American Nursing Home Health Care, Inc

The agency failed to develop an emergency preparedness (EP) plan that must be reviewed and updated at least every 2 years (See E 0004); failed to develop and maintain an EP plan that was based on both agency-based and community-based risk assessments (See E 0006); failed to ensure their emergency…

The agency failed to ensure its Quality Assessment and Performance Improvement (QAPI) program documented actions to measure, track and analyze quality indicators for improvement of patient care services (See G 642); failed to develop a program of relevant data collection used to monitor safety and…

The agency failed to ensure the home health aides were qualified to provide home health aide service (See 754), failed to ensure the home health aide competency evaluation addressed each of the subjects listed in paragraph (b)(3)(1), (iii), (ix), (x), and (xi) of this section and completed through…

The agency failed to ensure the clinical record was complete and included all clinical notes and complete medical record (See G1012); and failed to ensure a discharge summary was forwarded to the physician within 5 days of discharge and 2 days of transferring to an inpatient facility, resulting in…

The agency failed to develop an emergency preparedness (EP) plan that must be reviewed and updated at least every two years, resulting in no directions for agency personnel in the event of an actual emergency or disaster and the potential for poor patient outcomes.

The agency failed to develop an emergency preparedness (EP) plan that utilized and incorporated a facility and community-based all-hazards risk assessments, resulting in the potential for staff being unprepared to respond effectively during an actual or simulated emergency and the potential to…

The agency 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 the agency’s efforts of contacting these officials to engage in…

The agency failed to develop and update its emergency preparedness (EP) policies and procedures that were based on an EP plan, risk assessment, and communication plan, resulting in the agency's inability to implement appropriate emergency actions which could negatively affect the health and safety…

The agency failed to develop an emergency preparedness (EP) plan that included a policy/procedure concerning the use of volunteers and/or other emergency staffing strategies to address surge needs typically experienced during an actual emergency, resulting in the potential for an interruption in…

The agency failed to develop and maintain an emergency preparedness communication plan that integrated specific roles, tasks and responsibilities of its staff in the event of an actual emergency, resulting in the agency's inability to ensure the coordination of patient care during an emergency was…

The agency failed to ensure the emergency preparedness (EP) communication plan included a means for sharing information about the agency's occupancy, needs and its ability to aid the Incident Command Center, or designee, resulting in the lack of essential information in the event of an actual…

The agency failed to maintain emergency preparedness training/testing for staff, which is based on the emergency plan, resulting in the potential for inadequate staff response during an emergency.

The agency failed to provide documentation that it had participated in an agency wide and community-based full-scale exercise, each required at least every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency.

The agency failed to identify measurable improvement indicators for the Quality Assessment and Performance Improvement (QAPI) program since February 2024, resulting in the continuance of unrecognized patient care trends and the provision of substandard patient care.

The agency failed to develop a program of data collection and failed to ensure governing body approval of the frequency and detail of the data collection for the Quality Assessment Performance Improvement (QAPI) program for the last 28 months.

The agency failed to initiate any performance improvement activities with its Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the provision of substandard care and unmet patient care needs.

The agency failed to develop any performance improvement activities with its Quality Assessment Performance Improvement (QAPI) program to track and trend adverse patient events, analyze potential cause(s) and implement preventive actions, resulting in the potential for substandard care and unmet…

The agency failed to conduct a performance improvement project (PIP) as required since 2/2024, resulting in the lack of quality improvement measures concerning patient care services.

The agency failed to ensure its Governing Body (GB) was involved in the Quality Assessment and Performance Improvement (QAPI) program since 2/2024, resulting in the lack of oversight concerning the quality of patient care services rendered.

The agency failed to provide documented evidence of annual infection control education for 7 of 7 sampled staff members, including those employed through an arranged contract, which has the potential to negatively impact the safety and well-being of all patients serviced by the agency.

The agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide's performance of the required tasks with a patient…

The agency failed to ensure that 1 (Staff-C) of 1 Home Health Aide received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The agency failed to ensure documents in the clinical records were complete and appropriately authenticated with a signature and title, dated, and timed in 3 (P-2, P-3, P-7) of 7 records reviewed, resulting in records that are not authenticated, accurate, timely, and do not portray the care…

The agency failed to inform the patient in advance of the disciplines that will furnish care in 2 (P-1, P-3) of 7 patient records reviewed, resulting in the patient not having knowledge of the plan for treatment and the potential for unmet care needs.

The agency failed to ensure the patient received the written NOMNC (Notice of Medicare Non-Coverage) form in advance of terminating home care services in 3 (P-1, P-2, P-4) of 7 patient records reviewed, resulting in patients not having the right or opportunity to dispute the termination of Medicare…

The agency failed to inform all patients of the required State of Michigan’s toll-free hotline regarding complaints/grievances in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in the potential for unresolved patient care concerns to the State authority.

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 all diagnoses in 5 (P-1, P-2, P-3, P-4, P-6) of 7 records reviewed, resulting in incomplete clinical information to…

The agency failed to ensure the patient’s clinical record documented all medications with a completed reconciliation and failed to provide documented evidence that the physician was notified of identified drug interactions in for 4 (P-1, P-2, P-3, P-5) of 7 records reviewed.

The agency failed to ensure the Plan of Care (POC) was complete and included safety parameters to protect against injury/harm in 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 records reviewed; failed to include a comprehensive list of current medications in 2 (P-1, P-4) of 7 records reviewed; and…

The agency failed to ensure visit frequencies were provided only as ordered by the physician for 1 (P-3) of 7 records reviewed; and failed to provide skilled services as ordered in 1 (P-6) of 1 record reviewed with ordered occupational therapy (OT) services, resulting in the potential for the…

The agency failed to ensure the patient and caregiver were provided diagnosis teaching/instructions as requested within the referral for 4 (P-2, P-3, P-5, P-6) of 7 records reviewed, for a potential of unmet care needs.

The agency failed to provide all patients with written documentation of the correct contact information regarding the agency’s Clinical Manager in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure its Quality Assessment Performance Improvement (QAPI) program performed actions to measure the effectiveness of a chosen PIP (performance improvement project), developed to track improvements and a process to ensure improvements are sustained.

The agency failed to ensure that physical therapy (PT) services appropriately supervised the care provided by the physical therapy assistant (PTA) in 1 (P-5) of 4 records with PTA services, resulting in the potential for poor clinical outcomes.

The agency failed to ensure the home health aides were qualified to provide home health aide service for 1 (Staff-C) of 1 aides providing service, for a potential of substandard aide services.

The agency failed to maintain documentation of competency evaluations in 1 (Staff-C) of 1 Home Health Aides whose personnel file was reviewed, resulting in the potential for the provision of substandard care and unmet care needs.

The agency failed to ensure the Clinical Manager coordinated services for 2 (P-1, P-3) of 7 records reviewed, resulting in services potentially not being provided or late which could have poor patient outcomes.

The agency failed to ensure clinical notes were complete, accurate, and maintained for 2(P-1, P-3) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure a discharge summary was completed, provided the patient's current health status at the time of discharge, and progress toward goals in 2 (P-2, P-5) of 2 closed records, and failed to ensure a discharge and transfer summary was forwarded in 4 (P-2, P-3, P-5, P-6) of 7…

The agency failed to develop and implement an effective discharge planning process (SEE G-562); and failed to ensure all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences were sent to the health…

The agency failed to ensure the plan of care (POC) included safety measures/precautions (SEE G-572), failed to ensure the POC included measurable goals (SEE G-574), and failed to ensure verbal orders were authenticated and dated by the physician in accordance with the home health agency’s policies…

The agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement (QAPI) program in 2022, resulting in the potential development…

The agency failed to ensure the Administrator was responsible for all day-to-day operations (SEE G948); failed to ensure the Administrator or pre-designated person was available during all operating hours (SEE G-956); and failed to ensure at least one qualifying service was provided directly by…

The agency failed to define the meaning of abbreviations used in clinical notes to ensure understanding of the care provided to the patients admitted to the agency in 1 of 7 (MR#2) records reviewed (See 1010); failed to ensure the clinical record included physician referrals in 3 of 7 (MR# 5, 6, &…

The Agency failed to include an individual Emergency Preparedness (EP) plan for each patient as part of the comprehensive assessment for 2 of 7 records (MR# 3, 4) reviewed, resulting in the potential lack of patient care and appropriate response during an emergency.

The Agency failed to provide initial training in emergency preparedness policies and procedures, including contract employees, and failed to maintain documentation of training, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of…

The agency failed to develop and implement an effective discharge planning process, effecting 3 of 5 (MR# 3, 4, and 5) discharged records, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet patient care needs.

The agency failed to ensure all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences were sent to the health care practitioner in 4 of 5 (MR#s 2, 3, 4 and 5) sample transfer and discharge records…

The agency failed to ensure an individualized plan of care (POC) was signed by a doctor in 4 of 7 (MR #s 2, 3, 4 and 5) sample records reviewed potentially resulting in the lack of patient care needs being met and lack of physician oversight.

The governing board failed to approve a Performance Improvement Project (PIP) for the agency's Quality Assessment and Performance Improvement Program (QAPI) for the years 2022 and 2023. Findings included: Based on documents reviewed and interview, the Governing Body failed to approve a Performance…

The agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement (QAPI) program in 2022, resulting in the potential development…

The Agency failed to provide initial training in infection control policies and procedures, including contract employees, and failed to maintain documentation of ongoing training, resulting in the potential for patient and employee infections.

The agency failed to develop and implement policy and procedure to ensure all staff were vaccinated for COVID 19, and failed to document and track the COVID-19 vaccination completion, exemption, or temporary delay status for staff that provide patient care, treatment, or other services for the…

The agency failed to maintain a Clinical Laboratory Improvement Amendment (CLIA) laboratory waiver, resulting in the potential for the Agency to be performing unauthorized laboratory tests on patients.

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.

The agency failed to define the meaning of abbreviations used in clinical notes to ensure understanding of the care provided to the patients admitted to the agency in 1 of 7 (MR#2) records reviewed.

The agency failed to authenticate a discharge/transfer order with a date and signature in 1 of 5 (MR#2) discharged records reviewed.

The agency failed to ensure that clinical records were safeguarded against loss or unauthorized use, resulting in the potential compromise of protected health information.

The agency failed to ensure patient complaints were documented, investigated, and included actions and resolutions.

The agency failed to allow the patient to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to any changes in the care to be furnished in 1 of 7 records (MR# 3) reviewed.

The agency failed to provide information to the patient of the amount the patient may need to pay for services in 1 of 5 (MR#2) discharged records reviewed.

The Skilled Nurse failed to determine eligibility for the Medicare home health benefit, including home bound status in 2 of 7 (MR#2, 3) records reviewed, resulting in patients receiving unqualified home health benefits as required by Medicare.

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status including base line data and measurements, the patient's past medical history that included dates of onset, treatments and outcomes, history of events leading to…

The agency failed to ensure a registered nurse performed a comprehensive drug review in 5 of 7 (MR# 3, 4, 5, 6 & 7) sample records reviewed in which therapy only cases were ordered, resulting in the potential for undetected harmful medication side effects or interactions.

The agency failed to ensure the plan of care included safety measures and individualized, patient-specific, measurable outcomes and goals in 6 of 7 (MR#s 1, 2, 3, 4, 5, and 6) sample records reviewed, and failed to include medications prescribed to the patient on the plan of care in 1 of 7 (MR# 5)…

The agency failed to ensure verbal orders were authenticated and dated by the physician in accordance with the home health agency’s internal policies in 1 of 5 (MR# 5) sample discharge records reviewed potentially resulting in the lack of physician oversight.

The agency failed to ensure the clinicians followed the visit frequency ordered by the physician as indicated in the patient plan of care in 2 of 7 (MR# 3 and 5) sample records reviewed resulting in potential for physical decline and unmet patient care needs.

The Agency failed to ensure the Administrator was responsible for all day-to-day operations, resulting in the potential for patient needs to go unmet.

The agency failed to ensure the administrator or pre-designated person was available during all operating hours, resulting in the potential for patients needs to be unaddressed.

The agency failed to ensure the clinical record included physician referrals in 3 of 7 (MR# 5, 6, & 7) sample records reviewed, signed patient consents in 3 of 7 (MR# 4, 6 and 7) sample records reviewed, and failed to include complete clinician visit notes in 1 of 7 (MR# 5) sample records reviewed…

The agency failed to develop an emergency preparedness plan that was reviewed and updated at least annually (SEE E0004); failed to ensure their emergency plan was based on both a facility-based and community-based hazard risk assessment (SEE E0006); failed to ensure the Emergency Preparedness Plan…

The agency failed to ensure patients were informed of the name and contact information for the agency's administrator; ensure the information in the patient's admission folder was accurate regarding the reporting of complaints; ensure patients were informed in advance of the disciplines that will…

The agency failed to ensure the Registered Nurse conducted the initial assessment visit to determine the immediate care and support needs of the patent, including homebound status and eligibility for the Medicare home health benefit; failed to conduct a patient-specific, comprehensive assessment…

The agency failed to ensure the plan of care included measurable goals for 7 of 8 records reviewed (MR#s 1, 2, 3, 4, 5, 7, 8) (See G-574); failed to ensure physician orders were obtained prior to providing services for 3 of 8 records reviewed (MR#2, 7, 8) (See G-580); failed to accurately instruct…

The agency failed to ensure the Quality Assessment Performance Improvement (QAPI) program demonstrated measurable improvement in quality of care indicators by measuring, analyzing and tracking quality indicators for patient care (SEE G642); failed to ensure the Quality Assessment Performance…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement program (See G684); and failed to provide infection control…

The agency failed to ensure the physical therapist assisted the physician in evaluating the patient's level of function and helped to develop the plan of care; ensure that skilled nursing and physical therapy services were provided at the frequency ordered by the physician in the plan of care…

The agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency's provision of home health services…

The Agency (HHA) failed to ensure the clinical record was complete and included all comprehensive assessments, clinical notes, plans of care and physician orders for 7 records (MR# 1, 2, 3, 4, 5, 7, 8) from a total of 8 sampled records (G1012); failed to ensure a discharge summary had been prepared…

The agency failed to develop an emergency preparedness plan that was reviewed and updated at least annually, resulting in potential for patient or staff injury due to there being no directions for agency actions in the event of an actual emergency or disaster.

The agency failed to ensure their emergency plan was based on both a facility-based and community-based hazard risk assessment, resulting in the potential for patient or staff injury due to being unprepared to respond effectively in the event of an emergency.

The agency failed to ensure the Emergency Preparedness Plan addressed the services the agency could provide during an emergency and succession plans, affecting 48 of 48 patients served by the agency in the past 12 months, resulting the agency not being prepared to respond effectively during an…

The agency failed to have a process to contact and collaborate with local, tribal, regional, State and Federal emergency preparedness officials to prepare an integrated emergency preparedness program.

The agency failed to develop and establish written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessments and communication plan, resulting in the agency's inability to implement an emergency plan specific to the emergency or disaster.

The agency failed to incorporate an individualized Emergency Preparedness Plan into the comprehensive patient assessment for 8 of 8 records reviewed (MR #1, 2, 3, 4, 5, 6, 7 and 8) out of a total sample of 8 records reviewed, resulting in the potential for patient or staff injury in the event of an…

The agency failed to ensure the emergency preparedness policies and procedures included a process for informing state and local emergency preparedness officials of patients needing evacuation from their residence at any time due to an emergency/disaster situation, this had the potential to affect…

The agency failed to ensure the Emergency Preparedness Policy included procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency and to inform State and local officials of any…

The agency's Emergency Preparedness policy failed to address a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records affecting all 48 patients served by the facility in the past 12…

The agency failed to include in the Emergency Preparedness policy, a process for the use of volunteers and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency…

The agency failed to develop and maintain a communication plan for emergency preparedness affecting all 48 patients served in the past 12 months, resulting in the facility not being able to communicate effectively with facility staff, volunteers, other health care providers and emergency…

The agency failed to develop and maintain contact information for staff, entities providing services under arrangement, patient's physicians and volunteers, resulting in the lack of essential information in the event of an actual emergency for the agency's 48 patients serviced by the agency in the…

The agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, local emergency preparedness staff and other sources of assistance, resulting in the lack of essential information in the event of an actual…

The agency failed to develop and maintain an emergency preparedness communication plan that included a primary and alternate means for communicating with staff, Federal, State, tribal, regional, and local emergency preparedness officials, affecting all 48 patients admitted to the agency in the past…

The agency failed to develop and maintain an emergency preparedness communication plan that included a method for sharing information and medical documentation for patients under the agency's care with other health providers to maintain the continuity of care; a means, in the event of an…

The agency failed to ensure the emergency preparedness communication plan included a means for sharing information about the agency's occupancy, needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, affecting all 48 patients…

The agency failed to develop and maintain an emergency preparedness training and testing program that was based on an emergency plan, risk assessment, policies and procedures, and a communication plan as required, which had the potential to affect all 48 patients serviced by the agency, resulting…

The agency failed to develop, implement and maintain an emergency preparedness training program that included the following training activities: provide initial education on emergency preparedness policies and procedures; provide emergency preparedness training every two years; maintain…

The agency failed to perform testing of their emergency preparedness program as required affecting the 48 patients served by the agency in the past 12 months, resulting in the potential for being unprepared to respond effectively in the event of an actual emergency.

The agency failed to ensure the Quality Assessment Performance Improvement program demonstrated measurable improvement in quality of care indicators by measuring, analyzing and tracking quality indicators for patient care which had the potential to affect all 48 patients admitted in the past 12…

The agency failed to ensure the Quality Assessment Performance Improvement program used quality indicator data from the Outcome and Assessment Information Set items and other data to monitor the quality, effectiveness and safety of patient care services to identify areas in need of improvement…

The agency failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement program affecting all 48 of the agency's patients admitted in the last 12 months, resulting in the potential for the rendering of substandard care and unmet care needs.

The agency failed to track and analyze adverse events in order to implement preventative actions, which had the potential to negatively affect all 48 patients serviced by the agency in the past 12 months, resulting in the potential for patient injury or poor outcomes due to failing to prevent…

The agency failed to develop and act upon a performance improvement project affecting all 48 patients admitted to the agency in the past 12 months, resulting in the agency's inability to improve patient outcomes, safety, and quality of care.

The Governing Body failed to be responsible for ensuring the agency had an active and functioning Quality Assessment and Performance Improvement program that fulfilled all the regulatory requirements of this section, resulting in the potential to adversely affect the quality of care for the…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement program affecting all 48 patient's admitted in the past 12…

The agency failed to provide infection control education to staff affecting all 48 patients admitted in the past 12 months, resulting in the potential for spread of infections between patients and staff.

The agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency's provision of home health services…

The administrator failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for all services to be provided by contracted staff.

The agency failed to ensure patient records were retained for 5 years after the discharge of the patient in 1 of 4 discharged patients (MR #2), from a total sample of 8 records reviewed.

The agency failed to ensure that clinical records were safeguarded against loss or unauthorized use for 3 of 8 records reviewed (MR# 2, 7, 8), resulting in the potential compromise of protected health information for these 3 patients.

The agency failed to ensure patient records were retrievable for use after discharge of the patient in 1 of 4 (MR#2) discharged patients, from a total sample of 8 records reviewed.

The agency failed to ensure patients were informed of the name and contact information for the agency's administrator for 8 of 8 records reviewed (MR# 1, 2, 3, 4, 5, 6, 7, 8), resulting in the potential for patient complaints or concerns to go unaddressed which could affect the 48 patients the…

The agency failed to ensure the information in the patient's admission folder was accurate regarding the reporting of complaints for 8 of 8 records reviewed (MR# 1, 2, 3, 4, 5, 6, 7, 8), resulting in the potential for patient complaints or concerns to go unaddressed which could affect the 48…

The agency failed to ensure patients were informed in advance of the disciplines that will furnish care and the proposed visit frequency in 6 of 8 (MR# 1, 2, 5, 6, 7, 8) records reviewed, resulting in these 6 patients not having knowledge regarding their plans for treatment.

The agency failed to inform the patient of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient in 4 of 8 records reviewed (MR# 5, 6, 7, 8), resulting in the potential…

The agency failed to advise patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the areas where the patients reside, resulting in a lack of information regarding resources designated to address the needs and concerns of older persons which…

The agency failed to ensure the Registered Nurse conducted the initial assessment visit to determine the immediate care and support needs of the patent, including homebound status and eligibility for the Medicare home health benefit for 2 of 3 (MR# 6, 7) records in which nursing services were…

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…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine significant drug interactions in 7 of 8 (MR# 1, 2, 3, 4, 5, 7, 8) records reviewed, resulting in the potential for harmful medication effects for the 15 patients currently serviced by this…

The agency failed to ensure the comprehensive assessment was updated at the time of discharge in 2 of 3 (MR# 7, 8) discharged records reviewed, resulting in no assessment of the patient's health status at the time of discharge and no summary of the patient's progress in meeting care plan goals for…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable and the plan of care included patient specific/measurable interventions and goals that were based on patient needs in 7 of 8 records reviewed (M.R.#s 1, 2, 3, 4, 5, 7, 8), from a total sample of 8…

The agency failed to ensure the physical therapist (PT) provided services only as ordered by the physician in 3 of 8 records (MR #2, 7, 8) reviewed out of a total sample of 8 records reviewed, which resulted in the PT providing services not ordered by the physician.

The agency failed to accurately instruct patients on how to reach a nurse on weekends or after office hours for 1 of 3 (MR#5) joint survey home visits, resulting in patients not being able to contact a nurse on weekends or after hours which could affect the health and well-being of the agency's 15…

The agency failed to provide the patient with written documentation of the name and contact information for the agency's Clinical Manager, resulting in the potential for unaddressed patient concerns for the agency's 15 current patients.

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 48 patients serviced in the past 12 months, resulting in the agency's inability to improve patient care, health…

The agency failed to develop a Quality Assessment Performance Improvement program that considered incidence, prevalence and severity of problems in identified areas, which could have affected all 48 patients admitted to the agency in the past 12 months, resulting in the potential for poor patient…

The agency failed to identify and correct problems that affect patient health and safety, which had the potential to affect all 48 patients admitted in the past 12 months, resulting in the potential for failure to meet patient needs and prevent patient harm.

The agency failed to ensure performance improvement actions were implemented, measured and tracked to ensure improvements occurred and were sustained over time for patient care, safety and outcomes, which had the potential to negatively affect all 48 patients serviced by the agency in the past 12…

The agency failed to ensure the physical therapist assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 2 of 8 (MR#2 and 7) records reviewed, resulting in the potential for decline in physical functioning and unmet care needs for these 2…

The agency failed to ensure that skilled nursing and physical therapy services were provided at the frequency ordered by the physician in the plan of care for 7 of 8 (MR# 1, 2, 3, 4, 5, 7, 8) records reviewed, resulting in the potential for physical decline and negative patient outcomes for these 7…

The agency failed to ensure the physical therapist's (PT) initial assessment was complete for 1 of 8 records reviewed (MR#2) with PT services ordered; and failed to ensure skilled nursing and physical therapy prepared clinical notes for 5 of 8 (MR# 2, 4, 5, 7, 8) records reviewed, from a total of 8…

The agency failed to ensure the Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the lack of oversight of patient care and operations of the agency, affecting all 48 patients admitted to the agency within the past 12 months…

The agency failed to ensure the Alternate Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the lack of oversight of patient care and operations of the agency, affecting all 48 patients admitted to the agency within the past 12…

The agency failed to ensure the Clinical Manager made and provided oversight of the patient and personnel assignments for 1 of 8 (MR#6) records reviewed, affecting all 48 patients admitted in the past 12 months, resulting the provision of substandard care and the potential for poor patient outcomes.

The agency failed to ensure the Clinical Manager coordinated patient care in 7 of 8 (MR# 1, 2, 3, 4, 5, 7, 8) records reviewed, resulting in the potential for physical decline and negative patient outcomes for these 4 patients.

The agency failed to ensure the Clinical Manager coordinated services that were ordered on the referral form for 1 of 8 (MR# 6) records reviewed, resulting in nursing services not being provided to this patient.

The agency failed to ensure the clinical record was complete and included clinical notes for 7 of 8 (MR# 1, 2, 3, 4, 5, 7, 8) records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient's health status and progression towards goals.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 3 of 4 (MR# 6, 7, 8) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status…