All-4 One Home Healthcare Services, Inc

The agency failed to ensure its performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventative actions.

The agency staff failed to follow physician’s orders for two (2) of five (5) clinical records in the survey samples (clinical record #2 and 5).

The agency failed to provide coordination of care for one (1) of five (5) clinical records reviewed in the survey sample (clinical record #2).

The agency failed to send the patient's discharge summary to the primary care physician within 5 business days of discharge for one (1) of two (2) discharged patients in the survey sample (clinical record #2).

The agency failed to ensure property and person were treated with respect (see G428); failed to ensure patients would be free from neglect (see G430) failed to document that patients were allowed to participate in their care (see G434); failed to provide patients a written notice in advance of…

The agency failed to provide safe care as ordered by a physician.

The Governing Body and/or Administrator failed to ensure the overall management and organization of resources in order to attain and provide the highest practicable functional status.

The agency failed to include individual emergency preparedness plans (EPP) for each patient as part of their comprehensive assessment.

The agency failed to conduct adequate testing of its Emergency Preparedness Plan (EPP).

The agency failed to ensure the OASIS data accurately reflected the patient's status at the time of assessment for two (2) of two (2) patients in the survey sample who had a wound VAC dressing (clinical record #1 and #5).

The agency staff failed to follow the individualized plans of care for eight (8) of eight (8) patients in the survey sample (Clinical records #1, #2, #3, #4, #5, #6, #7 and #8).

The agency staff failed to follow physicians orders in a timely manner and failed to notify the physician of the delay in providing care.

The agency failed to conduct performance improvement projects (PIP) for the year of 2019. Specifically, the agency's Quality Assessment and Performance Improvement (QAPI) documentation failed to contain evidence of the completion of at least one (1) PIP for the year of 2019. Findings: One Medical…

The agency failed to follow accepted standards of practice related to infection control and prevention; and failed to mitigate the risk of COVID-19 transmission.

The agency failed to ensure that patients were treated with respect.

The agency failed to ensure a patient was free from neglect by anyone furnishing services on behalf of the HHA (Home Health Agency).

The agency failed to document informing patients verbally and in writing regarding the disciplines to furnish care and or the frequency of those proposed visits for eight (8) of eight (8) clinical records reviewed in the survey sample (Clinical records #'s 1-8).

The agency failed to provide a Notice of Medicare Non-Coverage (NOMNC) to Medicare patients in advance of terminating care for two (2) of three (3) closed/discharged patients whose records were reviewed in the survey sample, for which a NOMNC was applicable.

The agency failed to provide the necessary services required to meet the needs of a patient for one (1) of six (6) patients in the survey sample (Clinical record #1).

The agency failed to document each complaint with a documented investigation and/or resolution of the complaint for 12 of 26 complaints reviewed from 6/18/2020 to 12/18/2020. The findings: Twenty six complaints were reviewed in the agency on 1/25/2021. The complaint log revealed an incomplete…

The agency's staff failed to ensure plans of care contained all wound locations and wound care treatments as ordered by the physician for five (5) of eight (8) patients in the survey sample (Clinical records #1, #3, #4, #5 and #7).

The agency failed to ensure services and treatments were administered only as ordered by a physician for two (2) of eight (8) patients whose clinical records were reviewed in the survey sample (Clinical record #3 and #6).

The agency failed to document the patient's progress toward outcomes and goals specified in the plans of care for eight (8) of eight (8) clinical records reviewed in the survey sample (Clinical records: #1-8).

The agency failed to ensure the Administrator was responsible for all day-to-day operations of the home health agency.

The agency failed to ensure that each patients' plan of care was implemented and updated as required in eight (8) of eight (8) clinical records reviewed in the survey sample (Clinical records #1, #2, #3, #4, #5, #6, #7 and #8).

The agency failed to send the patient's discharge summary to the primary care physician within 5 business days of the patient's discharge for two (2) of six (6) discharged patients in the survey sample (Clinical records #1 and #4).