Mashovin Home Health Care, Inc

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 5 patients and 15 employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for all five patients and 15 employees.

The agency failed to maintain a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all five patients and 15 employees.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all 15 current patients.

The agency failed to ensure documented governing body oversite of the conduction of patient centered QAPI Program activities for all 15 patients and employees.

The Agency failed to include a process for cooperation and collaboration with local, Tribal, Regional, State, and Federal emergency preparedness officials including documentation of the facility's efforts to contact such officials.

The agency failed to ensure the utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement.

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

The agency failed to ensure CHHA completion of 12 hours of annual training for one (CHHA #1) of two CHHAs.

The agency failed to ensure the governing body provided oversight of agency operations and programs for 26 current patients and all employees.

The agency failed to ensure staff developed an individualized plan of care to include patient specific interventions for one (Patient #1) of 7 patients.

The agency failed to ensure the CHHA visit frequency was completed as ordered on the plan of care for two (Patient #3 and 7) of seven patients.

The agency failed to ensure CHHA supervisory visits were completed every 14 days for two (Pt #2 and 3) of five patients with CHHA services.