Agape Home Care

The facility failed to ensure the plan of care was implemented for two of seven sampled patients (Patient 1 and Patient 3) when: 1. Home Health Aide 1 (HHA 1) did not perform range of motion exercises (exercises done either independently or with assistance to improve joint flexibility and movement)…

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 employee files for staff included completed orientation checklists, reference verification checks, and background checks as specified in the facility’s policies and procedures (P&P) when: 1. A home health aide (HHA 1), two Licensed Vocational Nurses (LVN 1 and LVN 2)…

The agency failed to follow infection control guidelines risking cross contamination in 1 of 8 sample patients (Patient 2) when: 1. A nursing supply bag was placed on Patient 2’s bedroom floor without a barrier.

The agency failed to obtain the Cardiopulmonary Resuscitation (CPR) documentation card for 1 of 2 Licensed Vocational Nurse’s (LVN 1) who has direct patient contact.

The agency failed to identify all the medications that a patient was taking for one of eight sampled patients (Patient 2) when: Four medications that Patient 2 was taking were not indicated on the Medication Profile (a list of medications the patient is taking).

Based on interview and record review Patient 1’s current plan of care did not include a medication order from October 25, 2021, that was to be continued.

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 conduct and document a facility based risk assessment (facility-based includes, but is…

The agency failed to ensure that the Condition of Participation: G 117 484.12 Compliance with Federal, State and Local Laws, Disclosure and Ownership Information, and Accepted Professional Standards and Principles were in compliance as follows: 1. Based on observation, interview, and record review…

The agency failed to conduct and document a facility based risk assessment (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 [i.e. rural area versus a large…

The agency failed to work in partnership with other organizations within the community in order to coordinate a response to an emergency in a universe of eight (8) patients.

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 due to an 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 procedure to inform state and local officials of the availability of on-duty staff and patients they were unable to contact during an emergency in a universe of eight (8) patients.

The agency failed to conduct a full-scale emergency preparedness exercise that was community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [e.g., joint field office, emergency operation centers, etc.] and "boots on the ground"…

The agency failed to comply with state law for: 1. California Business and Professions Code (BPC) section 1265(a)(2), waived testing criteria (standards the agency must follow in order to perform laboratory (lab) testing on human beings) by failing to maintain a current clinical laboratory…

The agency failed to ensure its staff followed the agency's policy and procedure and professionally accepted infection control practices for three (3) of 10 sampled patients (Patients 1, 4 and 5) when: 1. For Patient 1, a Licensed Vocational Nurse (LVN 2) did not disinfect her hands after glove…

The agency failed to ensure clinical notes and assessments where incorporated into the patients' clinical records according to the time frame indicated in the agency's policy and procedure for two (2) of 10 samples patients (Patients 3 and 4).

The agency failed to ensure the comprehensive assessment was updated and the updated information was used in care planning for one (1) of 10 sampled patients (Patient 7).