Provision Home Care, LLC

The Agency (HHA) failed to develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually (E0004); failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an…

The agency failed to maintain compliance with this condition of participation.

The Agency (HHA) failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for…

The agency (HHA) failed to ensure that 2 of 2 Home Health Aides (HHa's #1, 2) employed by the Agency, received the required 12 hours of annual in-service training (G774); failed to maintain documentation of the required 12 hours of annual Home Health Aide in-services 2 of 2 Home Health aides (HHa)…

The Agency failed to ensure the Administrator was appointed by, and reported to the Governing Body (G946); failed to ensure that the home health agency was functioning under the supervision of an Administrator who was responsible for all day-to-day operations (G948); failed to ensure a qualified…

The Agency failed to develop and maintain an emergency preparedness program that included the required elements, that must be reviewed, and updated at least annually, resulting in the potential for the Agency's inability to provide safe patient care in the event of an actual emergency.

The Agency (HHA) failed to ensure the emergency plan included strategies based on a documented facility and community based risk assessment from an all hazards approach, in effort to effectively address emergency events, resulting in the potential to affect the Agency's ability to provide patient…

The Agency (HHA) failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document the it's efforts in contacting these officials to engage…

The Agency (HHA) failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment for 7 of 7 records (MR #1, 2, 3, 4, 5, 6, 7) for Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for negative patient outcomes…

The Agency (HHA) failed to include in its emergency plan, the procedures needed to follow-up with staff and patients to determine services that are needed in the event services are interrupted due to an emergency and to inform state and local authorities of any on-duty staff or patients that the…

The Agency (HHA) failed to implement in the Emergency Preparedness policy, the use of volunteers and 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, resulting…

The Agency (HHA) failed to develop and maintain a communication plan for emergency preparedness, resulting in the inability to communicate with staff and officials in the event of an actual disaster, resulting in the potential for uncoordinated care all patients serviced by this Agency in the event…

The Agency (HHA failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the following required subject areas (1) Names and contact information for the following: (i) Staff, (ii) Entities providing services under…

The Agency (HHA) failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to…

The Agency (HHA) failed to provide documentation for the required annual tabletop and community based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan since its initiation in 2009, resulting in the potential to affect all patients and…

The agency failed to ensure their Quality Assessment and Performance Improvement (QAPI) program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care in 2018, resulting in the potential for poor patient outcomes for the…

The agency failed to develop a performance improvement project (PIP) in 2018, resulting in the agency's inability to improve patient care outcomes, patient safety, and quality of care for the agency's 176 patients admitted in the past year.

The Governing Body failed to be responsible for ensuring the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, resulting in the potential to adversely affect the quality of care for the…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential spread of…

The agency failed to ensure annual infection control education was provided to staff employed or contracted by the agency, resulting in a lack of knowledge and training regarding current infection prevention/treatment practices in the home setting.

The agency (HHA) failed to ensure that 2 of 2 Home Health Aides (HHa's #1, and #2) employed by the Agency, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency (HHA) failed to ensure the Registered Nurse (RN) prepared clear written patient care instructions for the home health aide (HHa) regarding client needs, prior to providing care in 1 (MR #1) of 3 records in which Home Health Aide (HHa) services were provided, from a total of 7 sampled…

The agency failed to hold the appropriate CLIA (Clinical Laboratory Improvement Amendment) certification for laboratory services and was out of compliance with 42 CFR 484.100(c)(1), resulting in a lack of certification for patient laboratory services.

The Agency (HHA) failed to ensure that 1 of 1 Occupational Therapist (OT), who was granted clinical privileges, maintained an active and current license when providing care, resulting in the potential for the provision of unsafe care and unmet care needs.

The Agency (HHA) failed to ensure that 1 of 1 Certified Occupational Therapist Assistant (COTA), who was granted clinical privileges, maintained an active and current license to provide care, resulting in the potential for the provision of unsafe care and unmet care needs.

The Agency (HHA) failed to ensure that 1 of 1 Speech Language Pathologist (ST) who was granted clinical privileges, maintained an active and current license to provide care, resulting in the potential for the provision of unsafe care and unmet care needs.

The Agency (HHA) failed to include contact information for the Home Health Agency's Administrator in the agency's Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure the registered nurse (RN) conducted the initial assessment visit within 48 hours of referral to determine the immediate care and support needs of the patent including homebound status and eligibility for the Medicare home health benefit for 1 of 7 records reviewed (MR#…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy; failed to document the findings of the drug regime review and; failed to ensure the physician was notified of the findings in 1 record (MR…

The agency (HHA) failed to ensure the plan of care (POC) covered all pertinent treatments, and interventions with reportable parameters and measurable goals specific to the needs of the patient, for 1 record (MR #2), from a total of 7 sampled records reviewed, resulting in patients' not receiving…

The agency failed to ensure that care and services were provided only in accordance with physician's orders for 1 of 7 records reviewed (MR# 3) in which the patient was receiving services, with a total of 7 records reviewed, resulting in the potential for inappropriate patient care and service.

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

The agency failed to ensure that skilled services were administered in accordance with the physician's orders and the plan of care (POC) in 2 (MR's #6 and 7) of 7 sampled patients reviewed for skilled services, resulting in the potential for decline in physical functioning, unidentified health…

The Agency failed to maintain documentation of the required 12 hours of annual Home Health Aide in-services 2 of 2 Home Health aides (HHa) employed by the Agency (HHa's #1 and 2) resulting in lack of evidence of ongoing education and training and the potential for the provision of unsafe care for…

The Agency (HHA) failed to ensure on-site supervisory visits to the patient's home were made in order to supervise the care provided by the Home Health Aide for 1 of 3 records with Home Health Aide (HHa) services ordered, from a total of 7 sampled records reviewed (MR #1) resulting in the potential…

The Agency (HHA) failed to ensure the skilled discipline made an annual joint onsite observation visit at the patient's residence to observe the care being provided, for 2 of 2 Home Health Aides (HHa's #1, 2) employed by the Agency, resulting in the potential for the provision of substandard care…

The Agency failed to ensure the Administrator was appointed by, and reported to the Governing Body.

The Agency (HHA) failed to ensure that the home health agency was functioning under the supervision of an Administrator who was responsible for all day-to-day operations resulting in the potential for unmet patient care needs.

The Agency (HHA) failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The Agency (HHA) failed to ensure the Director of Clinical Services (DCS #1) coordinated patient care in 1 record (MR#1) in which the patient received services from more than one discipline, from a total of 7 sampled records reviewed, resulting in the potential for the provision of unsafe care and…

The Agency (HHA) failed to ensure the clinical record was complete and included assessments and clinical notes in 3 records, from a total of 7 sampled records reviewed (MR's # 4, 5 and 6), resulting in the physician not having a clear and concise clinical picture of the patient's health status and…

The Agency (HHA) failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals in 2 (MR #3, and 7) of 2 closed/discharged records, from a total of 7 records reviewed, resulting in the potential for unidentified…