Medicare to ensure standard quality care is being provided by home health agencies) and discharge summary with transmission to Medicare within 30…

The agency failed to follow physician's orders documented on the CMS 485 (a form provided by the Centers for Medicare and Medicaid Services-CMS-which documents a patient's plan of care and physician's orders) for one of seven sampled patients (Patient 2) when four Physical Therapy (PT) visits were…