Medlife Homecare Inc

The Agency failed develop and maintain a comprehensive emergency preparedness (EP) program that must be reviewed and updated at least every 2 years (E-0004); failed to ensure the development of an EP plan utilizing an all-hazards approach with a documented facility-based and community-based risk…

The agency failed to establish a Quality Assurance and Performance Improvement (QAPI) program (G642); failed to utilize quality indicator data and failed to have details of data collection approved by the governing body (G644); failed to have performance improvement activities (G646); failed to…

The agency failed to establish a governing body to assume full legal authority and responsibility for the agency’s overall management (G942); failed to ensure the administrator was appointed by the governing body (G946); failed to ensure the administrator was responsible for day-to-day operations…

The agency failed to develop a comprehensive emergency preparedness (EP) plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for agency personnel in the event of an actual emergency or disaster.

The agency failed to ensure an emergency preparedness (EP) plan was developed based on a facility and community-based risk assessment, utilizing an all-hazards approach, resulting in the inability to identify, develop, and prioritize an emergency response based on the hazards most likely to occur…

The agency failed to develop and implement an emergency preparedness (EP) policy and procedure that aligned with an established EP and communication plans that utilized an all-hazards approach, resulting in the inability to review and update policies at least every 2 years.

The agency failed to develop an emergency preparedness (EP) policy and procedure that included the staffing strategies to address surge needs during an emergency, resulting in the potential for an overburdened healthcare system due to non-essential healthcare visits in the event of an emergency.

The agency failed to develop and maintain an emergency preparedness (EP) communication plan, resulting in the inability to provide coordinated communication of patient care within the agency, across healthcare providers, and state and local emergency management officials during an emergency or…

The agency failed to develop and maintain an emergency preparedness (EP) communication plan that included contact information, resulting in the potential for the lack of effective communication and care coordination in the event of an emergency or disaster.

The agency failed to develop and maintain an emergency preparedness (EP) training and testing program that is based on agency established policies and procedures and an EP plan that had been reviewed and updated at least every 2 years.

The agency failed to provide initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees as appropriate, and failed to maintain documentation of training.

The agency failed to develop an emergency preparedness (EP) plan that can be tested annually and fulfill the required community/facility-based full-scale exercise at least every 2 years and an additional exercise every 2 years, opposite the year of the full-scale exercise, as per this requirement.

The agency failed to establish a Quality Assurance and Performance Improvement (QAPI) program since August 2024, resulting in the potential for a lack of quality improvement for the agency.

The agency failed to utilize quality indicator data and failed to have details of data collection approved by the governing body since August 2024, resulting in the potential for a lack of quality improvement for the agency.

The agency failed to have performance improvement activities since August 2024, resulting in the potential for a lack of quality improvement for the agency.

The agency failed to have performance improvement projects since August 2024, resulting in the potential for a lack of quality improvement for the agency.

The agency failed to ensure the governing body assumed overall responsibility and oversight of the Quality Assurance and Performance Improvement (QAPI) program since August 2024, resulting in the potential for a lack of quality improvement for the agency.

The agency failed to develop an effective coordinated agency-wide program for the surveillance, identification, prevention, coordination, and investigation of infectious and communicable diseases that is an integral part of the agency’s quality assessment and performance program.

The agency failed to provide evidence that infection control (IC) education was provided to all agency staff and failed to develop an IC program that included the IC education requirements for staff, patients and caregivers.

The agency failed to establish a governing body to assume full legal authority and responsibility for the agency’s overall management since August 2024, resulting in the potential for a lack of oversight for the agency.

The agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care, missed visits and unmet patient care needs.

The agency failed to ensure clinical record entries were properly authenticated for 1 (P-2) of 2 patients reviewed, resulting in an incomplete medical record.

The agency failed to ensure 2 (P-1 and P-2) of 2 patients' information was properly stored and safeguarded, resulting in the potential for unauthorized use of patient information.

The agency failed to ensure its Administrator was experienced and qualified to perform the day-to-day leadership functions required to oversee agency operations, resulting in lack of sufficient administrative oversight and the potential for the rendering of substandard care and unmet patient care…

The agency failed to include complete contact information for the agency's Administrator in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns and complaints.

The agency failed to ensure an initial assessment was performed within 48 hours of referral for 1 (P-2) of 2 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's health status at the time of admission for 2 (P-1 and P-2) of 2 patients reviewed, resulting in incomplete clinical information and a poor outcome towards determining the needs of these patients and for…

The agency failed to ensure the Plan of Care included all the required elements to ensure the needs of 1 (P-1) of 1 patient were met, resulting in the potential for care and services not being provided according to the patient's identified needs.

The agency failed to include contact information for the Home Health agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient care concerns.

The agency failed to ensure the administrator was appointed by the governing body, resulting in the potential for a lack of oversight for the agency.

The agency failed to ensure the administrator was responsible for day-to-day operations since August 2024, resulting in the potential for a lack of oversight of the agency and the potential for poor patient outcomes.

The agency failed to ensure a qualified pre-designated person was authorized, in writing, when the administrator is not available since 2024, resulting in the potential for a lack of oversight for the agency.

The agency failed to ensure a written contract was established with/for individuals who would be granted clinical privileges and provide home health services under arrangement to the agency's patients, resulting in lack of administrative responsibility, patient safety and oversight and the…

The agency failed to ensure the medical records were complete and contained all assessments, plans of care, and visit notes for 2 (P-1 and P-2) of 2 patients reviewed, resulting in lack of the ability to establish and maintain continuity of care and unmet patient care needs.

The agency failed to ensure a completed discharge summary was forwarded to the Physician within 5 days of the date of discharge for 2 (P-1, P-2) of 2 patients discharged from the agency's services, resulting in the potential for unidentified continuing health needs and lack of continuity of care.

The agency failed to ensure the physical therapist and physical therapy assistant completed visits at the frequency ordered by the physician for 2 of 8 (MR# 1 and 7) records reviewed, resulting in the provision of therapy services at a frequency not ordered by the physician.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 3 of 8 (MR# 5, 6, 7) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients, and failed to ensure the registered nurse conducted the initial…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 2 of 8 (MR# 5, 7) records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients and assist in developing the plans of care.

The agency failed to ensure a registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 5 of 8 (MR# 1, 4, 5, 7, 8) records reviewed, resulting in the potential for harmful medication…

The agency failed to ensure the plan of care included interventions, treatments, measurable outcomes, and goals related to the primary diagnoses for 4 of 8 (MR# 1, 2, 5, 7) records reviewed, resulting in the potential for poor patient outcomes for these patients.

The agency failed to ensure skilled professionals performed assessments of the patient's health status and needs in 3 of 3 (MR# 1, 5, 7) records reviewed with primary diagnoses of diabetes, resulting in the potential for unidentified health concerns and the potential for poor patient outcomes.

The agency failed to maintain a record of referral and acceptance of patients for services that were ordered for 2 of 8 (MR# 3 and 4) records reviewed, resulting in unmet record maintenance and availability.

The agency failed to ensure a discharge summary was sent to the primary care practitioner within 5 business days of the patient's discharge for 3 of 3 (MR# 1, 5, 7) discharge records reviewed, resulting in the practitioner not having knowledge of the patient's health status, progress towards goals…

The Agency failed to ensure the RN performed the initial start of care comprehensive assessment for 1 (MR# 2) record in which both Nursing and Physical Therapy services were ordered, from a total sample of 7 records reviewed, resulting in the potential for unmet care needs.

The Agency failed to document evidence of what issues were found on the comprehensive assessment and failed to ensure that the physician had been notified in 3 records (MR's #1, 2, 4) from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all 9…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 3 (MR's #2, 3, 6) of 3 records of patients with heart disease; 2 of which had a pacemaker, from a…

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status and needs in 3 (MR #6, 7, 3) of 2 records of patients with a diagnosis of congestive heart failure, from of a total sample of 7 records reviewed resulting in the…

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 2 of 2 (MR's #6, 7) records in which the patient was discharged from skilled services, resulting in the physician not having knowledge of the patient's health status at…