Supreme Home Care & Rehab

The agency failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment for 3 (P-5, P-6, P-7) records of patients who required individualized assessments in Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential…

The agency failed to ensure that at least one qualifying service was provided directly by Agency employees, resulting in the potential for interruption in continuity of care and unmet care needs for all 6 patients currently serviced by this agency.

The Agency failed to ensure that 2 (P-3, P-6) of 2 patients observed during home visits, from a total of 7 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of…

The agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 2 (P-5, P-7) patients assessed as needing assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, low self-esteem, and…

The agency failed to ensure the comprehensive assessment included a review of all medications, including over the counter and herbal medications to determine any adverse effects in 2 (P-6, P-4) of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients…

The agency failed to ensure the goals on the Plan of Care were objectively measurable to determine the patient's progress towards obtaining the goals in 3 (P-1, P-2, and P-3) of 7 records reviewed; and failed to ensure the plan of care include reportable pain parameters for 1 (P-4) 1 patient with a…

The agency failed to ensure treatments and services were provided only as ordered by the Physician for 1 (P-5) patient who required skilled home health services, from a total of 7 sampled records reviewed, resulting in the potential for the rendering of substandard, unsafe care and unmet care needs.

The agency failed to ensure the Physician was promptly notified of major drug to drug interactions in 2 (P-5, P-6) records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified untreated health issues related to drug interaction effects.

The agency failed to provide 2 (P-6, P-3) of 2 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, from a total of 7 sampled records reviewed, resulting in lack of direction for…

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to document the meaning of undefined abbreviations within the clinical records in 3 of 7 records reviewed (P-1, P-2, P-3), resulting in the inability to understand the documentation of the care provided to the patient.

The agency failed to ensure a qualified alternate, was appointed, in writing, to function in the Administrator's absence, resulting in the potential for uncoordinated agency functions and unmet care needs for all 6 patients currently serviced by this agency.

The agency failed to ensure a completed discharge summary was forwarded to the Physician within 5 days of the date of discharge for 2 (P-2, P-5) of 2 patients discharged from the agency's services from a total of 7 sampled records reviewed, resulting in the Physician's inability to assess the…

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 include a process for cooperation…

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

The agency failed to maintain and document infection control tracking for employees, failed to gather infection control data, failed to analyze infections and track infection trends (G-684); and failed to provide infection control education (G-686).

The agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency's provision of home health services.

The agency failed to develop an emergency preparedness plan that must be reviewed and updated at least annually.

The agency failed to develop an Emergency Preparedness program using a facility-based and community-based risk assessment, and utilizing an all hazards approach, resulting in the potential to negatively affect all patients and employees seen by the agency.

The Home Health Agency (HHA) 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 their efforts in contacting these officials…

The agency failed to develop Emergency Preparedness policies and procedures that aligned with the emergency plan, risk assessment and communication plan.

The agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least annually.

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 the communication plan.

The Agency (HHA) failed to develop a Quality Assessment Performance Improvement (QAPI) program that is at least capable of showing measurable improvements in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients, and to identify opportunities for improvement, and there was no documented evidence the…

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs.

The Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for…

The Agency (HHA) failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for…

The Agency (HHA) failed to provide documented evidence that infection control education was provided to all staff employed by the agency, and who were granted clinical privileges in 2020 and 2021, resulting in the potential for the development and spread of infections.

The home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans and…

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas, resulting in the potential for agency issues to go unresolved in high risk, high volume or…

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that considered incidence, prevalence, and severity of problems in identified areas of focus, resulting in the potential for the rendering of substandard…

The agency failed to develop an emergency preparedness plan that was reviewed and updated at least annually, resulting in no directions for agency actions in the event of an actual emergency or disaster.

The agency failed to provide physical therapy services as ordered in the plan of care for 3 of 5 (MR# 2, 3 and 5) records reviewed and, failed to ensure a written plan of care was completed to guide the care to be provided to the patient in 2 of 7 (MR#5 and MR#7) records reviewed (See G572); failed…

The agency failed to ensure their Quality Assessment and Performance Improvement program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care in 2018 (See G642); failed to collect and monitor quality indicator data 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 program (See G684); and the agency failed to ensure annual…

The agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status including wound appearance, blood sugars and nursing needs in 3 of 5 records reviewed in which nursing services were provided out of a total sample of 7 records reviewed…

The agency failed to ensure the home health aides received a minimum of 12 in-service hours each 12 month period for 2 of 2 home health aides employed by the agency for more than 12 months (Aide#1 and Aide#2), from a total of 2 Aide personnel files reviewed (See G774); failed to ensure the…

The agency failed to develop an emergency preparedness plan that was reviewed and updated at least annually, resulting in no directions for agency actions in the event of an actual emergency or disaster.

The agency failed to ensure the emergency plan was based on both a facility-based and community based hazard risk assessments affecting all 51 patients served by the agency in the past 12 months, resulting in the potential for being unprepared to respond in the event of an emergency.

The agency failed to ensure the Emergency Preparedness (EP) Plan addressed the patient population, the services the agency could provide during an emergency and succession plans affecting 51 of 51 patients served by the agency in the past 12 months, resulting the agency not being prepared to…

The Agency's emergency preparedness plan failed to include a process for cooperation and collaboration with local, tribal, 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 to…

The agency failed to develop and establish written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessments and communication plan, resulting in the agency's inability to implement an emergency plan specific to the emergency or disaster.

The agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 7 of 7 records reviewed (MR #1, 2, 3, 4, 5, 6 and 7) for Emergency Preparedness out of a total sample of 7 records reviewed, resulting in the potential for negative patient…

The agency failed to ensure the emergency preparedness policies and procedures included a process for informing state and local emergency preparedness officials of patients needing evacuation from their residence at any time due to an emergency/disaster situation, this had the potential to affect…

The agency failed to ensure the Emergency Preparedness Plan included procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency and to inform State and local officials of any…

The Agency failed to include 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; and failed to…

The agency failed develop and maintain a communication plan for emergency preparedness affecting 51 patients served in the past 12 months, resulting in the facility not being able to communicate effectively with facility staff, volunteers, other health care providers and emergency preparedness…

The agency failed to ensure initial and annual training in emergency preparedness policies and procedures was provided to all employees and contracted staff; failed to maintain documentation of emergency preparedness training provided to all staff; and failed to demonstrate staff knowledge of…

The agency failed to perform testing of their emergency preparedness program as required affecting 51 of 51 patients served by the agency in the past 12 months, resulting in the potential for being unprepared to respond effectively in the event of an actual emergency, which had the potential to…

The agency failed to provide physical therapy services as ordered in the plan of care for 3 of 5 (MR# 2, 3 and 5) records reviewed in which physical therapy services were ordered, resulting in the potential for functional decline for these patients; and failed to ensure a written plan of care was…

The agency failed to ensure their Quality Assessment and Performance Improvement 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 agency's 51…

The agency failed to collect and monitor quality indicator data for the Quality Assessment and Performance Improvement program; and failed to ensure the governing body approved the program's frequency and detail of data collection, resulting in the potential for poor patient outcomes for the…

The agency failed to ensure the Quality Assessment and Performance Improvement program developed a performance improvement project in 2018, resulting in the agency's inability to improve patient outcomes, safety, and quality of care for the agency's 51 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 in 3 out of 5 personnel files reviewed (Aide#1, Aide#2 and RN#2) out of a total sample of 5 personnel files reviewed, resulting in a lack of knowledge and training regarding…

The agency failed to ensure the home health aides received a minimum of 12 in-service hours each 12 month period for 2 of 2 home health aides employed by the agency for more than 12 months (Aide#1 and Aide#2), from a total of 2 Aide personnel files reviewed, resulting in a lack of educational…

The agency failed to ensure the registered nurse or physical therapist prepared written patient care instructions for the home health aide for 2 of 2 (MR# 2 and 4) patients in which aide services were provided, resulting in the aide providing services without a care plan and the potential for unmet…

The administrator 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 ensure patients were informed of the administrator's name and current business address in order to receive complaints, resulting in the potential for unaddressed patient concerns.

The agency failed to advise their patients of the names, addresses and telephone numbers of federally-funded and state-funded entities that serve the area where the patient resides, resulting in a lack of readily available access to community services and resources for the agency's 51 patients…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine significant drug interactions; and failed to ensure the physician was notified of the findings in 5 of 7 (MR# 1, 2, 4, 5 and 7) records reviewed, resulting in the potential for harmful…

The agency failed to ensure that the comprehensive assessment (including OASIS, outcome and assessment information set) was updated within 48 hours of discharge from the agency's services in 3 of 5 discharged records reviewed (MR# 5, 6 and 7), from a total sample of 7 records reviewed, resulting in…

The agency failed to ensure the plan of care developed for nursing services included individualized interventions, measurable outcomes and goals that were specific to the needs of the patient for 4 of 6 (MR#s 2, 3, 6 and 7) records reviewed in which skilled nursing services were provided, resulting…

The agency failed to ensure home health aide services, nursing services and oxygen treatments were provided only as ordered by the physician for 4 of 7 (MR# 2, 4, 5 and 6) records reviewed, resulting in the potential for the provision of inappropriate care and services.

The agency failed to coordinate the delivery of physical therapy services for 3 of 5 (MR# 3, 5 and 6) patients in which physical therapy services were ordered, resulting in the potential for functional decline for these patients.

The agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status including wound appearance, blood sugars and nursing needs in 3 of 5 records reviewed in which nursing services were provided out of a total sample of 7 records reviewed…

The agency failed to ensure the physical therapist assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 3 of 5 (MR# 3, 5 and 7) records reviewed in which physical therapy services were ordered; failed to ensure the registered nurse assisted…

The agency failed to ensure that skilled nursing and physical therapy services were provided at the frequency ordered in the plans of care for 5 of 7 (MR# 1, 3, 5, 6 and 7) records reviewed, resulting in the potential for decline in physical functioning, unidentified health concerns and unmet care…

The agency failed to ensure skilled professionals prepared clinical notes for 4 of 7 (MR# 1, 2, 3 and 4), records reviewed, resulting in the physician not having a complete clinical picture of the patient's health status and progress toward goals during the period of care.

The agency failed to ensure the home health aide provided care in accordance with the plan of care for 2 of 2 (MR# 2 and 4) patients in which aide services were provided, resulting in the aide providing services without a care plan and the potential for unmet care needs for both of these patients.

The agency failed to ensure the registered nurse or physical therapist completed an on-site supervisory visit to the patient's home at least every 14 days to supervise the services that were provided by the home health aide for 2 of 2 (MR# 2 and 4) records reviewed in which aide services had been…

The agency failed to ensure the skilled professional made an annual on-site observation visit at the patient's residence to observe the care being provided by the home health aide, for 2 of 2 home health aides (Aide#1 and Aide#2) employed for more than one year, resulting in a lack of oversight and…

The agency failed to ensure a discharge summary was completed and sent to the physician within 5 business days of the patient's discharge for 2 of 5 (MR# 2 and 4) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's…