Able Care

The agency failed to ensure the physical therapist conducted an initial assessment within 48 hours of the physician referral in 1 (P-4) of 7 records reviewed (see G516); failed to ensure that a comprehensive assessment was completed timely in 1 (P-4) of 7 records reviewed (see G520); and failed to…

The Clinical Director (CD-1) failed to ensure the oversight of: coordination of patient care (see G0962); physician referrals for the initiation of home care services (see G0964); and the development of an individualized plan of care (see G0968), resulting in the agency’s potential mismanagement of…

The Physical Therapist (PT) failed to provide services in accordance with the Plan of Care (POC) for 1 (P-7) of 5 records reviewed with PT services, and failed to sign the plan of care for 1 patient (P-2) from a total of 7 sampled records reviewed, resulting in the potential for decline in physical…

The agency failed to ensure staff followed expected infection control standards of practice during 1 (P-1) of 3 joint home visits conducted during the survey, potentially resulting in the risk of communicable disease transmission.

The agency failed to ensure the registered nurse included all pertinent safety measures in the home health aide (HHa) plan of care in 1 (Patient/P-7) of 1 record reviewed with home health aide services, resulting in the potential for the provision of unsafe care.

The agency failed to ensure the right of the patient to consent to or refuse care before treatment in 1 (P-1) of 7 records reviewed, potentially resulting in limited care options for this patient.

The agency failed to ensure the physical therapist (PT) conducted an initial assessment within 48 hours of the physician referral in 1 (P-4) of 7 records reviewed, resulting in a delay in assessment of immediate care needs and the potential for a poor patient outcome.

The agency failed to ensure the comprehensive assessment was completed timely for 1 (P-4) of 7 total sample records reviewed, resulting in a delay in assessment of immediate care and support needs of the patient and the potential for poor patient outcomes.

The agency failed to ensure that a comprehensive assessment accurately reflected the patient's current health status at the time of admission for 1 (P-4) of 7 total sample records reviewed, resulting in incomplete clinical information gathering and possible poor patient outcomes.

The agency failed to ensure the Plan of Care (POC) was detailed and individualized in 4 (Patient/P-2, P-4, P-5 and P-7) of 7 total records reviewed, resulting in the potential for poor clinical outcomes and unidentified goals, unmet patient goals.

The agency failed to ensure the plan of care was revised after nursing services were added in 1 (P-1) of 7 records reviewed, resulting in no measurable outcomes or goals for nursing services to track patient progress.

The home care agency failed to ensure skilled nursing (SN) provided appropriate supervision of services provided by the Licensed Practical Nurse (LPN) every 30 days for 1 (Patient/P-5) of 4 records reviewed with LPN services, resulting in a lack of supervision and oversight of patient care services…

The home care agency failed to ensure Physical Therapy (PT) provided appropriate supervision of services provided by the Physical Therapy Assistant (PTA) every 30 days for 1 (Patient/P-7) of 3 records reviewed with PTA services, resulting in a lack of supervision and oversight of patient care…

The agency failed to ensure the Clinical Director (CD-1) coordinated patient care for 1 (P-4) of 7 total sample records reviewed, resulting in the potential decline in physical functioning, unidentified health concerns and unmet care needs.

The agency failed to ensure the Clinical Director (CD-1) coordinated referrals for 1 (P4) of 7 records reviewed, resulting in the potential decline in physical functioning, unidentified health concerns and unmet care needs.

The agency failed to ensure the Clinical Director (CD-1) provided oversight of the development, implementation, and updates of an individualized care plan for 1 (P4) of 7 records reviewed, resulting in the potential of unidentified health concerns and unmet care needs.

The agency failed to ensure the clinical record was complete and included consent for treatment for home care services as required in 1 (Patient/P-7) of 7 total sample records reviewed, resulting in the agency not having a complete clinical record and the failure to secure HIPAA (Health Insurance…

The agency failed to ensure discharge summaries were sent to the physician within 5 business days of discharge in 4 (P-4, P-5, P-6 and P-7) of 4 records reviewed in which the patient was discharged from service; and failed to ensure transfer summaries were sent to the physician within 2 business…

The agency failed to develop an Emergency Preparedness Program that included an all-hazards risk assessment, addressed patient population, services provided and delegation of authority, cooperation and collaboration, a communication plan, training, and testing.

The Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening all staff employed by this agency, specifically who were granted clinical privileges, resulting in the potential development…

The Agency failed to ensure the Skilled Disciplines performed appropriate baseline assessments and re-assessments of the patient's health status and needs in 2 (MR's #4, 6) records of patients with diagnoses of Congestive Heart Failure, and Kidney Disease, from a total of 7 sampled records…

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

The facility failed to address patient population, identify types of services the Agency would provide in an emergency and the delegation of authority in an event of an emergency, resulting in the potential to hinder the agency's ability to provide continued patient care for all patients receiving…

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 and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least every 2 years.

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 failed to ensure that services were provided in accordance with the Plan of Care for 1 (MR #5) of 1 patient who was ordered to receive Home Health Aide services, from a total of 7 sampled records reviewed, resulting in the potential for poor grooming and low self-esteem.

The Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening all staff employed by this agency, specifically who were granted clinical privileges, resulting in the potential development…

The Agency failed to establish Vaccine protocol written policies and procedures that included (i) and (ii) the requirement for staff vaccination or exemption; (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for tracking/documenting…

The Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to providing care in 1 (MR #5) of 1 record in which Home Health Aide services were ordered, from a total of 7 sampled records…

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 patients currently serviced by this agency.

The Agency failed to ensure that 1 (MR's #6) of 3 patients observed during home visits, were included in the overall planning of care including informing the patient/caregiver in advance of the days and times in which services would be provided, from a total of 7 sampled records reviewed, resulting…

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (MR #5) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in the patient being denied the right to…

The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 4 (MR's #4, 5, 6, 7) of 3 records where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the…

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; and…

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 4 of 7 (MR# 1, 2, 3, 6) records reviewed, and failed to notify the physician of adverse…

The Agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient in 5 (MR's #1, 4, 5, 6, 7) of 5 records, from a total of 7 sampled records reviewed, resulting in…

The Agency failed to ensure the Physician was promptly notified of 1 (MR #6) of 1 patient observed during a home visit with low vital signs, from a total of 7 sampled records reviewed, resulting in the potential for unaddressed health conditions, decline in physiological functioning and unmet care…

The Agency failed to ensure the Skilled Disciplines performed appropriate baseline assessments and re-assessments of the patient's health status and needs in 2 (MR's #4, 6) records of patients with diagnoses of Congestive Heart Failure, and Kidney Disease, from a total of 7 sampled records…

The Agency failed to ensure the Speech Therapist assisted the Physician in evaluating the patient's level of functioning and helped to develop the plan of care for 1 (MR #6) of 1 record in which Speech Therapy services were ordered due to difficulty speaking, from a total sample of 7 records…

The Agency failed to ensure skilled services were provided in accordance with the Physician's orders and Plan of Care for 3 (MR's #4, 6, 7) records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, physiological decline, and unmet patient care…

The Agency failed to ensure the clinical record was completed and included detailed Skilled Nursing and Physical Therapy notes for 4 (MR's #1, 3, 6, 7) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health…

The Agency failed to establish a written agreement with its contracted agency that specified the terms of the agreement including 1).

The Home Health Agency failed to comply with the requirements of part 420 subpart C, of this chapter, and inform the state agency of the change of ownership and management information for this agency.

The Home Health Agency failed to inform the state agency, The Department of Licensing and Regulatory Affairs, of the change in Ownership, the change of the Administrator and the change of the Director of Clinical Services.

The registered nurse failed to complete a review of the patient's current medications, along with the start of care assessment, in order to identify any potential adverse effects, any significant drug interactions and any duplicate drug therapy and failed to report the findings to the physician in…

The agency failed to ensure the plan of care included orders for reporting uncontrolled pain and reportable pain parameters to the physician in 1 of 1 record reviewed (MR#1), out of a total sample of 1 active patient, which resulted in unmet pain issues for the patient.

The registered nurse failed to communicate with the physician and notify the physician of the ineffective pain management for 1 of 1 record reviewed (M.R. #1), out of a total sample of 1 active patient, which resulted in uncontrolled pain for the patient.