Town and Country Home Health Care

The home health agency failed to meet the Condition of Participation: G325 at 42 CFR 484.1. The agency failed to establish the conditions that a home health agency (HHA) must meet to participate in the Medicare program which includes being primarily engaged in providing skilled nursing or…

The home health agency failed to meet the Condition of Participation: G640 at 42 CFR 484.65. The agency failed to establish a quality assessment performance improvement program(QAPI); to measure, analyze and track quality indicators; to establish a system to collect and evaluate program data…

The agency failed to maintain ongoing collaboration and failed to review and update contact information for local, tribal, regional and state agencies for use in the event of emergency situations.

The facility failed to assure availability of emergency packets to be used in the event of an emergency evacuation of the patient from their residence.

The agency failed to establish a process to measure, analyze and track quality indicators.

The agency failed to utilize quality data to identify opportunities for improvement.

The agency failed to identify performance improvement activities.

The agency failed to ensure an ongoing quality assurance performance improvement (QAPI) program was implemented and maintained.

The facility failed to maintain a current contract for therapy provision, therefore lacking a second therapeutic service available for potential patients.

The facility failed to address the home health care patient population, including, but not limited to: persons requiring additional assistance and those with limited mobility; the type of services the facility had the ability to provide in an emergency; and continuity of operations in their…

The facility failed to implement a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness (EP) officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts…

The agency failed to complete comprehensive assessments for skilled patients every 60 days, beginning with the start of care (SOC) date for 2 of 2 skilled private pay patients (P1, P2) reviewed for home care services.

The agency failed to ensure supervisory visits of home health aides (HHAs) were completed every 14 days as required for 1 of 2 patients (P1) reviewed who had skilled nurse visits (SNV) and HHA services for longer than 14 days.

The facility failed to address the home health care patient/client population, including, but not limited to: persons requiring additional assistance and those with limited mobility; the type of services the facility had the ability to provide in an emergency; and continuity of operations…

The home health agency (HHA) failed to develop and include policies and procedures in the Emergency Preparedness (EP) plan, for ensuring all patients had an individualized emergency plan in the event of an emergency.

The facility failed to develop and implement emergency preparedness policies and procedures that included a system to inform state and local emergency preparedness officials of the need for patient evacuations from their residences, during an emergency.

Failed to ensure an individual facility-based risk assessment for each separately certified facility within the health system utilizing an all-hazards approach.

The agency failed to ensure each completed comprehensive assessment along with Outcome and Assessment Information Set (OASIS) data, was transmitted as required per OASIS guidelines to the State Agency, for 3 of 3 current patients (P3, P4, P5) and 2 of 2 discharged patients (P6, P7).

The agency failed to ensure the plan of care (POC) included a description of the risk for emergency department visits and hospital re-admissions, and advanced directives, for 6 of 6 patients (P1, P2, P3, P4, P5, P6, P7 ) admitted after January 13, 2018, whose records were reviewed.