Total Homecare Solutions, Inc

The agency failed to ensure the emergency preparedness plan was reviewed and updated at least every 2 years (see E0004); failed to ensure emergency preparedness policies and procedures based on the emergency plan, risk assessment and communication plan were implemented, reviewed, and updated every…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program, (See G 642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, (See G 644); failed to document the quality…

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 G 684); and failed to provide infection control…

The agency failed to ensure the Emergency Preparedness plan was reviewed and updated at least every 2 years, resulting in the potential to negatively impact all patients receiving services from this agency in the event of an emergency.

The agency failed to ensure emergency preparedness policies and procedures based on the emergency plan, risk assessment and communication plan were implemented, reviewed, and updated every 2 years, resulting in the potential for poor patient outcomes during the event of an emergency.

The agency failed to maintain an Emergency Preparedness communication plan that was updated at least every 2 years, resulting in the inability to coordinate patient care for the patients served by this agency in the event of an emergency.

The agency failed to provide initial training in emergency preparedness to 2 (Staff C, D) of 3 personnel files reviewed of clinical staff, resulting in the potential for unprepared responses to emergencies and an interruption in the provision of needed patient care services.

The agency failed to ensure exercises to test the emergency preparedness plan were conducted annually according to the regulation, resulting in the potential for poor patient outcomes in the event of an actual emergency.

The agency failed to ensure the plan of care included patient-specific measurable outcomes and goals based on the comprehensive assessment and current patient needs in 5 (P-1, 2, 3, 4, 5) of 7 records reviewed; and failed to adhere to stated goals for discharge in the Plan of Care (POC) before…

The Agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 8 patients that were admitted during the past 12 months, resulting in a potential for poor patient outcomes due to the provision of…

The Agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the Quality Assessment and Performance Improvement (QAPI) program, which had the potential to negatively affect all 8 patients serviced by the…

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented any performance improvement projects, the reasons for conducting these projects along with measurable tracking and trending measures to ascertain progress achieved during the last three years…

The Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect…

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 provide infection control education to staff, resulting in the potential for transmission of communicable disease to all patients served by this agency.

"He is the only one on the Governing Board." The Agency failed to establish a Governing Body that is composed of more than one individual as required.

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 1…

The Agency failed to ensure a physician's response was documented when medication reconciliations identified safety concerns regarding drug interactions or duplications in 3 (P-1, P-2, P-6) of 7 records reviewed out of a total sample of 7 records, resulting in the continuance of potentially unsafe…

The Agency failed to ensure the Plan of Care (POC) covered all pertinent interventions with reportable parameters, and patient safety precautions for 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, from a total sample of 7 records reviewed, resulting in the potential for unidentified, abnormal…

The Agency failed to ensure a discharge summary was forwarded to the physician within 5 days of discharge in 5 (P-3, P-4, P-5, P-6, P-7) of 5 closed records reviewed, out of a total sample of 7 records reviewed.

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 5 of 5 (MR# 2, 3, 4, 6 and 7) records reviewed with therapy only services from a total of 7…

The agency failed to ensure the comprehensive assessment was updated at the time of discharge in 1 of 7 (MR# 1) discharged records reviewed, from a total of 7 records reviewed, resulting in no summary of the patient's progress in meeting care plan goals.

The agency failed to ensure that 4 of 4 contracts (Contract #1, 2, 3 and 4) included the provision that the Home Health Agency (HHA) must maintain overall responsibility for the services provided under contract.

The agency failed to ensure that discharge and transfer summaries were complete, provided the patient's current health status at the time of discharge and transfer, documented progress toward goals, provided an updated medication list and were sent to the physician in 6 of 7 records (MR #'s 1, 2…