Adept Home Health Services, Inc

The facility failed to ensure its emergency preparedness plan and policies and procedures were reviewed and updated (as necessary) at least every two (2) years.

The facility failed to ensure they had a performance improvement project (PIP - a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) in progress…

The facility failed to ensure staff followed infection control practices for two of three patients in which home visits were conducted (Patient 2 and 3) when: 1. During wound care for Patient 2, Quality Assurance Staff (QA) did not change her gloves after removing old wound dressings and wore the…

The facility failed to ensure its Quality Assurance Performance Improvement (QAPI - a data-driven, systematic approach to improving safety and quality in healthcare settings) committee gathered information regarding the agency’s performance in conducting Licensed Vocational Nurse (LVN) joint…

The facility failed to ensure one of seven sampled patients (Patient 6) received skilled nursing home health visits in the frequency as ordered by the physician for the certification period of March 15, 2025, through to May 13, 2025. This had the potential for Patient 6 to have unmet care needs and…

The agency failed to ensure they had documented evidence that a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for three of seven sampled patients (Patients 3, 6 and 7) when there was no documentation indicating supervisory visits were performed.

The home health agency (HHA) failed to implement a performance improvement activities as part of their Quality Assessment, Performance Improvement Program (QAPI-a quality management system used to improving the quality of care and services delivered by the HHA) when the HHA did not track, analyze…

The agency failed to provide the names, addresses, and telephone numbers of federally and state-funded entities to one of eight sampled Patients (Patient 3).

The home health agency (HHA) failed to provide information on how to access auxiliary aids and language services to one of eight sampled Patients (Patient 1).

The Home Health agency (HHA) failed to provide contact information of other HHA agencies for one of eight sampled patients (Patient 8) when Patient 8 was discharge for a cause (a patient being discharge for refusing services).

The Home Health agency (HHA) failed to document in the clinical record the efforts made to resolve the problem for one of eight sampled patients (Patient 8) when Patient 8 was discharged for a cause.

The facility failed to complete monthly calendar records per their policy, when three out of three Patients’ (Patient 1, Patient 2, and Patient 3) in-home records contained a monthly calendar where scheduled home visits were to be listed, however, it was blank.

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: A.

The agency failed to ensure that the Condition of Participation: G 640 484.65 Quality assessment and performance improvement (QAPI) was in compliance as follows: A.

The agency failed to ensure that the Condition of Participation: G 680 484.70: Infection prevention and control was in compliance when: Based on interview and record review, the agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment…

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 to maintain an integrated response during a disaster or emergency for 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

The agency failed to develop individual patient emergency preparedness plans based on and included in the patients' comprehensive assessments for 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

The agency failed to develop procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

The agency failed to develop a procedure to provide for emergency staffing during a disaster or emergency, for 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

The agency failed to develop a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for 10 of 10 sampled patients…

The agency failed to develop 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 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

The agency failed to provide training to all staff, as well as contracted staff, on the emergency preparedness policies and procedures and "Community Emergency Preparedness Plan [CEPP]," for 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

The agency failed to develop policy and procedures on conducting 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, emergency operation…

The agency failed to measure, analyze or utilize quality indicator (a measureable element of the agency's practice that can be used to assess the quality of care provided) data in order to assess the agency's processes of care, services, and operations, for 10 of 10 sampled patients (Patients 1, 2…

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 including data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency's services.

The agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had…

The agency's Governing Body (GB) failed to ensure a Quality Assessment and Performance Improvement (QAPI) Program was implemented, maintained and evaluated for effectiveness, for 10 of 10 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

The agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment Performance Improvement (QAPI) program in order to identify infection trends (analysis of a pattern), develop action plans and improve disease prevention in 10 out of 10 sampled…

The agency failed to ensure a review of all medications the patients were taking was conducted for two of 10 sampled patients (Patients 3 and 4) when: A.

The agency failed to ensure the plan of care and physician's order indicated Certified Home Health Aide (CHHA) visit frequencies for one of 10 sampled patients (Patient 4).

The agency failed to ensure a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for five of 10 sampled patients (Patients 1, 3, 4, 5 and 9).

The agency failed to ensure skilled nursing clinical notes were in Patient 5's clinical record within the 14-day time frame indicated in the agency's policy and procedure titled, "Skilled Notes Turn Around Time." This failure had the potential to cause distribution of inaccurate and incomplete…