Legacy Home Health, Inc

The facility failed to ensure their Emergency Preparedness Plan was being implemented when three of 21 staff members were not knowledgeable about the facility’s designated alternate meeting location in case of emergencies.

The facility failed to ensure the performance improvement project (PIP- concentrated effort on a particular problem in one area of the facility or facility wide; involves gathering information systematically to clarify issues or problems and intervening for improvements) of their Quality Assessment…

The facility failed to follow infection control guidelines when expired medical supplies were found on the medical supply room and were available for use.

The facility failed to ensure patients clinical records were stored in locked, waterproof file cabinets in a designated clinical records room in accordance with the facility’s policies and procedure.

The facility failed to ensure personal health information were kept confidential when Certified Home Health Aide (CHHA) received and sent Patient 1’s clinical records using her personal cell phone.

The agency failed to ensure criminal background check was performed prior to hire or prior to working with patients for one of six sampled employee (Speech Therapist (ST)).

The agency failed to follow infection control guidelines risking cross contamination in one (1) of seven (7) sampled patients (Patient 7) when a nursing supply bag was placed on Patient 7’s living room floor without a barrier.

The home health agency (HHA) failed to follow their policy and procedure for tracking and documenting COVID-19 ( a respiratory disease which causes difficulty in breathing) vaccination status of staff who received COVID 19 boosters.

The agency failed to ensure that the Home Health Aide was following the Home Health Aide Care Plan prepared by the Registered Nurse for one (1) of seven (7) sampled patients (Patient 2).

Based observation, interview, and record review, The home health agency (HHA) failed to provide the names, addresses, and telephone numbers of federally and state-funded entities for one of 7 sampled Patients (Patient 5).

The home health agency (HHA) failed to provide information on how to access auxiliary aids and language services for one of 7 sampled Patients (Patient 5).

The home health agency (HHA) failed to document the existence and the resolution of one complaint/grievance for the month of September and one complaint/grievance for the month of October 2021. This failure had the potential for the HHA’s Patients’ complaints/grievance to go untracked and…

The agency failed to follow infection control guidelines risking cross contamination in one (1) of seven (7) sampled patients (Patient 7) when a nursing supply bag was placed on Patient 7’s living room floor without a barrier.

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to develop strategies to address emergency events identified by the agency's risk…

The agency failed to ensure the Condition of Participation: G 510 484.55 Comprehensive Assessment of Patients was in compliance when based on observation, interview, and record review, the agency failed to ensure an adequate review of all medications the patients were taking was conducted for two…

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 measure, analyze or utilize quality indicator (a measureable element of the…

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 ensure the Condition of Participation: G 750 484.80 Home health aide services was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure written patient care instructions were provided to the Certified Home Health Aide (CHHA) for two of…

The agency failed to ensure that the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance as follows: 1. Based on interview and record review, the agency's Governing Body (GB) failed to assume full legal authority and responsibility for the…

The agency failed to develop strategies to address emergency events identified by the agency's risk assessment for 12 months, in a universe of 47 patients.

The agency failed to provide for the continuity of operations during an emergency when a succession of authority plan (a plan indicating who will take control in the absence or inability of another) was not in place for 12 months, in a universe of 47 patients.

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 12 months, in a universe of 47 patients.

The agency failed to implement procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process for 12 months, in a universe of 47 patients.

The agency failed to ensure a procedure was established to provide for emergency staffing during a disaster or emergency for 12 months, in a universe of 47 patients.

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 12 months, in a universe of 47 patients.

The agency failed to develop a back-up plan in the event of communications (phone service, including cellular phone and internet) failure during a disaster or emergency for 12 months, in a universe of 47 patients.

The agency failed to develop a policy and 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 12 months, in a universe of 47 patients.

The agency failed to provide training to all staff, as well as contracted staff, on the emergency preparedness policies and procedures and "Emergency Operations Plan, EOP" for 12 months, in a universe of 47 patients.

The agency failed to implement its policy and procedures on conducting full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency…

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 two of seven sampled patients (Patient 1 and 3) when: 1. For Patient 1, one Skilled…

The agency failed to measure, analyze or utilize quality indicator (a measureable element of the agency's practice that can be used to assess the quality of care provided) data in order to assess the agency's processes of care, services, and operations for 10 months, in a universe of 47 patients.

The agency's Governing Body (GB) failed to approve the frequency and detail of the Performance Improvement Program's data collection for 10 months, in a universe of 47 patients.

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 assurance and performance improvement (QAPI) program was implemented, maintained and evaluated for effectiveness for 10 months, in a universe of 47 patients.

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 10 months, in a universe…

The agency failed to ensure written patient care instructions were provided to the Certified Home Health Aide (CHHA) for two of seven sampled patients (Patients 1 and 5).

The agency's Governing Body (GB) failed to assume full legal authority and responsibility for the agency's overall management and operation in a universe of 47 patients when: 1. No GB meetings were conducted.

The agency failed to ensure an adequate review of all medications the patients were taking was conducted for two of seven sampled patients (Patients 3 and 4) when: 1. The agency was unaware of five medications Patient 3 was taking and that three medications had been stopped.

The agency failed to conduct an on-site Certified Home Health Aide (CHHA) supervisory visit every 14 days for one of seven sampled patients (Patient 5).

The agency's Governing Body (GB) failed to appoint an Administrator in a universe of 47 patients.

The agency's Governing Body (GB) failed to appoint a pre-designated person (Administrator Designee) to act in the absence of the Administrator in a universe of 47 patients.