National Home Health Care Agency

The agency failed to:1. Ensure the registered nurse conducted the initial assessment to determine the patients immediate care and support needs in 1 (P-1) of 7 records reviewed potentially resulting in unmet patient needs, and 2. Ensure the initial assessment was completed within 48 hours of…

The agency failed ensure the patient received the home health services which were written in the plan of care in 1 (P-1) of 7 records reviewed resulting in the potential for patient decline and poor patient outcomes (See G0572); failed to ensure the individualized plan of care included all patient…

The agency failed to ensure the patient received the home health services which were written in the plan of care in 1 (P-1) of 7 records reviewed resulting in the potential for patient decline and poor patient outcomes.

The agency failed to ensure the registered nurse provided written patient care instructions for the home health aide in 1 (P-4) of 1 record reviewed which included home health aide services resulting in aide services being provided without individualized care and safety instructions.

The agency failed to ensure that 4 (P-1, P-2, P-4 and P-7) of 7 records reviewed were included in their overall planning of care including informing the patient/caregiver in advance of which services would be provided and disciplines that will furnish care, and the agency failed to ensure this home…

The agency failed to: 1. Ensure the registered nurse conducted the initial assessment to determine the patients immediate care and support needs in 1 (P-1) of 7 records reviewed potentially resulting in unmet patient needs, and 2. Ensure the initial assessment was completed within 48 hours of…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status leading to home care needs in 3 (P-5, P-6 and P-7) of 7 records reviewed, resulting in incomplete clinical information to aid in determining the needs of the…

The agency failed to ensure a review of all medications the patient was taking in 2 (P- 1 and P-3) of 7 records reviewed, and the agency failed to Identify any potential significant drug interactions and duplicate medication therapy in 7 (P-1, P-2, P-3, P-4, P-5, P-6 and P-7) of 7 records reviewed…

The registered nurse failed to document on the comprehensive assessment the primary caregivers' willingness, ability, their availability and scheduled hours and days to provide peripherally inserted central catheter (PICC) antibiotic care in 1 (P-5) of 1 records reviewed with which the patient is…

The agency failed to ensure the comprehensive assessment was updated at discharge in 2 (P-2 and P-4) of 7 records reviewed resulting in a lack of assessment data to determine the patient’s progress toward meeting the care plan goals at discharge.

The agency failed to ensure the individualized plan of care included all patient clinical data such as equipment/supply needs, safety measures, nutritional requirements, patient specific interventions, treatments, goals, and measurable outcomes in 6 (P-1, P-3, P-4, P-5. P-6 and P-7) of 7 records…

The agency failed to ensure visit frequencies were provided only as ordered by the physician for 2 (P-5, P-6) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services.

The agency failed to ensure the verbal order for home health services was documented in the patient’s clinical record in 1 (P-3) of 7 records reviewed resulting in no physician guided instruction documented for this patient’s start of care and the potential for poor patient outcomes.

The agency failed to ensure the patient and caregiver were provided wound care teaching/instructions for 1 (P-5) of 2 records reviewed with wound care, for a potential of improper wound care and unmet care needs.

The agency Administrator failed to ensure the agency phone answering system included agency specific information for patients, representatives, or other callers to identify the agency when calling, from the date of attempted survey on 3/20/25 to the current survey which began on 6/16/25, resulting…

The clinical manager failed to provide oversight of referrals to ensure that a patient in need of Speech Language Pathology (a service not offered by this agency), was referred elsewhere in 1 (P-2) of 7 records reviewed resulting in a delay in the needed service and potential for a poor patient…

The agency failed to ensure clinical notes were accurate for 1 (P-6) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to complete a discharge summary that included all pertinent information and was sent to the physician in 5 (P-1, P-3, P-5, P-6, P-7) of 7 discharged records reviewed, resulting in no information regarding the goals accomplished during the course of care, and the patient's…

The agency failed to inform the patient in advance of the disciplines that will furnish care and the proposed visit frequency in 4 records reviewed (MR# 2, 4, 5 and 7) from a total sample of 7 records reviewed, resulting in the patient not having knowledge of the plan for treatment and potential…

The agency failed to ensure the physician was notified of potential drug interactions and failed to ensure a registered nurse reviewed patient medications for 5 of 7 (MR#'s 1, 2, 4, 5 and 7) records reviewed, resulting in the potential for harmful medication effects for these patients.

The agency failed to ensure services were provided only as ordered by the physician in 1 of 7 (MR #6) records reviewed, resulting in the potential for the provision of inappropriate care and services.

The qualified therapists failed to supervise the services that were provided by the therapy assistants for 2 of 2 records reviewed (MR# 6 and 7) with physical therapy assistant services were provided, out of a total of 7 records with therapy services, for a potential for unmet therapy needs.

The agency failed to ensure clinical notes were accurate for 1 of 7 (MR# 2) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure transfer summaries were sent within 2 business days to the receiving facility/physician for 3 of 3 (MR# 2, 3 and 7) records reviewed in which the patient was transferred, and failed to ensure the discharge summary was complete, provided the patient's current health…

The agency failed to maintain a coordinated agency-wide surveillance program for the identification and prevention of COVID-19, resulting in the potential development and spread of a contagious viral infection between agency staff and the agency's 16 current patients.

The agency failed to provide education of the COVID-19 virus for 1 of 2 patients/caregivers (MR# 2) resulting in the potential spread of a contagious viral infection between agency staff and the agency's 16 current patients.

The agency failed to ensure the patient received written notice of the complete patient rights requirements and notice regarding the agency's transfer and discharge policies in advance of furnishing care (See G412); failed to include the administrator's name in the contact information section of…

The agency failed to ensure written patient care instructions for a home health aide were prepared by the registered nurse or other appropriate skilled professional in 1 of 2 records (MR#3) reviewed in which HHA services were provided (see G798); failed to provide services only as ordered in the…

The agency failed to ensure the Emergency Preparedness (EP) Plan addressed the patient population, the services the agency could provide during an emergency and succession plans affecting 51 of 51 patients served by the agency in the past 12 months, resulting the agency not being prepared to…

The agency failed to ensure the Emergency Preparedness (EP) Plan addressed the patient population, the services the agency could provide during an emergency and succession plans affecting 51 of 51 patients served by the agency in the past 12 months, resulting the agency not being prepared to…

The agency failed to ensure the Emergency Preparedness (EP) Plan addressed procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the…

The agency failed to ensure the Emergency Preparedness (EP) Plan included procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency and to inform State and local officials of…

The agency failed to ensure the Emergency Preparedness (EP) Plan included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records affecting 51 of 51 patients served by the agency in the…

The agency failed to ensure the Emergency Preparedness (EP) Plan addressed 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 Emergency Preparedness (EP) Plan/Communication Plan included the names and contact information for each patient's physician, other facilities and volunteers affecting 51 of 51 patients served by the agency in the past 12 months, resulting the agency not being…

The agency failed to ensure the Emergency Preparedness (EP) Plan/Communication Plan included a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care affecting 51 of 51 patients…

The agency failed to ensure the Emergency Preparedness (EP) Plan/Communication Plan included a means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee affecting 51…

The agency failed to perform testing of their emergency preparedness program as required affecting 51 of 51 patients served by the agency in the past 12 months, resulting in the potential for being unprepared to respond effectively in the event of an actual emergency.

The agency failed to ensure the patient was informed of the agency's transfer and discharge policies regarding the agency's transfer and discharge policies including the reasons the agency may transfer or discharge the patient, resulting in a lack of patient rights information for the agency's 22…

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, objective baseline data for future assessments, and ascertained the patient's immediate care…

The agency failed to approve the agency QAPI activities.

The nurse failed to adequately assess and monitor the needs of the patient in one of seven records reviewed (MR#1), resulting in the potential for unidentified care needs.

The agency failed to ensure a home health aide plan of care was created with clear and complete instructions for the aide tasks to be performed including the amount, frequency, and duration of visits.

The agency failed to ensure the patient received written notice of the complete patient rights requirements and notice regarding the agency's transfer and discharge policies in advance of furnishing care, resulting in a lack of patient rights information for the agency's 22 current patients.

The agency failed to include the administrator's name in the contact information section of the patient's rights/complaints statements, resulting in the potential for unaddressed patient concerns or complaints for the agency's 22 current patients.

The agency failed to inform the patient in writing of their right to..."Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property," resulting in a lack of knowledge of their rights for the agency's 22 current patients.

The agency failed to inform the patient in writing of their right to "Participate in, be informed about and consent/refuse care in advance of and during treatment with respect to..." sections (i) through (viii), resulting in a lack of knowledge of their rights for the agency's 22 current patients.

The agency failed to inform the patient/caregiver before care was initiated of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient in five of seven sampled records…

The agency failed to inform the patient in writing of their right to..."Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care," resulting in a lack…

The agency failed to advise their patients of the names, addresses and telephone numbers of federally-funded and state-funded entities that serve the area where the patient resides, resulting in the potential for unmet patient care needs for the agency's current 22 patients.

The agency failed to inform the patient in writing of their right to..."Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA (home health agency) or an outside entity," resulting in a lack of knowledge of their rights for the agency's 22…

The agency failed to inform patients of the right to access and how to access auxiliary aids and language services, resulting in the potential for unmet patient care needs for the agency's current 22 patients.

The agency failed to ensure the comprehensive assessment included a review of all medications to determine major drug interactions, any adverse effects, failed to document the findings of the drug regimen review as required, and failed to ensure the physician was notified of potential drug…

The registered nurse failed to document on the comprehensive assessment the primary caregivers' willingness, ability, their availability and scheduled hours and days to provide care for the patients in one of seven records reviewed (MR# 1) for a potential of an unavailable caregiver to provide…

The agency failed to ensure the plan of care included safety precautions; functional limitations; objectively measurable goals and outcomes; specific individualized interventions based on the patients initial assessment; specific treatments needed; and the frequency and duration of visits to be…

The agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care (POC) for Skilled Nursing (SN) and Physical Therapy (PT), in one of seven records reviewed with SN and PT services provided (MR#s 1); and failed to ensure a physician's order for the…

The agency failed to ensure treatments were provided in accordance with a physician's order in 2 of 7 records reviewed out of a total sample of 7 records (MR #4 and 5), which resulted in the potential for the patient to receive inappropriate treatments.

The Agency (HHA) failed to include contact information for the Home Health Agency's Clinical Manager on the Plan of Care in one of seven records reviewed (MR#s 1), 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 1 of 7 records reviewed in which nursing services were provided out of a total sample of 7 records reviewed (MR #5), which resulted in the potential for…

The physical therapist failed to assist the physician in developing the plan of care in regards to the location of the patient's pain, ordering ultrasound treatments that included the measure of watts per square centimeters (W/cm2), and amount of time that ultrasound with biofreeze would be used…

The Registered Nurse (RN) and Physical Therapist failed to provide services as ordered by the physician and according to the plan of care for four of seven (MR# 1, 2, 4, and 5) resulting in the potential for decline in physical functioning, unidentified health concerns, and unmet care needs.

The agency failed to ensure the professional staff prepared complete and accurate clinical notes in 3 of 7 records reviewed out of a total sample of 7 records (MR #4, 5 and 7), resulting in the Physician not having a complete clinical picture of the patient's health status and needs, and the…

The agency failed to ensure the home health aide (HHA) provided services only as ordered in the plan of care for 1 of 1 patients (MR#4) in which HHA services were observed during a surveyor joint visits, from a total sample of 2 records reviewed in which HHA services were provided, resulting in the…

The agency failed to ensure the home health aide (HHA) documented accurately the care provided during the HHA home visits in 1 of 1 patients (MR#4) in which HHA services were observed during a surveyor joint visit, from a total sample of 2 records reviewed in which HHA services were provided…

The registered nurse failed to perform on-site supervision of the home health aide (HHA) at least every 14 days in one of two records reviewed in which HHA services were provided (MR #4) out of a total of 7 records reviewed, resulting in ineffective home health aide supervision.

The Home Health Agency (HHA) failed to ensure the discharge and transfer summaries were complete and provided the patient's current health status at the time of discharge/transfer, status of problems identified throughout the course of care, and a summary of care or services provided and sent to…