Trillium Home Care Solutions, LLC

The agency failed to develop an Emergency Preparedness plan that included policies, procedures, a communication plan, exercises, training, and testing.

The agency failed to develop a Quality Assurance Performance Improvement program that was capable of showing measurable improvement in health outcomes, patient safety and quality of care by collecting, measuring, analyzing and tracking quality indicators to assess the agency's processes of care…

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 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 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 ensure the emergency preparedness communication plan included a means for sharing information about the agency's occupancy, needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, affecting all patients served…

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 home health agency failed to conduct exercises to annually test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the clinic's…

The agency failed to develop a Quality Assurance Performance Improvement program that was capable of showing measurable improvement in health outscomes, patient safety and quality of care by collecting, measuring, analyzing and tracking quality indicators to assess the agency's processes of care…

The Agency failed to develop a Quality Assessment Performance Improvement program that selected, performed and documented annual quality improvement projects for the 2019, 2020 and 2021 calendar years, resulting in the Agency's inability to improve in patient care, health outcomes, patient safety…

The Governing Body failed to ensure the agency had an active, functioning and ongoing Quality Assessment and Performance Improvement program that fulfilled all the regulatory requirements of this section, resulting in the potential poor quality of care and negative outcomes for the agency's…

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 failed to ensure clinical records were retrievable and available for surveyor review for 1 of 1 patients who received services from the agency (MR #1) out of a total sample of 1 patient.

The agency failed to ensure the Administrator (Adm#1) was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the lack of oversight of patient care and operations of the agency, affecting all patients admitted to the agency, resulting in the potential…

The agency failed to ensure that 1 of 1 administrators (Adm#1) had an orientation or training, resulting in the potential for an unqualified administrator operating the agency.

The Administrator (Adm#1) and the Governing Body failed to identify in writing, an alternate administrator and an alternate Clinical Manager, for a potential lack of oversight and management of patient care services and staff.

The agency failed to provide any services, resulting in the agency not functioning as an operational business.