A and E Home Health Services, Inc

The agency failed to ensure 1 of 7 staff members was knowledgeable about the location of the agency’s designated and alternate meeting location in case of emergencies.

The agency failed to ensure a medication reconciliation (a critical safety process of creating the most accurate list of a patient's current medications including name, dosage, frequency, route, and expiration and comparing it against physician's orders) was conducted for one of seven sampled…

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the…

The agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients.

The agency failed to conduct and document a community-based and/or facility-based risk assessment (community/facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; patient population; facility type and potential surrounding community assets…

The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients.

The agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients.

The agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness officials, for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients.

The agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients.

The agency failed to provide training to contracted staff on the emergency preparedness policies and procedures and “Emergency Preparedness Plan,” for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients.

The agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office or emergency operation centers.] and “boots on the…

The agency failed to ensure the patients’ comprehensive assessments were completed within five (5) days of the start of care for two of seven sampled patients (Patients 2 and 7) when Patient 2 did not receive an initial Physical Therapy (PT) evaluation and Patient 7 did not receive an initial…

The agency failed to ensure an individualized plan of care was developed within five days and reviewed, approved, and signed by a physician within 30 days of the patient’s start of care for three of seven sampled patients (Patients 3, 6 and 7) when: 1. For Patient 3, Certified Home Health Aide…

The agency failed to measure and analyze quality indicators (a measurable element of the agency’s practice that can be used to assess the quality of care provided) in order to assess the agency’s processes of care, services, and operations, for the 2021 and 2022 years reviewed, in a universe of 35…

The agency failed to use quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency’s services.

The agency’s Governing Body (GB) failed to provide oversight for its Quality Assessment and Performance Improvement (QAPI) Program for the 2021 and 2022 years reviewed, in a universe of 35 patients when: 1. The Governing Body failed to oversee the QAPI Program to ensure the measurement and analysis…

The agency failed to ensure its staff followed the agency’s policy and procedure and professionally accepted infection control practices for one of seven sampled patients (Patient 2) when a Physical Therapy Assistant (PTA 1) did not follow clean bag technique (a set of procedures to follow to…

The agency failed to ensure patients’ rights were protected when the state toll free home health telephone hot line, its contact information, hours of operation and its purpose to receive complaints was not provided to three of seven sampled patients (Patients 1, 2, and 3).

The agency failed to ensure the patients' initial assessment was completed within 48 hours of the patients’ referral order for two of seven sampled patients (Patients 6 and 7).

The agency failed to ensure a review of all medications the patients were taking was conducted for three of seven sampled patients (Patients 1, 2, and 3) when: 1. For Patient 1: the Medication Profile (MP-a current list of all medications prescribed for a specific patient), indicated the wrong…

The agency failed to ensure verbal orders were signed, within 30 working days, for one of seven sampled patients (Patient 7).

The agency failed to ensure Certified Home Health Aide (CHHA) service needs were reassessed and additional CHHA visits requested, from the physician, for one of seven sampled patients (Patient 3) when Patient 3’s family was struggling with helping Patient 3 with her activities of daily living…