Iris Home Health Services, LLC

The Agency failed to ensure COVID-19 prevention/precautions were implemented and followed by staff.

For 1 of 2 (Registered Nurse- E#5) staff members interviewed, the Agency failed to ensure patient surveillance for COVID 19 was conducted prior to home visits in accordance with its process.

The Governing Body failed to develop, establish, implement, evaluate, and maintain an effective, ongoing, data-driven Quality Assessment and Performance Improvement program.

The Governing Body failed to establish, implement, and plan for ongoing evaluation and maintenance of an effective Agency wide infection control program and incorporate this into its Quality Assessment and Performance Improvement (QAPI) program.

For 3 of 3 (Home Health Aide- HHA#1, HHA#2, HHA#3) active HHAs and for 3 of 3 (Pt #1, Pt #3, and Pt #6) patients, the Governing Body failed to ensure the provision of Home Health Aide (HHA) services was provided by qualified personnel, in accordance with the physician ordered HHA Plan of Care…

For 1 of 1 (E#11) Social Worker, the Governing Body failed to ensure services offered were approved by the State.

The Agency failed to ensure oversight of: employee orientation, evaluations, and qualifications; program and services; agreements; and budget.

The Agency failed to conduct a community-based risk assessment.

The Agency failed to ensure its patient classification/prioritization emergency list was complete and updated.

The Governing Body failed to establish a Quality Assessment and Performance Improvement (QAPI) program with quality indicators, benchmarks, data collection methods/frequency/numbers, tracking method, analysis procedure, and ongoing evaluation process to continuously improve and maintain quality of…

For 11 of 11 (E#2, E#3, E#4, E #5, E#6, E#7, E#8, E#9, HHA#1, HHA#2, and HHA#3) direct patient care employees, the Agency failed to ensure employee immunization status was assessed, documented, or any action taken in accordance with its policy, to prevent the potential for cross contamination.

For 3 of 3 (Home Health Aide-HHA#1, HHA#2, and HHA#3) active HHAs, the Agency failed to ensure demonstrated competency on a live person, not a mannequin, was performed, prior to providing care to Agency patients, and annually, in accordance with its policy.

For 1 of 3 (Pt #1) patients, the Agency failed to ensure supervisory visits for the Home Health Aide (HHA) were conducted by the Registered Nurse (RN) no less than every two weeks.

The Agency failed to ensure oversight of its overall program and services.

The Governing Body failed to prepare and maintain an overall plan and budget, inclusive of an annual operating budget, and a three year capital expenditure plan.

For 1 of 7 (Pt #1) patients, the Agency failed to ensure the visit notes were completed the day the service was provided and incorporated into the record within seven days, in accordance with its policy.

The Agency failed to ensure patient's records were retrievable by the patient without charge.

For 1 of 1 (E#4) Licensed Practical Nurse (LPN), the Agency failed to ensure the employee signed job description was accurate.

For 1 of 2 (Pt #7) patients reviewed for wound care, the Agency failed to ensure the Plan of Care included expectations for required treatments for wound care services.

For 2 of 7 (Pt's #3, Pt #6) patients, the Agency failed to ensure treatments were ordered by a physician.

For 1 of 1 (Pt #2) patient home visit where Physical Therapy Assistant (PTA) (E #6) was observed providing care, the Agency failed to ensure education and training were provided to the patient as ordered in the plan of care.

In 1 of 1 (Pt #2) Medication Profile reviewed during a home visit, the Agency failed to ensure written medication instructions were written in plain language.

For 1 of 2 (Pt #1) patients reviewed for wound care, the Agency failed to ensure the wound care treatments were provided as ordered.

For 2 of 3 (Pts #3 and #6) patients reviewed for Home Health Aide (HHA) services, the Agency failed to ensure the HHA provided services as directed on the HHA Care Plan.

For 2 of 2 ( HHA#1 and HHA#2- Home Health Aides) employed greater than one year, the Agency failed to ensure an annual on-site visit was performed to observe and assess HHA care and services during the provision of patient care.

For 2 of 2 (E#2 and E#4) nursing personnel employed less than 12 months, the Agency failed to complete initial orientation and competency evaluations which accurately reflected whether staff were qualified to provide care and services, in accordance with its policy.

For 1 of 1 (E#9) contracted employee, the Agency failed to ensure the written agreement included Agency oversight and the length of time the agreement would be in effect.