Senior Friend Home Care

The home health agency failed to meet the CFR 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care.

The facility failed to develop and maintain annual emergency preparedness training and testing based on the emergency plan, risk assessment, policies and procedures, and the communication plan for 1 of 1 Emergency Preparedness (EP) plan.

The agency failed to encode and electronically transmit completed OASIS assessments to the Center of Medicare and Medicaid (CMS) system within 30 days of completing the assessment of the for 10 of 12 (P1, P2, P3, P4, P6 P8, P9, P10, P11, P12, ) patients reviewed.

Based on interview and document review the facilility failed to completed and submit to provider a discharge summary for a resident that was discharged from services.

The agency failed to ensure visits were conducted in accordance with physician orders for 1 of 7 patients (P3), and failed to notify the physician when the visits were not conducted in accordance with the plan of care (POC).

The agency failed to implement an infection control program that included tracking, trending and analysis of client infections.

The facility failed to perform a compatency evaluation on 2 of 5 staff reviewed employee compatence.

The facility failed to offer 12 hours per year of register nurse led inservice training to the home health aide staff.

The facility failed to admit the patient to services or have a provider order to delay admission within 48 hours (hr) of referral.

The facility failed to complete a full medication reconciliation for 1 of 2 patients (P5) reviewed during home visit.

The agency failed to notify a provider and family of change of condition when on 8/8/25, home health Aide (HHA)-A and homemaker (HMK)-A noted P1 to have had a change in health condition.

The HHA failed to develop an emergency preparedness program that met all of the standards specified within the condition, including a comprehensive approach to meet the health, safety and security needs of the staff and client population during an emergency or disaster situation.

The facility failed to ensure compliance with all applicable Federal, State and local emergency preparedness requirements.

The home health agency (HHA) failed to conduct a comprehensive all-hazards community-based risk assessment to determine potential disasters which could impact the HHA and develop corresponding policies and procedures to ensure patient safety and quality care during a disaster.

The home health agency failed to develop in its emergency preparedness plan (EPP) a written emergency communication plan that contained a description of how the facility will coordinate patient care within the facility, across healthcare providers, and with state and local public health departments…

The agency failed to develop and maintain an emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures and an appropriate communication plan.

The facility failed to obtain signatures to show the Patient Bill of Rights and Responsibilities were given to the patient for 6 of 7 (P1, P2, P3, P4, P6, P7) residents reviewed for patient bill of right signature pages.

The facility failed to obtain signed service agreements to show a participation in Care for 5 of 7 (P1, P2, P3, P6, P7) residents reviewed for participation in care.

The agency failed to provide notification of consideration for discharge for cause for 1 of 2 (P6) patients reviewed for discharge.

The agency failed to make efforts to resolve problems with patient's behavior for 1 of 2 (P6) patients reviewed for discharge.

The agency failed to provide information on other community agencies who may be able to provide services to the patient for 1 of 2 (P6) patients reviewed for discharge.

The agency failed to document attempts to resolve problems with a patient's behavior in the medical record of 1 of 2 (P6) patients reviewed for discharge.

The home health agency failed to admit the patient within 2 days of receiving referral or obtain an order to delay admission for 4 of 7 (P1, P3, P6, P7) patients reviewed for admission.

The agency failed to ensure visits were conducted in accordance with physician orders for 2 of 7 patients (P3, P7), failed to notify the physician when the visits were not conducted according to the plan of care (POC), and to educate the patient on the risks of missed visits or attempt to…

The agency failed to have the plan of care reviewed or revised by the provider no less than every 60 days for 2 of 7 (P4, P6) patients reviewed for plan of care.

The agency failed to ensure a patient's discharge was communicated to the physician issuing orders for the agency's plan of care (POC) and other health care professionals who would be responsible for providing care and services to the patient after discharge from the home health agency for 1 of 2…

The facility failed to ensure nursing aid services provided to patients were ordered by the patient's physician for 2 of 7 (P4, P6) patients reviewed for nursing aid services.

The facility failed to provide supervision via supervisory visits for nurse aids who performed home health services for 1 of 7 (P6) patients reviewed for nurse aid services.

The agency failed to ensure their emergency preparedness policies and procedures addressed the use of volunteers in an emergency, or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs…

The agency failed to ensure their emergency preparedness policies and procedures addressed alternative means of communication with staff and outside agencies in the event of an emergency.

The agency failed to ensure visits were conducted in accordance with physician orders for 4 of 7 patients (P1, P3, P4, P5) and failed to notify the physician when the visits were not conducted according to the plan of care (POC).

The home health agency (HHA) failed to ensure screening for COVID-19 signs and symptoms was completed prior to the start of a visit for 2 of 3 patients (P3, P4) observed during home visits.

The agency failed to ensure 2 of 7 patients (P1, P7) were informed and consented to services or care being provided, including an ongoing changes in services.

The agency failed to ensure a patient's discharge was communicated to the physician issuing orders for the agency's plan of care (POC) and other health care professionals who would be responsible for providing care and services to the patient after discharge from the home health agency for 1 of 2…

The agency failed to ensure physical therapy and occupational therapy visits were provided as ordered in the plan of care (POC) for 1 of 7 patients (P1) reviewed.