Marshall County Home Health, Inc

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2023 for all patients and employees.

The agency failed to ensure governing body oversite of: 1. An operating budget, capital expenditure plan and allocation of resources activities for calendar years 2022 and 2023; and 01/01/24 to 07/23/24 and; 3. Agency program evaluation for calendar years 2022 and 2023 and for 01/01/24 to 07/23/24…

The agency failed to ensure an ABN was provided prior to being discharged from the agency for one (Patient #7) of eight patients.

The agency failed to ensure individualized patient POCs included a skilled nursing pain goal for six (Patients #1, 3, 4, 5, 7 and #8) of eight patients.

The agency failed to ensure care was coordinated between the agency and physician for one (Patient #5) of eight patients.

The agency failed to ensure: SN notified the physician of exceeded weight reporting parameter for one (Patient #5) of eight patients and; SN notified the physician for exceeded pain reporting parameter for two (Patients #5 and #8) of eight patients.

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 completed transfer summaries were provided to the receiving service provider for three (Patients #6, 7 and #8) of eight patients.

The agency failed to ensure an all hazard risk assessment was dated when completed for the agency effecting 39 patients and all staff members.

The agency failed to ensure an Emergency Preparedness Communication Plan included required information related to the staff contact information for the agency, potentially effecting all patients and staff during a real life emergency situation.

The agency failed to ensure an emergency preparedness disaster table top exercise and/or drill was conducted for calendar year 2019 for all patients and staff members.

The agency failed to ensure completion of a transfer/discharge summary for two (Pt's #6 and #7) of seven patients.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for 39 patients and all employees.

The agency failed to ensure: 1) The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency and; 2) The Infection Control Program was included in…

The agency failed to ensure governing body oversite of: 1. a patient centered QAPI Program and 2. an operating budget and allocation of resources activities for calendar year's 2019, 2020 and 01/01/21 to 08/11/21 effecting 39 patients and all staff.

The agency failed to ensure medication regimen changes were updated on the medication profile for one (Patient #1) of seven patients.

The agency failed to ensure individualized patient POC's included interventions and goals related to the primary diagnosis for one (Patient #3) of seven patients.

The agency failed to ensure SN staff performed wound care as ordered on the POC for one (Patient #5) of seven patients.

The agency failed to ensure physical therapy was provided as ordered for one (Patient #6) of seven patients.

The agency failed to develop a patient centered QAPI Program.

The agency failed to develop performance improvement projects prior to August of 2018. This failed practice had the potential to jeopardize client health and the provision of health related care due to unidentified problems and the lack of corrective measures to combat problem related areas.

The agency failed to ensure clinical notes were completed for two (Patients #3 and 4) of seven patients.