Pec Healthcare

The agency failed to measure, analyze, and track quality indicators to assess the processes of care as part of the QAPI program.

The agency failed to maintain an infection control program related to the use of hand hygiene and the use of a medical equipment for one of 13 sampled patients (Patient 5), creating the risk of the spread of infection.

The agency failed to ensure the infection control data was analyzed and evaluated to monitor the effectiveness of the agency’s infection control program.

The hospice failed to timely authenticate the entries made into the clinical record for seven of 13 patients (Patients 1, 2, 3, 7, 9,11, and 12), creating the risk of not having the complete and accurate information.

The agency failed to ensure the complaint was thoroughly investigated for one nonsampled patient (Patient A).

The agency failed to ensure the medication profiles were updated to reflect the current medications to include the specific indications and parameters for their use, and include all side effects, actual or potential drug interactions, and duplicate drug therapy for six of 13 sampled patients…

The agency failed to ensure the updated comprehensive assessment was completed within 48 hours of the patient's return to home from the hospital for one of 13 sampled patients (Patient 13), creating the risk of not providing necessary care and services timely to meet the care needs for this patient.

The agency failed to ensure the POC included specific information related to the indication for the PRN discipline visits and the use of the compression stockings for three of 13 sampled patients (Patients 2, 3, and 8).

The agency failed to ensure the verbal orders were dated by the physician for one of 13 sampled patients (Patient 13), creating the risk of not providing appropriate, consistent, and quality care to the patient.

The agency failed to ensure the coordination of care related to the patient’s refusal of treatment for one of 13 sampled patients (Patient 3).

The agency failed to coordinate the care to meet the patients' care needs for two of 13 sampled patients (Patients 5 and 9), creating the risk of not providing the necessary care and services to these patients.

The agency failed to provide the written instructions outlining the visit schedules for three of 13 sampled patients (Patients 5, 6, and 7).

The agency failed to provide the name and contact information of the clinical manager for two of 13 sampled patients (Patients 5 and 6).

The agency failed to ensure the care and services were provided in accordance with the POC for three of 13 sampled patients (Patients 7, 10, and 13).

The agency failed to ensure the agency's skilled professionals prepared the accurate clinical notes for five of 13 sampled patients (Patients 2, 5, 7,10, and 11), creating the increased risk of substandard healthcare outcomes to these patients. #. Review of Patient 5's clinical record was initiated…

The agency failed to ensure the discharge summaries were completed for two of the 13 sampled patients (Patient 12 and 13), creating the risk of substandard care provided to these patients as their clinical information were not complete.

The agency failed to ensure the individualized emergency care plans were included as part of the comprehensive assessment for six of 20 sampled patients (Patients 9, 10, 11, 13, 15, and 20), creating a risk of not addressing the care needs for the patients during the emergency.

The agency failed to ensure the emergency preparedness P&P addressed a system of medical documentation that preserved patient information, protected confidentiality of the patient information, and secured and maintained the availability of the records, creating the increased risk of not protecting…

The agency failed to ensure the emergency preparedness P&P included 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 emergency.

The agency failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets, creating the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the HHA.

The agency failed to the written assignment for CHHA was prepared by the RN for one of 20 sampled patients, creating the risk of not providing the necessary care and services to this patient.

The agency failed to ensure the agency's RN provided supervision to the CHHA to ensure quality of care and services provided for one of 20 sampled patients (Patient 7), creating the increased risk of providing substandard healthcare to this patient.

The agency failed to ensure the clinical records were complete timely for five of 20 sampled patients (Patients 1, 5, 7, 18, and 19), creating the risk of substandard care provided to these patients as their clinical information was not complete.

The agency failed to ensure the grievances were thoroughly investigated as per the agency's P&P for three nonsampled patients (Patients A, B, and C), creating the risk of violating the patient's rights and not providing quality of care and services to these patients.

The agency failed to ensure the RN conducted the initial assessment visit within 48 hours of referral for two of 20 sampled patients (Patients 3 and 16), creating the risk of not identifying and addressing the care needs in a timely manner for this patient.

The agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for two of 20 sampled patients (Patients 5 and 16), creating the risk of not identifying and…

The agency failed to ensure the review of the patient's medication included all of the patient's medications and identified the duplicate drug therapy and its side effects for nine of 20 sampled patients (Patients 1, 4, 7, 9, 10, 11, 13, 15, and 20), creating the risk of not identifying the…

The agency failed to ensure the comprehensive assessments were updated within the last 5 days of every 60 days for three of 20 sampled patients (Patients 8, 16, and 18), creating the increased risk of not addressing the care needs for these patients.

The agency failed to ensure the comprehensive assessment was complete at discharge timely for one of 20 sampled patients (Patient 2), creating the risk of not updating the patient's status for this patient.

The facility failed to ensure the POCs included specific vital signs parameters to notify the physician, IV access and wound location, specific information of the medication administration, and the responsible person to perform ileostomy care for 15 of 20 sampled patients (Patients 1, 2, 3, 4, 6…

The agency failed to ensure the verbal orders were put in writing, signed, and dated by the SN; and signed by the physician within 30 working days as per the State regulations for eight of 20 sampled patients (Patients 2, 5, 9, 14, 15, 16, 18, and 19), creating the risk of not providing…

The agency failed to ensure the coordination of care related to elevated BP, MSW visit, and wound care for three of 20 sampled patients (Patients 3, 18, and 19), creating the increased risk of not addressing the care needs for these patients.

The agency failed to coordinate care involving the patient/PCG related to low pulse rates and BPs for two of 20 sampled patients (Patients 1 and 20), creating the risk of not providing the necessary care and services to these patients.

The agency failed to ensure the PCG received the education regarding catheter and ileostomy care for one of 20 sampled patients (Patient 17), creating the risk of not providing the necessary care and services to this patient.

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for nine of 20 sampled patients (Patients 1, 4, 6, 13, 14, 15, 18, 19, and 20), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to ensure the teaching provided by the SN related to specific parameters for BP, heart rate, and BS levels were ordered by the physician for one of 20 sampled patients (Patient 18), creating the risk of not providing appropriate, consistent, and quality care to this patient.

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes related the patient's wound location and medications for two of 20 sampled patients (Patients 14 and 19), creating the increased risk of substandard healthcare outcomes to this patient.

The agency failed to ensure the CHHA provided care and services in accordance with the POC for two of 20 sampled patients (Patients 7 and 17), creating the risk of not providing necessary care and services to these patients.

The agency's Administrator failed to responsible for the day-to-day operations as the agency's P&Ps related to IVIG administration and wound measurement were not implemented for two of 20 sampled patients (Patients 6 and 14), creating the increased risk of substandard healthcare outcomes to these…