Reliable Home Health Patient Care Co

The Agency failed to ensure the Plan of Care (POC) included objectively measurable and individualized goals in 1 (Patient/P-1) of 5 records reviewed with Skilled Nursing (SN) ordered out of a total sample of 7 records reviewed; failed to include all pertinent safety precautions in 1 (P-1) of 7…

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators and show measurable improvement in patient care and services (See G 642); failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance…

The agency failed to ensure 1 of 1 home health aides (HHA-1) had the required in-services documented in the record, see (G-774); and failed to ensure a yearly on-site home health aide supervisory visit for HHA-1 was documented in the record, see (G-812).

The Agency failed to develop and update Emergency Preparedness (EP) policies and procedures that were based on an agreed upon all-hazards risk assessment, resulting in the Agency's inability to implement appropriate emergency actions which could negatively affect the health and safety of all…

The home health agency (HHA) failed to document initial training in emergency preparedness policies and procedures for 7 of 8 (PT-1, PT-2, PT-3, RN-1, RN-2, HHa-1, DON-1) employee records reviewed, including contract employees, and failed to maintain documentation of training for 7 of 8 (PT-1…

The Agency failed to develop, implement, and maintain a Quality Assessment and Performance Improvement (QAPI) program which provided documentation of its efforts to measure, track and analyze quality indicators that represented pre-established performance improvement projects (PIP's) designed to…

The Agency failed to develop performance improvement activities, as part of the Agency's Quality Assessment Performance Improvement (QAPI) program, to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of…

The Agency failed to develop a Performance Improvement Project (PIP) within its QAPI (Quality Assessment Performance Improvement) program, resulting in the Agency's inability to effectively monitor proposed improvements in patient care, health outcomes, patient safety, quality of care and overall…

The Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care, maintained patient safety standards, and was evaluated for its effectiveness, resulting in the potential…

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

The Home Health Agency failed to provide documented evidence that infection control education was provided to 2 of 8 employee records (PT-1, PT-3) reviewed, including contracted staff, employed by the agency and who were granted clinical privileges, resulting in the potential for the development…

The agency failed to ensure 1 of 1 home health aides (HHa-1) received at least 12 hours of in-services each year, resulting in the potential for un-met care needs and poor patient outcomes.

The Agency failed to ensure Skilled Nursing provided adequate patient care instructions for the home health aide (HHa) regarding patient needs and safety precautions prior to the provision of care in 1 (Patient/P-1) of 1 record reviewed with HHa services ordered, from a total of 7 sampled records…

The Agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 1 (Patient/P-1) of 7 records reviewed, resulting in incomplete clinical information to aid in determining the needs of this patient and for measuring the patient's progress toward…

The Agency failed to ensure the patient's medication reconciliation was updated and revised within 48 hours of the patient's return to home following hospitalization for 1 (Patient/P-1) of 1 record reviewed with a ROC (resumption of care) visit post-hospitalization, out of a total sample of 7…

The Agency failed to ensure the plan of care failed to include safety precautions, safety parameters concerning blood oxygen levels, and objectively measurable goals specific to the individualized needs of the patient in 5 (P-1, 4, 5, 6, 7) records, from a total of 7 sampled records reviewed…

The Agency failed to ensure services were provided only as ordered by the physician in 1 (Patient/P-1) of a total sample of 7 records reviewed, resulting in the potential to negatively affect all 11 patients currently serviced by the Agency.

The Agency failed to ensure the physician was promptly notified of an SCIC (significant change in condition) for 1 (Patient/P-1) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of this patient.

The Agency failed to ensure that the Plan of Care (POC) was updated to reflect the current information from the updated comprehensive assessment in 1 (Patient/P-1) of 1 record reviewed with a ROC (resumption of care) visit post-hospitalization, out of a total sample of 7 records reviewed, resulting…

The agency failed to ensure 1 of 1 contracted home health aides (HHa-1) participated in agency sponsored in-services, resulting in the potential for poor patient outcomes.

The Agency failed to ensure that the home health aide (HHa) plan of care included all pertinent safety precautions for 1 (Patient/P-1) of 1 record reviewed with aide services, out of a total sample of 7 records reviewed, resulting in the potential for unmet care needs and poor clinical outcomes for…

The Agency failed to ensure a transfer summary was complete in 1 (Patient/P-1) of 1 record reviewed with a transfer, out of a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs.

The Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to establish written policies and procedures to ensure all staff were fully vaccinated for the Covid-19 virus and failed to establish a contingency plan for those staff who were not vaccinated, resulting in the potential for the development and spread of the Covid-19 infection to…

The Agency failed to provide documented evidence that the Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the potential for lack of oversight of patient needs (G946); the Administrator failed to ensure the Clinical Manager was…

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 to affect the Agency's ability to provide safe patient care in the event of an actual emergency.

The Agency failed to conduct a facility-based and community-based risk assessment resulting in the potential for failure to identify hazards associated with the facility and less than optimal outcomes during an emergency event.

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency's emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster.

The agency failed to provide documentation for the required annual tabletop and community based full-scale exercises or any documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff not being properly prepared for an actual emergency.

The agency failed to ensure the plan of care included all safety measures to prevent injury, and measurable goals in 3 of 7 records (MR #4, 5, 6) from a total of 7 records reviewed.

The Agency failed to establish written policies and procedures to ensure all staff were fully vaccinated for the Covid-19 virus and failed to establish a contingency plan for those staff who were not vaccinated, resulting in the potential for the development and spread of the Covid-19 infection to…

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 and unmet care needs.

The Agency failed to include contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packet for Skilled Nurse openings, resulting in the potential for unaddressed concerns for all patients serviced by this agency.

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.

The agency failed to ensure the registered nurse conducted the initial assessment of the patient for 1 of 7 (MR #6) records reviewed in which Skilled Nursing services were ordered, which has the potential to negatively affect the health and well-being of these patients.

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, baseline data, and history of events leading to current home…

The Agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 1 (MR's #2) of 2 patients assessed as needing assistance with ADLs; and failed to ensure 2 (MR #1, 2) of 2 patient's Medical Social Work needs were met, resulting in the potential…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications by a registered nurse (RN), to determine any adverse effects; and failed to ensure the physician was notified of potential drug interactions in 5 records (MR #2, 3, 5, 6, 7), from a total of 7…

The agency failed to provide 3 (MR#'s 1, 2, 3) of 3 patients with a Medication Profile that included the names, dosages and frequencies, indications for use and associated side effects of the patient's prescribed medication, in plain language, from a total of 7 sampled records reviewed, resulting…

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

The Agency disciplines failed to provide care and services as ordered in the Plan of care in 2 (MR's #1, 2) records of patients who required Medical Social Work, Occupational Therapy, Physical Therapy and Skilled Nursing services, from a total of 7 sampled records reviewed, resulting in the…

The Agency failed to provide documented evidence that the Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the potential for lack of oversight of patient needs.

The Administrator failed to ensure the Clinical Manager was available at all times during hours of operation, resulting in the potential for lack of clinical and supervisory oversight of patient care services and unmet care needs for all patients serviced by this agency.

The agency failed to ensure the Clinical Manager coordinated services that were ordered on the referral form for 1 of 7 (MR #6) records reviewed and coordinated clinical oversight regarding staff scheduling and visit frequency for 1 of 7 (MR #6) records reviewed, resulting in services not being…

The Clinical Manager failed to ensure the Plans of Care were implemented in accordance with the Physician's orders in 2 (MR's #1, 2) of 3 records in which services were ordered and not provided, from a total of 7 sampled records reviewed, resulting in patients not receiving care and services to…

The Agency failed to ensure a discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 1 (MR# 7), of 2 closed records, from a total of 7 records reviewed, resulting in…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; failed to develop a method of screening visitors and all 5 current staff employed by this agency who were currently providing services, and failed to develop an…

The agency failed to provide education of the COVID-19 virus for 2 of 4 patients/caregivers (MR#s 3 and 4) resulting in the potential spread of a contagious viral infection between agency staff and the agency's 18 current patients.

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

The agency failed to ensure patients were informed of the administrator's name and current business address in order to receive complaints (Refer to G-0414); failed to ensure the patient's family or guardian was notified of their right to exercise the patient's rights in 1 of 2 records reviewed in…

The agency failed to ensure the physical therapist completed a comprehensive assessment that was accurate and reflective of current health status and identified the patient's immediate needs for 3 of 3 records (MR#s 3, 6 and 7) reviewed in which the physical therapist initiated the start of care or…

The agency failed to ensure the Plan of Care (POC) included objectively measurable and individualized goals and outcomes in 7 of 7 records reviewed (MR#s 1, 2, 3, 4, 5, 6 and 7) of a total of seven records reviewed (Refer to G-572); failed to ensure the plan of care included all pertinent…

The agency failed to ensure their Quality Assessment and Performance Improvement program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care in 2018 (See G642); failed to collect and monitor quality indicator data for the…

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

The agency failed to document their efforts to contact and collaborate with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency.

The agency failed to develop written emergency preparedness policies regarding the use/role of volunteers during an emergency.

The agency failed to develop and maintain contact information for staff, entities providing services under arrangement, patient's physicians and volunteers, resulting in the lack of essential information in the event of an actual emergency for the agency's current 15 patients.

The agency failed to ensure the patient's family or guardian was notified of their right to exercise the patient's rights in 1 of 2 records reviewed in which the patient was assessed to have a cognitive impairment and signed their own consents (MR#4) of a total sample of 7 records reviewed…

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments…

The agency failed to ensure the Plan of Care (POC) included objectively measurable and individualized goals and outcomes in 7 of 7 records reviewed (MR#s 1, 3, 3, 4, 5, 6 and 7) of a total of seven records reviewed, resulting in a potential for failure to measure progress toward achievement of…

The agency failed to provide occupational therapy services, or home health aide services as ordered by the physician for 1 of 2 records reviewed (MR#s 1) in which occupational therapy or home health aide services were ordered, resulting in the potential for physical decline and poor outcomes for…

The agency failed to ensure their Quality Assessment and Performance Improvement 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 agency's 87…

The agency failed to collect and monitor quality indicator data for the Quality Assessment and Performance Improvement program; and failed to ensure the governing body approved the program's frequency and detail of data collection, resulting in the potential for poor patient outcomes for the…

The agency failed to ensure the Quality Assessment and Performance Improvement program developed a performance improvement project in 2018, resulting in the agency's inability to improve patient outcomes, safety, and quality of care for the agency's 87 patients admitted in the past year.

Executive Responsibilities For Qapi

The Clinical Manager failed to provide supervision of all patient care services and staff, resulting in the potential for lack of clinical and supervisory oversight of patient care services and unmet care needs for all patients serviced by this agency.

The administrator failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for all services to be provided by contracted staff.

The Agency (HHA) failed to ensure that all entries in the medical record were legible in 3 of 7 records reviewed (MR#s 1, 2, and 4), failed to document the patient's name accurately on the medical record in 1 of 7 records (MR#2), and failed to authenticate the records with signatures and dates in 3…

The agency failed to ensure patients were informed of the administrator's name and current business address in order to receive complaints, resulting in the potential for unaddressed patient concerns.

The Agency (HHA) failed to inform the patient, in advance, of the disciplines that will furnish care, and the proposed visit frequency in one of a 1 of 7 sampled records reviewed (MR# 2), resulting in the patient not having knowledge or a say in the plan for treatment.

The agency failed to ensure they could protect the patient's right to confidentiality of the clinical records maintained by the agency.

The agency failed to inform the patient of proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the HHA reducing or terminating on-going care in 3 of 7 sampled records reviewed (MR#s 1, 2, and 3), resulting in the patient not having a right to dispute the end of their…

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 a lack of readily available access to community services and resources for the agency's 87 patients…

The agency failed to ensure the physical therapist completed a comprehensive assessment that was accurate and reflective of current health status and identified the patient's immediate needs for 3 of 3 records (MR#s 3, 6 and 7) reviewed in which the physical therapist initiated the start of care or…

The agency failed to ensure the comprehensive assessments included an assessment of patient identified goals in 7 of 7 records reviewed (MR#s 1, 2, 3, 4, 5, 6, and 7 ) out of a total sample of 7 records, which resulted in the potential for less than optimal patient outcomes due to patient goals…

The agency failed to document in the comprehensive assessment the patient's continuing need for recertification services in 1 of 2 patient records (MR# 7) reviewed with a recertification, of a total of 7 records reviewed, potentially providing services the patient does not require.

The Agency failed to ensure the patient's Activities of Daily Living needs were adequately met in the patient's home for 3 of 3 patients (MR#s 1, 3, and 4) assessed as needing assistance with ADLs of a total of 7 sampled records, resulting in potential for poor hygiene, psychological decline and…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 1 record (MR's #1), from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all 15 active…

The agency failed to document on the comprehensive assessment the primary caregivers' willingness, ability, their availability and scheduled hours and days to provide care for patients in 4 (MR#s 1, 2, 4 and 6) from a total of 7 sampled records reviewed, resulting in a potential for patient injury…

The agency failed to document the patient's representative (if any) in the comprehensive assessment in 1 (MR#4) from a total of 7 sampled records reviewed, resulting in lack of contact information to communicate the needs of the patient if needed.

The agency failed to ensure the plan of care included all pertinent functional limitations, services to be provided, appropriate interventions, parameters for weight gain for Congestive Heart Failure (CHF) patients, and treatments specific to the needs of the patient for 6 of 7 records reviewed…

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

The agency failed to promptly alert the physician regarding the patient's pain level in 2 of 7 records reviewed (MR#s 2 and 7), from a total sample of 7 records reviewed, resulting in the potential for poor patient outcomes.

The agency failed to ensure the registered nurse and physical therapist performed complete assessments and re-assessments of the patient's health status including wound assessments and vital signs in 1 of 7 records reviewed in which nursing services and physical therapy services were provided out…

The agency failed to ensure the clinical record was complete and included clinical notes for 1 of 7 (MR# 1) records reviewed.

The Agency failed to ensure the Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the potential for lack of oversight of patient needs.

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 Administrator failed to ensure the Clinical Manager was available during all operating hours, resulting in the potential for lack of clinical and supervisory oversight of patient care services and unmet care needs for all patients serviced by this agency.

The home health agency failed to ensure the plans of care were implemented according to the physicians orders for 1 of 5 active records reviewed (MR# 6), for a potential of unmet care needs.

The agency failed to ensure the clinical record was complete and included clinical notes for 1 of 7 (MR# 1) records reviewed.