All Needs Senior Services

The agency failed to ensure the Clinical Manager coordinated patient care (See G962).

The agency failed to ensure that 2 of 7 (P-1, 2) patients were included in their overall planning of care including informing the patient/caregiver in advance of discharge in which services would cease, resulting in a lack of inclusion in planning, lack of informed consent, and unmet care needs.

The Practice Manager failed to ensure the coordination of patient care services for 6 of 7 (P-1, 2, 4, 5, 6, 7) records reviewed, resulting in a potential decline in physical functioning and resulting in the potential for the provision of care inconsistent with the plan of care and unmet care needs.

The agency (HHA) failed to ensure the Registered Nurse conducted the initial assessment visit within 48 hours of referral for 1 record reviewed (P-2), see (G-514), failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status with…

The agency failed to ensure the plan of care included measurable goals for 3 of 7 records reviewed, (P-5, 6, 7) see (G-572), failed to include interventions, parameters, and safety precautions in 3 of 7 records reviewed (P-5, 6, 7) see (G-574), failed to ensure the frequency of visits ordered were…

The agency's QAPI Program failed to include evidence of measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care (refer to G-642); and failed to provide evidence of Governing Body approval…

The agency failed to conduct exercises to annually test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the agency's response to and…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status with baseline data for future assessments, in 2 of 7 records reviewed (P-6, 2) out of a total of 7 records reviewed, resulting in the potential for unmet care…

The agency failed to develop a plan of care that included patient-specific measurable outcomes and goals to use in determining the patient's progress towards obtaining goals in 7 (P-1,2,3,4, 5, 6, 7) of a total of 7 records reviewed, resulting in the agency and patient being unable to ascertain if…

The Home Health Agency (HHA) failed to ensure the frequency of visits ordered on the Plan of Care (POC) were followed in 1 of 7 (P-5) records reviewed, from a total sample of 7 records reviewed, resulting in the potential for unmet patient needs.

The agency's QAPI Program failed to include evidence of measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The agency failed to provide evidence of Governing Body approval of the agency's Quality Assessment and Performance Improvement Program for 2023 or 2024. Findings included: On 2/7/2024 at 10:00 a.m., the Administrator (ADM#1) was asked to provide the Governing Body Meeting Minutes for 2023. The…

The agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases while providing nursing services to a patient during a home visit in 1 of 3 survey home visits (P-1) provided within the home of…

The agency failed to include the frequency and duration of visits on the Aide Care Plan for 1 of 1 (P-4) records that included Home Health Aide Services.

The agency failed to include a signed plan of care in the record for 6 of 7 (P-1, 2, 3, 4, 5, 6) records reviewed, from a total of 7 records reviewed, resulting in the potential for unmet care needs.

The Agency failed to ensure the Registered Nurse conducted the initial assessment visit within 48 hours of referral, to determine the immediate care needs of the patient, including homebound status for 1 (P-2) record in which Skilled Nursing services were needed, from a total of 7 records reviewed…

The agency failed to notify the physician of potential major drug interactions resulting from the combination of medications the patient was prescribed in 4 of 7 (P-1,2,3,4) records reviewed.

The Plan of Care failed to include interventions to address the patients Congestive Heart Failure (CHF) in 4 of 7 patients (P-3, 4, 6, 7), failed to include interventions for 3 of 4 patients (P-2, 3 and 7) diagnosed with Type 2 Diabetes (DM2), failed to include weight parameters in 2 of 7 patients…

The agency failed to ensure the physician was notified of changes in care ordered in the plan of care (POC) for 2 of 7 (MR# 5, 7) records reviewed, resulting in the potential for physical decline and negative patient outcomes.

The agency failed to ensure physical therapy (PT), medical social worker (MSW), and Home Health Aide (HHa) services were provided as ordered by the physician in the plan of care for 2 of 7 (P-5, P-1) records reviewed, resulting in the potential for physical decline and negative patient outcomes.

The agency failed to document patient information in the clinical notes in 2 of 7 (P-6 and 7) records reviewed, resulting in inaccurate or misunderstood communication in patient healthcare clinical records, and the potential for negative patient outcomes.

The agency failed to include clinical visit notes for skilled nursing in 1 of 7 (P-2) records.

The agency failed to include the name and contact information of the physician on the Plan of Care (POC) or in the clinical record in 1 of 7 records (P-1) reviewed, resulting in the patient/staff of the agency not having the name and contact information of the attending physician.

The agency failed to include discharge summaries in the patient record and failed to document submission to the physician in 2 of 7 records (P-2, P-5) who were discharged, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care…

The agency failed to ensure visit frequencies were provided only as ordered by the physician for 1 of 3 (MR# 1) records reviewed, out of a total of 3 records, resulting in the potential for the provision of inappropriate care and services.

The Agency failed to develop and update its Emergency Preparedness plan to include plans to address the global pandemic COVID-19 (E0004); failed to develop Emergency Preparedness policies and procedures that addressed the use of volunteers or other emergency staffing strategies during an emergency…

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, measurable data to use as a baseline for future assessments…

The agency failed to provide skilled nursing services as ordered in the plan of care for 1 of 7 (MR# 4) and to document signed physician plans of care in 7 of 7 (MR#s 1, 2, 3, 4, 5, 6, 7) records reviewed (refer to G-572); failed to ensure the plan of care included patient specific safety measures…

The agency failed to ensure their Quality Assessment and Performance Improvement (QAPI) program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care (refer to G-642); failed to collect and monitor quality indicator data for…

The Registered Nurse failed to supervise the services provided by the Licensed Practical Nurse (LPN) in providing wound care to 1 of 1 record reviewed with wound services (MR# 4) and LPN supervision with a home visit in 1 of 1 record reviewed (MR# 7) (G726).

The agency failed to ensure the home health aide received a minimum of 12 in-service hours (G774); failed to ensure the RN (registered nurse) prepared written patient care instructions alerting the home health aide (HHa) to the safety precautions and special conditions that were applicable to each…

The agency failed to document referrals in 3 of 7 (MR#s 4, 5, 6) records reviewed, failed to document patient consents for services and frequency in 4 of 7 (MR# 4, 5, 6, 7) records reviewed, failed to document visit notes in 1 of 7 (MR# 6) records reviewed, failed to have physician signed plans of…

The agency failed to develop and update its Emergency Preparedness plan to include plans to address the global pandemic (COVID-19), resulting in staff being ill-prepared to address the crisis and the potential for poor patient outcomes for patients serviced from 3/15/2020 to 1/26/21. Findings…

The agency failed to develop Emergency Preparedness policies and procedures that addressed the use of volunteers or other emergency staffing strategies during an emergency, resulting in the potential for the interruption in care and services for the 21 patients currently serviced by the agency.

The agency failed to develop and maintain a communication plan for the emergency preparedness plan, including names and contact information for staff, community, state and federal entities providing services, patients' physicians and volunteers, affecting all patients served and staff, resulting in…

The agency failed to develop and maintain an emergency preparedness training and testing program on the COVID-19 disease, for 14 of 14 active staff members, resulting in the potential for staff being unprepared to respond effectively during an actual emergency, which had the potential to affect all…

The agency failed to ensure initial training in emergency preparedness policies and procedures was provided to all employees; failed to provide training of the updated emergency preparedness policies and procedures on the COVID-19 disease; and failed to demonstrate staff knowledge of the emergency…

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, measurable data to use as a baseline for future assessments…

The agency failed to provide skilled nursing services as ordered in the plan of care for 1 of 7 (MR# 4) and to document signed physician plans of care in 7 of 7 (MR#s 1, 2, 3, 4, 5, 6, 7) records reviewed.

The agency failed to ensure the skilled nurse documented the patient's treatments and medication as ordered by the physician for 2 of 2 (MR# 4, 7) records reviewed in which the treatment was not provided as ordered and failed to provide physical therapy (PT) services in 2 of 5 (MR# 6, 7) medical…

The agency failed to ensure their Quality Assessment and Performance Improvement (QAPI) program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety, and quality of care, resulting in the potential for poor patient outcomes for the agency's…

The agency failed to collect and monitor quality indicator data for the Quality Assessment and Performance Improvement program; and failed to ensure the governing body approved the program's frequency and detail of data collection, resulting in the potential for poor patient outcomes for the…

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs for the current 21 patients receiving services from the agency.

The agency failed to ensure the home health aide received a minimum of 12 in-service hours in 2020 for 2 of 2 (Aide#1 and Aide#2) home health aides employed by the agency for more than 12 months, resulting in a lack of educational opportunities pertinent to patient care for the aides.

The agency failed to ensure the RN (registered nurse) prepared written patient care instructions alerting the home health aide (HHa) to the safety precautions and special conditions that were applicable to each patient, for 4 of 5 records reviewed (MR#'s 1, 2, 3, 5) in which HHa services were…

The agency failed to document referrals in 3 of 7 (MR#s 4, 5, 6) records reviewed, failed to document patient consents for services and frequency in 4 of 7 (MR# 4, 5, 6, 7) records reviewed, failed to document visit notes in 1 of 7 (MR# 6) records reviewed, failed to have physician signed plans of…

The agency failed to ensure that clinical records were safeguarded against loss or unauthorized use for 7 of 7 records reviewed (MR#s 1, 2, 3, 4, 5, 6, and 7) from a total of 7 sampled records reviewed, resulting in the potential compromise of protected health information and the potential for…

The agency failed to ensure patients were informed in advance of the disciplines that will furnish care and the proposed visit frequency in 4 of 7 (MR's # 4, 5, 6, 7) records reviewed, resulting in these patients not having knowledge regarding their plans for treatment.

The agency failed to ensure the comprehensive assessment included a review of all medications to identify any potential adverse effects, drug reactions, or interactions for 4 of 7 (MR# 2, 4, 6, and 7) records reviewed, resulting in the potential for harmful medication effects for these patients.

The agency failed to ensure the comprehensive assessments were updated to include an assessment of the patient's current health status and continuing needs for home health services for 1 (MR #2) of 1 record in which the patient was recertified for home care, from a total sample of 7 records…

The agency failed to ensure the plan of care included patient specific safety measures based on the patient's initial assessments in 4 records reviewed (MR#s 1, 2, 6, 7) from a total of 7 records reviewed; and physician orders for PICC line dressing changes for 1 of 1 (MR#4) records reviewed…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 of 1 record reviewed (MR#6) in which the patient had symptoms of a urinary tract infection and not feeling well, resulting in a potential for a poor patient outcome.

The agency failed to develop a Quality Assessment Performance Improvement program that focused on high risk, high volume or problem-prone areas specific to the agency, affecting all 41 patients serviced in the past 12 months, resulting in the agency's inability to improve patient care, health…

The Registered Nurse failed to supervise the services provided by the Licensed Practical Nurse (LPN) in providing wound care to 1 of 1 records reviewed with wound services (MR# 4) and LPN supervision with a home visit in 1 of 1 records reviewed (MR# 7), resulting in failure of the LPN to provide…

The agency failed to ensure on-site supervisory visits to the patient's home were completed by the registered nurse at least every 14-days to supervise the care provided by the home health aide for 1 of 5 (MR#5) records reviewed in which aide services were provided for a period of time greater than…

The Home Health Agency failed to ensure the plan of care included individualized measurable goals and outcomes, and visit notes failed to document the patient's progress towards achieving those identified goals in 3 of 7 records reviewed (MR# 1, 2 and 3) out of a total of 7 sampled records…

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 2 of 2 (MR#s 3 and 7) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status…