Safe Care Home Health Services

The agency failed to ensure their emergency preparedness plan was reviewed and updated at least every 2 years.

The agency failed to ensure policies and procedures were reviewed and updated at least every 2 years.

The agency failed to ensure the plan of care includes objectively measurable goals to use to determine the patient's progress towards achieving the goals in 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 records reviewed, resulting in the inability to determine when the patient is ready for discharge.

The agency failed to inform patients and caregivers of the correct state toll free home health hot line phone number, resulting in a lack of information to voice concerns or questions regarding Safe Care Home Health Services.

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any duplicate therapy, drug interactions, or adverse effects; and failed to ensure the physician was notified regarding potential medication interactions for 2 (P-6, P-7) of 7 records…

The agency failed to ensure the plan of care included a frequency and duration of nursing visits for 1 (P-6) of 6 records reviewed with nursing services, resulting in uncertainty of nursing visits and nursing care for this patient.

The agency failed to document the patient's blood sugar results in 2 of 4 records reviewed (P-2, P-3) for patients with a primary diagnosis of Diabetes.

The agency failed to ensure that visit notes were completed and submitted into the patient's record as required during the course of care in 1 of 7 records reviewed.

The home health agency failed to ensure all signatures were authenticated and included a date and title of the primary author, and all physician's orders were signed and dated, for a potential of unapproved entries in the medical record.

The home health agency failed to investigate all complaints received from a patient or caregiver, for a potential of unaddressed complaints submitted to the agency.

The home health agency failed to document all complaints and their resolutions, for a potential of unresolved complaints submitted to the agency.

The Agency (HHA) failed to develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually (See E0004); failed to include strategies for addressing emergency events identified by the risk assessment (See E0006); failed to address type of services the HHA has…

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

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

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 establish an emergency plan (EP) that was based on an all-hazards risk assessment at both the facility-based and community-based levels, resulting in the potential to affect the agency's ability to provide patient care in the event of an actual emergency.

The facility failed to include delegations of authority and succession plans in an event of an emergency, resulting in the potential to hinder the Agency's ability to provide continued patient care.

The Agency 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 Agency's efforts of contacting these officials to engage in…

The agency failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment for 10 of 10 records (MR #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) for Emergency Preparedness from a total of 10 sampled records reviewed, resulting in the potential for negative…

The agency 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 agency is…

The agency 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.

The agency 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 failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; failed to provide emergency preparedness training at least annually…

The agency failed to conduct exercises to annually test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the agency's response to 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 outcomes, safety, and quality of care for the agency's 488 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 failed to ensure skilled nursing (SN) provided appropriate oversight and communication with the licensed practical nurse (LPN) in 1 of 7 records reviewed (MR#2) in which the patient had been assigned LPN care to furnish the patient's needs, from a total sample of 10 records reviewed…

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 failed to ensure 1 of 1 contract (Contractor-A) 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 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 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 home health agency failed to ensure patient complaints, efforts to correct and resolution outcomes were documented for all patients admitted to the agency, resulting in the potential for patient complaints and concerns to go unaddressed.

The agency 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 review; and failed to ensure the physician was notified of the findings in 2 of 10 records reviewed…

The agency failed to ensure the comprehensive assessment (including OASIS, outcome and assessment information set) was updated at the time of discharge in 1 of 3 discharged records reviewed (MR# 7), resulting in an incomplete assessment of the patient's health status at the time of discharge.

The agency failed to ensure the plan of care (POC) included all medications, pertinent treatments, and interventions with reportable parameters and measurable goals specific to the needs of the patient, for 5 records (MR# 1, 2, 4, 5, 7) from a total of 10 sampled records reviewed, resulting in…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 of 2 records reviewed (MR#2) in which the patient was treated for wounds along with uncontrolled blood pressure and blood glucose levels, from a total sample of 10 records reviewed, resulting in the…

The agency 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 a qualified alternate administrator, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in a lack of organization and direction of the agency's ongoing functions to assure the availability and…

The agency failed to ensure there was a written agreement with an individual to provide home health aide services for 1 of 1 independent contractor (Aide-G) providing patient care, resulting in a lack of agency responsibility for 2 patients cared for by Aide-G.

The agency failed to ensure the clinical record contained interventions and treatments for the patient's surgical incisions for 1 of 1 record reviewed (MR#7) in which the patient had recent heart surgeries, resulting in the potential for poor outcomes for this patient.

The agency failed to ensure the discharge summaries were complete and provided the patient's current health status at the time of discharge, status of problems identified throughout the course of care, provided summary of care from all services ordered, and timely submission to the physician within…