Seniors Home Health Care, Inc

The agency failed to maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments (See E0006); failed to maintain, review, and update written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk…

The Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services and failed to maintain a program that included surveillance of communicable diseases as part of its Quality Assessment Performance Improvement…

The Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of its Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated…

The Agency failed to ensure the ordered Skilled disciplines performed initial and ongoing assessments of the patient's health status and needs in 2 (P-1, P-2) records of patients who required ongoing monitoring of their health status, from a total of 7 sampled records reviewed, resulting in the…

The agency failed to maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual disaster.

The agency failed to maintain, review, or update the written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan, resulting in the agency's inability to implement appropriate emergency actions.

The agency failed to maintain, review, and update written emergency preparedness policies and procedures to follow up with on-duty staff and patients to determine needed services, in the event there is an interruption in services during or due to an emergency, resulting in the agency's inability to…

The agency failed to maintain, review, and update written emergency preparedness policies and procedures to address surge needs during an emergency, resulting in the agency's inability to implement appropriate emergency actions.

The agency failed to maintain, review, and update written emergency preparedness communication plan, resulting in the agency's inability to implement appropriate emergency actions.

The agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and communication plan, resulting in the agency’s inability to ensure staff actions align with the emergency plan.

The agency failed to conduct exercises to test the emergency plan, resulting in the agency's inability to implement appropriate emergency actions.

The Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services and failed to maintain a program that included surveillance of communicable diseases as part of its Quality Assessment Performance Improvement…

The Agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order 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 Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2021 and 2022 calendar years, resulting in the Agency's inability…

Based interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety, and was evaluated for effectiveness, resulting in the…

The Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of its Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated…

The Agency failed to provide documented evidence that infection control education and in-services was provided to all staff employed by this agency, including contracted staff, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by…

The agency failed to ensure that 3 (P-3, P-2, P-6) of 3 patients observed during a home visit, were included in the overall planning of their care, including consulting with the patient and caregiver in advance of the days in which services would be provided, resulting in the lack of participation…

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 2 (P-1, P-4) of 3 discharged records, from a total of 7 sampled records reviewed, resulting in the patient being denied the right…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission to home care for 5 (P-1, P-2, P-4, P-5, P-6, P-7) of 7 sampled records reviewed, resulting in incomplete clinical information to aide in determining the needs…

The Agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for one (P-1) patient who required assistance with grooming and bathing, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene and psychological…

The agency failed to ensure the comprehensive assessment reflected an accurate review of all patient medications to determine any adverse effects, failed to ensure the Registered Nurse provided oversight of the review process, and failed to provide documented evidence of the drug regime review in 7…

The agency failed to ensure the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 2 (P-5, P-7) of 7 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs.

The Agency failed to ensure the ordered Skilled disciplines performed initial and ongoing assessments of the patient's health status and needs in 2 (P-1, P-2) records of patients who required ongoing monitoring of their health status, from a total of 7 sampled records reviewed, resulting in the…

The agency failed to ensure skilled nursing, physical therapy, and occupational therapy services were provided as ordered by the physician for 4 (P-1, P-2, P-4, P-7) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for decline in…

The Agency failed to ensure the clinical record was completed and included detailed Physical Therapy notes for 2 (P-2, P-3) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient…

The agency failed to ensure physical therapy communicated with the physician relating to services ordered within the plan of care for 1 of 7 (P-6); and, failed to ensure the Physician was notified of elevated pain levels for 1 (P-3) patient who experienced pain outside the reportable parameters…

The agency failed to ensure skilled professionals participated in agency-sponsored in-service training, resulting in a lack of training and educational opportunities for 9 skilled professionals employed by the agency or under arrangement.

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 the date of discharge in 2 (P-1, P-4) of 2 closed records from a total of 7 records reviewed…

The agency failed to provide education of the COVID-19 virus for 3 of 4 patients/caregivers (MR# 1, 2, and 4) resulting in the potential spread of a contagious viral infection between agency staff and the agency's 7 current patients.