Bright Horizons Home Health Services, Inc

The agency failed to ensure the emergency preparedness plan address the patient population, including but not limited to the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

The hospice failed to develop the emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least every two years.

The agency failed to develop the emergency communication plan to include the name and contact information of the staff, entities provided services under agreement, patients physicians and volunteers.

The agency failed to develop the emergency communication plan to include the name and contact information for the Federal, State, regional, and local emergency preparedness staff and other sources of assistance.

The agency failed to develop the emergency communication plan to include the primary and alternate means for communicating with the HHA's staff and the the Federal, State, regional, and local emergency management agencies.

The agency failed to ensure the initial training in emergency preparedness plan was provided to all of the staff including the contracted staff and volunteers, consistent with their expected role and demonstrate knowledge of emergency procedures.

The agency failed to conduct and participate in a full-scale exercise that is community-based, facility based functional exercises that may include a mock disaster drill and analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise…

The agency failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets.

The agency failed to accurately code the OASIS for one of eight sampled patients (Patient 4).

The agency failed to ensure a written individualized plan of care was developed and care and services were provided as per the POC and P&P for five of eight sampled patients (Patients 1, 3, 4, 6, and 7).

The agency failed to utilize the quality indicator data in the design of its program.

The hospice failed to document the reasons for conducting or selecting the PIP for the years of 2023 and 2024; and consistently measure the progress achieved on these projects.

The agency failed to provide at least one of services directly by the agency's staff.

The agency failed to ensure the clinical records were completed and authenticated for six of eight sampled patients (Patients 1, 3, 4, 6, 7, and 8).

The agency failed to ensure the patient and PCG were advised of the availability of the toll-free state hotline established by the State and that the purpose of the hotline to receive complaints for three of eight sampled patients (Patients 2, 3, and 8).

The agency failed to ensure the initial assessment visits were conducted within 48 hours of the referral or within 48 hours of the patient's return home for three of eight sampled patients (Patients 1, 5, and 6).

The agency failed to ensure the initial comprehensive assessments were completed no later than five calendar days after the SOC, consistent with the patients' immediate needs for seven of eight sampled patients (Patients 1, 2, 3, 4, 5, 6, and 8).

The agency failed to ensure the review of the medications included the patient's current medications to identify any potential adverse effects and drug reactions for one of eight sampled patients (Patients 2).

The agency failed to ensure the comprehensive assessment was updated within the last 5 days of every 60 days for one of eight sampled patients (Patient 5).

The agency failed to ensure the update comprehensive assessment was completed within 48 hours of the patient's return to home from the hospital for one of eight sampled patients (Patients 5).

The agency failed to ensure the discharge assessment was completed for two of eight sampled patients (Patients 2 and 6).

The agency failed to ensure the POC included the required components for seven of eight sampled patients (Patients 1, 2, 4, 5, 6, 7, and 8).

The agency failed to ensure the patients received care and services as per the written POCs for two of eight sampled patients (Patients 3 and 8).

The agency failed to ensure the verbal orders were authenticated timely for four of eight sampled patients (Patients 4, 5, 6, and 7).

The agency failed to ensure a written individualized plan of care and services were reviewed and revised for one of eight sampled patients (Patient 5).

The agency failed to ensure the physician was notified promptly related to the changes of conditions for one of eight sampled patients (Patient 4).

The agency failed to ensure effective communication with the patient's physician for five of eight sampled patients (Patients 1, 3, 4, 5, and 6).

The agency failed to ensure the ST services was integrated for one of eight sampled patients (Patient 2).

The agency failed to ensure the services were integrated in the POC for two of eight sampled patients (Patients 4 and 5).

The agency failed to provide the written instructions outlining the disciplines (SN and PT) visit schedules for three of eight sampled patients (Patients 1, 3, and 8).

The agency failed to provide the written instructions outlining any treatments to be administered by the HHA personnel and personnel acting on behalf of the HHA for two of eight sampled patients (Patients 3 and 8).

The agency failed to ensure the clinical managers’ contact information were provided to three of eight sampled patients (Patients 2, 3, and 8).

The agency failed to ensure the patient and/or caregiver was provided education as per the plan of care for three of eight sampled patients (Patients 4, 6, and 8).

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for three of eight sampled patients (Patients 2, 5, and 6).

The agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of eight sampled patients (Patients 6).

The agency's Administrator failed to be responsible for the day-to-day operations as the agency's P&P. *Pain assessment was incomplete as per the agency's P&P for two of eight sampled patients (Patients 1 and 5). *Wound assessment P&P was not followed for two of eight sampled patients (Patients 3…

The agency failed to employ qualified personnel, including assuring the development of personnel qualifications and policies. -The Administrator failed to have at least one year of supervisory or administrative experience in home health care or related programs and physical requirements as per job…

The agency failed to maintain accurate and complete clinical records for four of eight sampled patients (Patients 3, 6, 7, and 8).

The agency failed to ensure the completed discharge summaries were sent to the primary care practitioner within five business days of the discharge date for two of eight sampled discharged patients (Patients 2 and 5), and the completed transfer summary for three of eight sampled patients (Patients…