St Joseph Villa Homecare & Hospice

The agency failed to include on the patient’s revised/updated plan of care, the patient’s progress toward the measurable outcomes and goals identified by the home health agency and the patient, for 5 of 5 patients (Patient 2, 4, 5, 6, and 8) who had a revised/updated plan of care.

Deficiencies cited at G572 and G592. Findings are: G572 Based on clinical record review, policy and procedure review, and staff interview, the agency failed to complete an individualized plan of care, identifying patient-specific measurable outcomes and goals, for 6 of 6 patients reviewed (Patient…

Deficiencies cited at G642 Findings are: G 642 Based on review of the agency's policy and procedure, review of documentation of the Home Health QAPI (Quality Assurance and Performance Improvement) meeting annual agendas dated 2019 and 2020 and staff interview, the agency failed to follow its policy…

Deficiencies cited at G 948. Findings are: G948 Based on review of clinical records, the job description for the agency Director of Home Care/Administrator, policies and procedures, and staff interviews, the agency Administrator failed to organize and direct the day-to-day operations of the agency…

Deficiencies cited at G1022. Findings are: G 1022 Based on review of clinical records, review of policy and procedure and staff interview the agency failed to complete a transfer summary and send it to the receiving health care facility within 2 days of becoming aware of an unplanned transfer of…

The agency failed to complete an individualized plan of care, identifying patient-specific measurable outcomes and goals, for 6 of 6 patients reviewed (Patient 1, 2, 3, 4, 5, and 6) and the agency failed to notify the patient's physician when Home Health Aide (HHA) services were not provided…

The agency failed to follow its policy and procedure to improve the performance and processes determined to be directly related to patient outcomes.

The agency failed to include information regarding the patient's progress toward measurable outcomes and goals identified by the agency and the patient in the updated plan of care for 6 of 6 patients, (Patient 1, 2, 3, 4, 5, and 6).

The agency Administrator failed to organize and direct the day-to-day operations of the agency to ensure the agency's continued compliance with state and federal regulations for home health agencies following the 7/2/2019 revisit survey.

Staff interview the agency failed to complete a transfer summary and send it to the receiving health care facility within 2 days of becoming aware of an unplanned transfer of 1of 2 patients (Patient 4) transferred from the agency.

Deficiencies cited at 484.60 (a)(1) G572, 484.60 (a)(2)(xii-xvi) G574, and 484.60(a)(3) G576 Findings are: G572 Based on record review, policy and procedure review, and staff interview, the agency failed to notify the physician for modifications to the plan of care when Home Health Aide (HHA) and…

Deficiencies cited at 484.105(b)(1)(ii) G948 and 484.105(b)(2) G954 Findings are: G948 Based on review of clinical records, personnel files, the agency's job description for the Director of Home Care, policies and procedures, and staff interviews, the agency Administrator failed to organize and…

The agency's emergency preparedness plan failed to include a policy requiring agency staff to include individualized plans for the agency's patients in the event of an emergency as part of the comprehensive assessment; and failed to include an assessment of each patient's potential risks in the…

The agency failed to provide training of the agency's emergency preparedness policies and procedures for 15 of 19 new and existing direct employees and contracted personnel records reviewed (Staff- D, E, F, G, H, I, J, K, L, M, N, O, P, Q, and S) . The agency employs 34 direct and 3 contracted…

The agency failed to notify the physician for modifications to the plan of care when Home Health Aide (HHA) and Skilled Nursing (SN) services were not provided according to the frequency ordered on the physician approved plan of care for 2 of 11 patient records reviewed (Patient 8 and 9).

Failed to perform proper hand hygiene and failed to clean multi-use equipment, after use with an agency patient and prior to returing the equipment t the nurse bag during 1 of 4 home visits (Patient 4).

The agency failed to obtain and maintain a copy of the patient's or legal representative's signature confirming they received a copy of the notice of rights and responsibilities for 1 of 11 (Patient 2) patient records reviewed.

The agency failed to conduct an initial assessment of the patient's needs within 48 hours of receiving a referral for Home Health Care (HHC) Services for 2 of 11 patient records reviewed (Patient 7 and 9).Census was 86. Findings are: A.

The agency failed to update the comprehensive assessment during the last 5 days of every 60 day period for 1 of 11 patient records reviewed (Patient 5).

The agency failed to include on the plan of care, the patient's risk for emergency department visits and re-hospitalization, interventions to address the identified risks, patient or patient's caregiver education, training, and patient specific interventions to facilitate a timely discharge, and…

The agency failed to revise the plan of care to include all orders received from the patient's physician for 1 of 11 sampled clinical records (Patient 2).

The agency failed to conduct an on-site visit by the Registered Nurse (RN) every 60 days with the Home Health Aide (HHA) present to observe the HHA performing cares for 3 of 3 patients who received HHA services only (Patient 1, 2, and 8).

The agency Administrator failed to organize and direct the day-to-day functions of the agency to ensure compliance with state and federal regulations for home health agencies as required in the agency's Director of Home Care job description.

The agency failed to have a qualified, pre-designated person to act in the absence of the Administrator for 1 of 1 back-up Administrators (Staff- B) . The agency employs 1 person to act in the absence of the Administrator.

The agency failed to provide a transfer summary to the receiving facility, once the Home Health Agency (HHA) became aware of the transfer, for 3 of 3 patient records reviewed,who had a transfer from the HHA (Patient 1, 8, and 9).