Integris Home Care Northeast

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

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were documented (after action summary response) from 05/12/23 to 12/31/23; and 01/01/24 to 11/07/24 for all patients and employees.

The agency failed to ensure utilization of QAPI data 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 Program activities that included self-monitoring efforts (follow up) that identified and evaluated outcomes to improve care, services and operations for all patients and employees.

The agency failed to ensure governing body oversite of an agency program evaluation for calendar year 2023 and 01/01/24 to 11/05/24 for all patients and employees.

The agency failed to ensure coordination of care or communication with physicians were conducted prior to patient discharged from the agency for four (Patients #9, 11, 12 and 14) of 15 patients.

The agency failed to ensure start of care within 48 hours of referral for one (Patient #7) of 15 patients.

The agency failed to ensure individualized patient POC included: 1. Speech Therapy and PEG feeding tube interventions and goals that were discontinued in the prior certification period for one (Patient #2) of 15 patients; 2. A last changed or intervention due date for urinary catheter management…

The agency failed to ensure care was coordinated between the agency and physician for two (Patients #7 and #8) of 15 patients.

The agency failed to ensure services were provided as ordered on the POC for: 1. SN to conduct urinary catheter change every month for one (Patient #5) of 15 patients; 2. SN to conduct assessment of patient blood sugar every visit and notify the physician of blood sugar less than 60 and greater…

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 a completed transfer/discharge summary was provided for three (Patients #1, 12 and #13) of 15 patients.

The agency failed to ensure the governing body showed responsibility for the management and operation of the agency, developed a budget and provided oversight of the agency's Quality Assessment and Performance Improvement Program.

The agency failed to ensure development of an individualized plan of care for seven (Patients #1, 2, 3, 5, 6, 11 and 12) of thirteen patients.

The agency failed to ensure the governing body showed responsibility for the management and operation of the agency, developed a budget and provided oversight of the agency's Quality Assessment and Performance Improvement Program.

The governing body failed to ensure professional direction was provided to the agency.

The governing body failed to document the appointment of a qualified administrator responsible for day to day operations for all current patients and agency employees.

The governing body failed to ensure professional direction was provided in the agency's daily functions.

The agency failed to ensure an ongoing, comprehensive QAPI program was approved by the governing body.