Providence Home Health Agency, Inc.

The facility failed to develop, implement, evaluate, and maintain an effective, ongoing, agency-wide, data-driven QAPI program.; failed to provide documentation showing the agency's executive responsibilities for the definition, implementation and maintenance of a program for quality improvement…

Agency failed to ensure the plan was reviewed and updated at least every 2 years, for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1).

Agency failed to ensure policies and procedures address informing State and local emergency preparedness officials about homebound patients in need of evacuation from their residences at any time due to an emergency situation for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1).

Agency failed to ensure policies and procedures address the use of volunteers or other emergency staffing strategies in an emergency for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1).

Agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, the program scope, for one (1) of one (1) QAPI program documentation requests (QAPI# 1).

Agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, program data, for one (1) of one (1) QAPI program documentation requests (QAPI# 1).

Agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, agency program activities, for one (1) of one (1) QAPI program documentation requests (QAPI# 1).

Agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, tracking adverse patient events, for one (1) of one (1) QAPI program documentation requests (QAPI# 1).

Agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, defining agency executive responsibilities, for one (1) of one (1) QAPI program documentation requests (QAPI# 1).

The agency failed to ensure a qualified therapist (registered and/or licensed by the State in which they practice) should perform the comprehensive assessment for therapy services ordered for one (1) of seven (7) CR reviewed.

The agency failed to reconcile medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy…

Agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, high risk, high volume, or problem-prone areas, for one (1) of one (1) QAPI program documentation requests (QAPI# 1).

Agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, incidence, prevalence, and severity of problems for one (1) of one (1) QAPI program documentation requests (QAPI# 1).

Agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, ensuring improvements are sustained, for one (1) of one (1) QAPI program documentation requests (QAPI# 1).

Agency failed to send a discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency (HHA) (if any) within five (5) business days of the date of the order for…

The agency failed to obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for one (1) of three (3) discharged clinical records (CR) reviewed (CR#2).

The agency failed to ensure a nurse reviewed all medications the patient is currently using for two (2) of three (3) clinical records (CR) reviewed (CR#1, CR#2).

The agency failed to communicate with the patient revisions related to plans for the patient's discharge for three (3) of three (3) discharged clinical records (CR) reviewed (CR#1-CR#3).

The agency failed to ensure appointment of a qualified, pre-designated person, who is authorized in writing, by the Administrator and the governing body, who will assume the same responsibilities and obligations as the administrator for one (1) of one (1) interviews performed (Interview #1).

Agency failed to send a discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency (HHA) (if any) within five (5) business days of the date of the order for…

The agency failed to follow the agency ' s policy for adhering to physician orders and failed to provide care as ordered for two (2) of two (2) clinical records with ventilatory care.

The agency failed to ensure that the registered nurse performing the comprehensive assessment and developing the plan was signed by the registered nurse who developed the plan of care and completed the comprehensive assessment.

The administrator failed to ensure the directing of the agency's ongoing functions by failing to ensure provision of patient services in accordance with regulatory function.

The agency failed to ensure that nursing care services were made in accordance with the orders on the plan of care for five (5) of eight (8) clinical records.

The agency failed to ensure that the registered nurse performing the comprehensive assessment and developing the plan was signed by the registered nurse who developed the plan of care and completed the comprehensive assessment.

The facility failed to ensure that the registered nurse checked all medications to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy and…