Suburban Home Care, Inc

The agency failed to develop an Emergency Preparedness Program that met the Federal, State and local requirements of this section (See E0004); failed to complete an Emergency Preparedness Plan that was based on a facility and community based risk assessment (See E0006); failed to contact and…

The agency failed to ensure the initial comprehensive assessment visit was made within 48 hours of the date of the referral for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, and 7) records reviewed (See G514); failed to ensure the comprehensive assessment included baseline information detailing the patient's…

The agency failed to ensure the skilled nurse performed complete assessments and re-assessments of a diabetic patient that is chair/bedbound and developed a wound in 1 of 1 record reviewed (MR#2) (See G574).

The agency failed to develop a Quality Assessment Performance Improvement program to optimize patient outcomes and to have at least one performance improvement project this year.

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 program (See G684); and failed to document infection control…

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 conduct a facility-based and community-based risk assessment resulting in the potential for failure to identify hazards associated with the facility and less than optimal outcomes during an emergency event.

The agency failed to contact and collaborate with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency.

The agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 3 of 7 records reviewed (MR #1, 2, and 3) for Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for negative patient outcomes in the…

The agency failed to provide documentation for the required annual tabletop and community based full-scale exercises or any documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff not being properly prepared for an actual emergency.

The agency failed to ensure their Quality Assessment and Performance Improvement program was at least capable of showing measurable improvements in indicators to enhance patient outcomes, safety and quality of care in 2018 and 2019, resulting in the potential for poor patient outcomes for the…

The agency failed to develop a performance improvement project in 2018 and 2019, resulting in the agency's inability to improve patient outcomes, safety, and quality of care for the agency's 24 patients admitted in the past year.

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 program, resulting in the potential spread of infections…

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 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 the initial comprehensive assessment visit was made within 48 hours of the date of the referral for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, and 7) records reviewed, resulting in a delay in determining the immediate care and support needs of the patient and the potential decline of…

The agency failed to ensure the comprehensive assessment included baseline information detailing the patient's current health at the time of admission for 5 of 7 (MR# 1, 4, 5, 6, and 7) records reviewed, resulting in incomplete clinical information to assist in determining the needs of the patient.

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, and 7) records reviewed, resulting in the potential for…

The agency failed to ensure the comprehensive assessment (including OASIS, outcome and assessment information set) was updated at the time of discharge in 2 of 6 (MR# 6, and 7) discharged records reviewed, resulting in no assessment of the patient's health status at the time of discharge and no…

The agency failed to ensure the plan of care (POC) identified the types of services required, the frequency and duration of visits to be made, all pertinent interventions, safety measures to protect against injury, and patient and caregiver education needs for 5 of 7 records reviewed (MR# 2, 4, 5…

The agency failed to ensure medications and visit frequencies were provided only as ordered by the physician for 5 of 7 (MR# 1, 2, 5, 6, and 7) records reviewed, out of a total of 7 records, resulting in the potential for the provision of inappropriate care and services.

The agency failed to ensure the physician was notified of changes in 4 of 7 records reviewed (MR#s 1, 4, 6, and 7) from a total of 7 sampled patients resulting in unidentified health concerns, delay in treatment and unmet patient care needs.

The agency's skilled professional services failed to coordinate care to ensure communication with the patient was effective for facilitating care as ordered by the physician for 3 of 7 (MR#1, 6, and 7 ) resulting in the patient's inability to receive ordered services.

The Agency failed to ensure the clinical record was complete and accurately captured the patients assessments for 2 records (MR# 1 and 3) from a total of 7 sampled records reviewed, resulting in an incomplete clinical record that fails to communicate a clear and concise clinical picture of the…

The agency failed to ensure a discharge summary was completed and sent to the physician within 5 business days at the time of discharge in 6 of 6 (MR# 1, 3, 4, 5, 6, and 7) discharged records reviewed, resulting in the physician not being informed of the patient's health status at the time of…