Joy Health Care Services

The agency failed to ensure the emergency preparedness plan consistently included strategies for addressing emergency events identified by the risk assessment, creating the potential risk of not providing the necessary care and services to the patients during an emergency event.

The agency failed to ensure the emergency preparedness agency P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an…

The agency failed to ensure the communication plan included the contact information for the entities providing services under arrangement and patients' physician, creating the risk of not able to contact or request for assistance during the emergency events.

The agency failed to ensure the emergency communication plan included a primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies, creating the risk of not able to contact or request for assistance in the emergency events.

The agency failed to ensure the emergency preparedness communication plan included a method for sharing the information and medical documentation for the patients under the HHA's care, as necessary, with other health providers to maintain the continuity of care.

The agency failed to ensure the emergency preparedness communication plan included a means of providing information about the HHA's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, Incident Command Center, or designee.

The HHA failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets, creating the risk of not reporting and coordinating the patient care assessments timely for the patients receiving care and services at the agency.

The hospice failed to document the reasons for conducting or selecting the PIP for the 2023 and 2024 and consistently measure the progress achieved on these projects.

The agency failed to implement and maintain the agency's infection control program which included surveillance, identification, prevention, control, and investigation of infections.

The agency failed to ensure the clinical records were complete, authenticated and accurate for five of seven sampled patients (Patients 1, 3, 4, 5, and 8), creating the risk of substandard care provided to these patients as their clinical information was not complete.

The agency failed to ensure Patient A's grievance was investigated as per the agency's P&P.

The agency failed to provide a complaint resolution to Patient A's complaint as per agency's P&P.

The agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the SOC date for two of seven sampled patients (Patients 3 and 7), creating the risk of not identifying and…

The agency failed to ensure the review of the medications included all of the patient's current medications to identify any potential adverse effects and drug reactions for three of seven sampled patients (Patients 3, 4, and 5).

The agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for three of seven sampled patients (Patients 1, 3, and 5), creating the increased risk of not addressing the care needs for these patients.

The agency failed to ensure the POCs included specific information related to medications, nutritional requirement, DME and supplies for four of seven sampled patients (Patients 4, 5, 7, and 8) creating the risk of not addressing the care needs for these patients.

The agency failed to ensure the treatment was provided only as ordered by the patient's physician for three of the seven sampled patients (Patients 1, 3 and 6), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to revise and update the POC for three of seven sampled patients (Patients 3, 4, and 8), creating the risk for not providing the necessary care and services to meet the care needs for these patients.

The agency failed to ensure effective communication with the patient's physician for four of seven sampled patients (Patients 1, 3, 5, and 8), creating the risk of not providing necessary care and services to these patients.

The agency failed to ensure the services provided to the patient was coordinated for one of seven sampled patients (Patient 4), creating the risk of not providing the necessary care and services to this patient.

The agency failed to provide a written instructions outlining the visit schedule for one of seven sampled patients (Patients 4).

The agency failed to ensure the clinical managers contact information were provided to three of the seven sampled patients (Patients 3, 4 and 5), creating the risk of substandard care provided to these patients as the contact information were not available.

The agency failed to ensure the patients received care and services as per the written plan of care for four of the seven sampled patients (Patients 1, 3, 4, and 7).

The agency failed to ensure the patient and or caregiver was provided an education related to disease process and management of diabetes, medication and Port-a catheter care as per the plan of care for two of the seven sampled patients (Patients1 and 4), creating the risk of not providing the…

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for four of 7 sampled patients (Patients 1, 4, 5, and 7), creating the increased risk of substandard healthcare outcomes to these patients.

The agency failed to ensure care and services were provided in accordance with the care plan for one of seven sampled patients (Patient 3), creating the risk of not providing appropriate, consistent, and quality care to this patient.

The agency's Administrator failed to be responsible for the day-to-day operations related to the written agreements with Contractors 1, 2, 3, 4, 5, and 6. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. d.

The agency's Administrator failed to be responsible for the day-to-day operations as the agency's P&P related to wound assessments was completed in accordance with the agency's P&P for two of 7 sampled patients (Patients 1 and 7).

The agency failed to ensure their emergency preparedness plan and P&Ps included a process for cooperation and collaboration with the state and federal emergency preparedness officials.

The agency failed to ensure the emergency preparedness plan and P&Ps included procedures to inform the state officials regarding patients in need of evacuation from their residences due to an emergency situation based on the patient’s medical condition and home environment.

The agency failed to ensure the emergency preparedness plan and P&Ps included procedures to inform state officials of any on-duty staff they are unable to contact in the event of an emergency.

The agency failed to ensure the emergency preparedness plan and P&Ps included the updated names and contact information of the entities providing services under agreement, patients' physician, and volunteers.

The agency failed to ensure the emergency preparedness plan and P&Ps included the contact name and information for the federal emergency preparedness staff.

The agency failed to ensure the emergency preparedness plan and P&Ps included the information related to the alternate means of communicating with the federal, state, regional, and local emergency management agencies.

The agency failed to ensure the emergency preparedness plan and P&Ps included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.

The agency failed to ensure the agency conducted additional exercises that may include every two years, opposite the year the full-scale or functional exercise was conducted.

The agency failed to ensure the completed discharge summary was sent to the primary care practitioner after discharge from the HHA for one of the seven sampled patients (Patient 1), creating the risk of not providing the necessary care and services to this patient after discharge from the HHA.

The agency failed to ensure the physician was informed when the care and services were not provided timely as ordered for three of seven sampled patients (Patients 2, 6, and 7), creating the risk of not providing appropriate, consistent, and quality of care to these patients.

The agency failed to provide the written information related to services provided by the CHHA for one of seven sampled patients (Patient 4), creating the risk of not providing the necessary information to this patient.

The agency failed to ensure their Covid- 19 Vaccination P&P included at least weekly testing for unvaccinated staff.

The agency failed to ensure the written agreements for the contracted medical staffs (Medical Director, Associate Medical Directors 1 and 2, and Contracted Providers 1 and 2) providing medical services and rehabilitation company (Companies 1, 2, 3, and 4) providing PT, OT, ST, RD and MSW services…

The agency failed to ensure the CLIA waiver certificate was current when conducting the blood glucose testing for two of seven sampled resident (Patient 6 and 7), creating the risk of not meeting the regulatory standards related to laboratory testing.

The agency failed to ensure the clinical record was completed in a timely manner for two of seven sampled patients (Patients 1 and 3), creating the risk of not appropriately authenticating the contents of the patient's clinical record.

The agency failed to ensure the written information was provided to the patient's preferred language for one of the seven sampled patients (Patient 4), creating the risk of violating the patient's rights and not providing quality of care and services to this patient.

The agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for six of seven sampled patients (Patients 1, 2, 3, 4, 6, and 7), creating the risk of not…

The agency failed to ensure the medication profiles were updated for four of seven sampled patients (Patients 3, 4, 5, and 6), creating the risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients.

The agency failed to ensure an individualized plan of care was completed for one of the seven sampled patients (Patient 4), creating the risk of not addressing the care needs for this patient.

The agency failed to ensure the physicians verbal orders were signed and dated by the qualified staff for furnishing or supervising the care for two of the seven of seven sampled patients (Patients 1 and 4), creating the risk of not providing appropriate, consistent, and quality care to these…

The agency failed to ensure any revisions to the plan of care of one of seven sampled patients (Patient 7) was communicated to the patient/patient representative or caregiver and physician, creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to coordinate the care needs of one of seven sampled patients (Patient 4), creating the risk of not providing the necessary care and services to this patient.

The agency failed to provide the written instructions on the SN visit schedule for three of seven sampled patients (Patients 3, 4, and 5), creating the risk of not providing the necessary information to these patients.

The agency failed to provide the name and information of the clinical manager for two of seven sampled patients (Patients 3 and 4), creating the risk of not providing the necessary information to these patients.

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for four of the seven sampled patients (Patients 1, 2, 4, and 6), creating the risk of not providing appropriate, consistent, and quality care to the patient.

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for six of seven sampled patients (Patients 2, 3, 4, 5, 6, and 7), creating the increased risk of substandard healthcare outcomes to this patient.

The agency's Administrator failed to be responsible for the day to day operations related the development P&P for wound assessment and weight monitoring; and failed to maintain the current CLIA certificate of waiver.

The agency failed to ensure the QAPI (Quality Assessment and Performance Improvement) program's scope included the following: 1. Was capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety…

The agency failed to ensure the QAPI (Quality Assessment and Performance Improvement) program included the following: The utilization of quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program.

The agency failed to ensure the QAPI (Quality Assessment and Performance Improvement) program included the program's activities.

The agency failed to ensure the QAPI (Quality Assessment and Performance Improvement) program included performance improvement activities that tracked adverse patient events, analyzed their causes, and implemented preventive actions.

The agency failed to ensure the Physical Therapy Aide (PTA) followed agency infection Control Policies and Procedures (P&P), accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases during the PTA home visit (HV)…

The governing body failed to ensure the following: 1. That the agency had implemented its QAPI (Quality Assessment and Performance Improvement) program; 2. That the agency had conducted staff and all contracted staff training concerning the agency's Emergency Preparedness Policies and Procedures…

The agency failed to ensure the medications listed in the patients' Plan of Care (POC) and in the home medication profile list, were updated accurately and completed, for two of seven sampled patients (Patients 2 and 1), when: 1. For Patient 2, two medications the patient was currently taking…

The agency failed to ensure: 1. The diagnoses for ordered respiratory medications were included in the Plan of Care (POC) for one of seven sampled patients(Patient 6) and, 2. The medication the patient was taking was documented on the POC for one of seven patients (Patient 1).

The agency failed to: 1. Ensure the patients' Plan of Care (POC) was followed and there were physicians orders for all Physical Therapy (PT) visits or missed/delayed PT visits for three of seven sampled patients (Patients 1, 4, and 7); 2. Ensure POC was followed and there were physicians orders for…

The agency failed to ensure the patient's physician was promptly alerted to any changes in the patient's condition or needs that suggested that outcomes were not being achieved and/or the Plan of Care (POC) should be altered for two of seven sampled patients (Patients 1 and 6) by failing to ensure…

The agency failed to ensure the QAPI (Quality Assessment and Performance Improvement) program included the agency's performance improvement activities with a focus on high risk, high volume, or problem-prone areas.

The agency failed to ensure the QAPI (Quality Assessment and Performance Improvement) program included the agency's performance improvement activities in consideration with incidence, prevalence, and the severity of problems in those areas.

The agency failed to ensure the QAPI (Quality Assessment and Improvement Program) took actions aimed at performance improvement, and, after implementing those actions, the agency measured its success and tracked performance to ensure that improvements were sustained.

The agency failed to ensure Physical Therapy (PT) and/or Occupational Therapy (OT) services were ordered by the physician, as indicated in the Plan of Care (POC) for three of seven sampled patients (Patients 1, 4, and 7) as follows: 1. POC was followed and there were physicians orders for all PT…

The agency failed to ensure the Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST), and Medical Social Worker (MSW) participated in the agency's in-service training classes.

The agency failed to ensure the care and services provided by a Licensed Vocational Nurse (LVN) to one of seven sampled patients (Patient 6), was supervised by a Registered Nurse (RN.) This failed practice placed the patient at risk for not having ongoing assessments per the Plan of Care (POC)…

The agency failed, when: 1. Multiple medical supplies stored in the medical supply storage area and in the nursing visit bag, were observed beyond the expiration dates; and 2. Multiple topical medications stored inside the nursing visit bag and left inside the car, were exposed to excessive…

The agency failed to ensure the medical records and Plans of Care (POC) for two of seven sampled patients (Patients 1 and 2) included all medications the patients were taking when: 1. For Patient 1, the agency failed to include the Ibuprofen 600 mg (milligrams) three times a day with food, as…