Royale Home Health Care, Inc

The agency failed to ensure the initial assessment to determine immediate care needs for the patient was conducted within 48 hours of the referral in 4 (P-1, P-2, P-3, P-7) of 7 records reviewed resulting in the potential for unmet care needs and poor patient outcomes (See G0514); failed to ensure…

The administrator failed to be responsible for all day-to-day operations by not keeping an accurate record of his employee roster, resulting in the potential for unqualified or untrained personal to be working for this agency (see G948); failed to ensure a qualified, pre-designated person was…

The agency failed to ensure the Emergency Preparedness (EP) communication plan included updated, complete, and accurate information to contact staff, resulting in the potential to affect the safety of all 13 patients receiving services from this agency in the event of an emergency.

The agency failed to ensure Emergency Preparedness (EP) training was provided to staff every 2 years per regulation and annually per agency policy for 16 of 16 current staff members, resulting in the potential for an unprepared staff response in the event of an actual emergency.

The agency failed to include agency relevant scenarios to test the agency's emergency plan, failed to analyze the facility's response, and failed to maintain documentation for 5 of 5 Emergency Preparedness (EP) testing drills for 2 of 2 years, resulting in the potential for less than optimal…

The agency failed to ensure missed visits altering the plan of care frequency were rescheduled and communicated with the doctor per agency policy in 2 (P-1 and P-3) of 7 records reviewed, resulting in the potential for unmet patient care needs and poor patient outcomes.

The agency failed to ensure personnel followed accepted Infection Control standards of practice during the provision of care and services for 2 (P-4 and P-6) of 3 joint patient home visit observations resulting in the potential for the transmission and development of infection.

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 failed to ensure the initial assessment to determine immediate care needs for the patient was conducted within 48 hours of the referral in 4 (P-1, P-2, P-3, P-7) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s health status at the time of admission for 2 (P-1, P-2) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and to assist in developing the…

The agency failed to follow agency policy regarding reconciliation and management of high risk drugs in 4 (P-2, P-4, P-5, P-6) of 7 records reviewed; and failed to verify patient medications upon admission in 2 (P-2 and P-6) of 7 records reviewed, resulting in the potential for harmful medication…

The agency failed to ensure the goals on the Plans of Care were objectively measurable to determine the patient's progress towards obtaining the goals in 2 (P-4, P-5) of 7 records reviewed resulting in the inability to determine the patient's progress towards obtaining the goals.

The agency failed to promptly notify the Physician concerning a vital sign outside of the specified reportable parameters for 1 (P-4) of 7 records reviewed, resulting in a potential poor clinical outcome.

The agency failed to ensure the patient and caregiver were provided with the name of the correct clinical manager, resulting in all 13 of the agency’s active patient’s being uninformed of who to contact with any concerns.

The agency failed to ensure their skilled professionals provided the services that were ordered by the physician as indicated in the plan of care in 2 (P-3 and P-6) of 7 records reviewed potentially resulting in unmet patient needs and a poor patient outcome.

The agency failed to ensure their skilled professionals provided the patient's caregiver with education needed to properly evaluate the patient's blood sugars in 1 (P-6) of 7 records reviewed resulting in unmet needs of the caregiver and potentially resulting in poor patient outcomes.

The administrator failed to be responsible for all day-to-day operations by not keeping an accurate record of his employee roster showing 7 (Con-1, RPT-1, RN-3, HHA-1, PTA-1, OM-1, and AA-1) of the agency's 16 employees were not listed on the initial staff list provided, resulting in the potential…

The agency failed to ensure a qualified, pre-designated person was identified and approved by the governing body as the alternate administrator to be responsible in fulfilling the roll of the administrator in his absence in 5 of 5 months since the previous alternate administrator left in January…

The agency failed to ensure the Clinical Manager coordinated services for 1 (P-4) of 7 records reviewed, resulting in services not being provided to this patient.

The agency failed to ensure the clinical record contained details of all interventions and treatments in 1 (P-1) of 7 records reviewed, resulting in an inaccurate and incomplete medical record.

The agency failed to ensure a discharge summary was completed, provided the patient's current health status at the time of discharge, and progress toward goals in 1 (P-4) of 2 closed records; the agency failed to ensure the discharge summary was sent to the physician in 1 (P-1) of 2 closed records…

The agency failed to ensure the registered nurse conducted the initial assessment visit within 48 hours of referral, to determine the immediate care needs of the patient, including homebound status for 2 of 7 (MR#s 1 and 3) records reviewed (Refer to G-514); failed to conduct a patient-specific…

The agency failed to develop a Quality Assessment Performance Improvement (QAPI) program to optimize patient outcomes.

The agency failed to provide services as ordered in the Plan of Care in 1 of 7 records reviewed (MR#1), resulting in the potential decline of the patient's health status.

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) Program to optimize the agency's patient outcomes.

The agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program to ensure the effectiveness and safety of services, quality of care, and to identify opportunities for improvement.

The agency failed to track adverse patient events, analyze their causes, and implement preventive actions.

The agency failed to initiate any performance improvement projects for 2020 that were based on QAPI program activities, data collected, and emphasizes identified needs for agency and patient improvements resulting in no programs to improve the home health services provided by the agency.

The Governing Body failed to ensure a Performance Improvement Program for quality improvement and patient safety is defined, implemented, maintained, addresses priorities for improved quality of care, patient safety, and that all improvement actions are evaluated for effectiveness.

The agency failed to ensure to document and track the COVID-19 vaccination completion, exemption, or temporary delay status for 1 of 14 (Staff-D) staff that provide patient care, treatment, or other services for the agency.

The agency failed to ensure 1 of 1 contract (Contractor# 1) met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that received contracted services.

The agency failed to ensure 1 of 2 (Staff-F) contracted occupational therapists were licensed to provide therapy services, resulting in the potential for substandard care for the agency's 58 patients who may received occupational therapy services in the past 12 months.

The agency failed to ensure the registered nurse conducted the initial assessment visit within 48 hours of referral, to determine the immediate care needs of the patient, including homebound status for 2 of 7 (MR#s 1 and 3) records reviewed in which Skilled Nursing services were ordered, resulting…

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, and history of events leading to current home care needs in 2…

The agency failed to ensure the physician was informed of the results of the medication review for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 2 of 7 (MR#s 3 and 4) records reviewed, resulting in the potential for harmful medication effects…

The agency failed to ensure the plan of care included measurable outcomes and goals for skilled nursing for 4 of 7 (MR#s 1, 2, 3, 4) records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress towards goals.

The Agency failed to initiate any performance improvement activities within their QAPI program that focused on high risk, high volume, or problem prone areas, resulting in the potential for agency issues with negative consequences for high risk, high volume, or problem prone areas that could affect…

The Agency failed to initiate any performance improvement activities within their Quality Assessment Performance improvement Program (QAPI), that addressed incidence, prevalence, and severity of problems identified amongst the agency's own patient population as areas of focus to improve patient…

The agency failed to ensure the medical social worker performed an assessment of the patient's health status and needs in 1 of 2 (MR# 3) records reviewed with social work services, resulting in the potential for unidentified health concerns, delay in care needs, and poor patient outcomes.

The Agency failed to ensure that the skilled nurse followed the visit frequency ordered by the physician as indicated in the patient plan of care in 1 (MR# 5) of 7 sample records reviewed resulting in potential for physical decline and unmet patient care needs.

The agency failed to ensure 2 of 3 (Staff-J and Staff-K) home health aides were qualified to provide services, resulting in the potential provision of substandard care for the agency's 58 patients who may received aide services in the past 12 months.

The agency failed to ensure to have a written agreement with 3 of 4 (Staff-D, Staff-E, and Staff-G) independent contractors furnishing services under arrangement to agency patients, resulting in a lack of overall responsibility by the agency for the services provided under arrangement.

The Agency failed to ensure that the clinical record contained the individualized patient plan of care and the physical therapy evaluation in a timely manner in 1 (MR# 5) of 7 sample records reviewed resulting in the potential for unmet patient-specific care needs and education.

The agency failed to insure a detailed transfer summary was sent to the receiving health care facility within 2 business of becoming aware of the transfer for 1 of 1 (MR# 3) records reviewed with transfers to other health care facilities, resulting in a lack of information to ensure continuity of…