Care First Home Health Services, Inc

The Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The agency failed to develop and maintain an Emergency Preparedness training and testing program that was based on the emergency plan, risk assessment, policies, procedures, and the communication plan, that had been updated at least every 2 years.

The agency failed to ensure the physical therapist followed standards of practice per agency policy to prevent the transmission of infections and communicable diseases for 1 (P-6) of 3 patients with whom a joint home visit was conducted potentially resulting in the spread of infectious agents to…

The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the Agency terminating on-going care for 1 (P-1) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services.

The agency failed to ensure the initial assessment was conducted within 48 hours of the patient’s return home to determine the patient’s immediate care needs and homebound status in 1 (P-5) of 8 sample records reviewed resulting in a delay in care and services, and the potential to negatively…

The agency failed to ensure the comprehensive assessment included a review of all medications prescribed to the patient and include all medications in the medication reconciliation in its entirety for possible drug interactions and duplicate therapy per agency policy in 1 (P-5) of 8 sample records…

The agency failed to ensure a plan of care was established that directed the course of care provided for 1 (P-4) of 1 patient to which a plan of care had not been established prior to the provision of care and services, from a total of 7 sampled records reviewed, resulting in the potential for the…

The agency failed to ensure the Physician was promptly notified of a significant change in condition for 1 (P-2) patient who had negative fluctuations in weight and failed to promptly notify the Physician of major drug interactions and duplicate drug therapy in 3 (P#'s 2, 3, 4) records from a total…

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 1 (P-4) record in which Physical Therapy services were ordered, from a total sample of 7 records reviewed, resulting in the potential…

The Agency failed to ensure services were provided as ordered in the Plan of Care for 1 (P-2) of 1 patient observed during a home visit, who required cardiovascular and diabetic monitoring, and 2 patients (P#'s 1, 3) who required Occupational Therapy services, from a total of 7 sampled records…

The agency failed to ensure a completed discharge summary was sent to the physician within 5 days of the patient's date of discharge in 3 (P#'s 7, 1, 3) records in which the patient was discharged from the agency, resulting in a lack of health information available to the physician for continuity…

The Agency failed to ensure the Registered Nurse followed accepted standards of practice in assuming responsibility for the care of 1 (MR #5) of 1 patient who required wound care management, from a total of 7 sampled patient records reviewed (see G704); failed to document weights for a Congestive…

The Agency failed to provide care and services in accordance with the plan of care in 1 (MR's #5) of 7 records reviewed, resulting in unmet care needs and an increase in wound size.

The Agency failed to ensure the Registered Nurse followed accepted standards of practice in assuming responsibility for the care of 1 (MR #5) of 1 patient who required wound care management, from a total of 7 sampled patient records reviewed, resulting in interruption in needed care and services…

The agency failed to ensure the registered nurse conducted the initial assessment visit to determine the immediate care needs of the patient, including homebound status for 1 of 4 (MR#4) records reviewed in which both skilled nursing and therapy services were ordered, resulting in the potential for…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 4 of 7 (MR# 4, 5, 6, and 7) records reviewed, resulting in incomplete clinical information to aid in determining the needs of this patient and for measuring the patient's progress…

The agency failed to ensure a registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 2 of 4 (MR# 2, 4) records reviewed with therapy only services.

The agency failed to ensure the plan of care included all pertinent diagnoses, patient-specific safety measures, interventions, and education for 1 of 7 (MR# 4) records reviewed, resulting in the potential for a poor patient outcome.

The agency failed to document weights for a Congestive Heart Failure patient and notify the physician of elevated edema and pain levels in 1 record, from a total of 7 sampled records reviewed (MR's #5), resulting in the physician not having a clear and concise clinical picture of the patient's…

The agency failed to ensure the patient and caregiver were provided wound care teaching/instructions for 1 of 1 record reviewed (MR's #5) with wound care, for a potential of improper wound care and unmet care needs.

The agency failed to ensure clinical notes were accurate for 2 of 7 (MR#4 and 5) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure the Administrator's position was appointed by the Governing Body and this appointment was documented (G 946); the Administrator failed to be responsible for all day-to-day operation of the Home Health Agency (G 948); failed to ensure a Clinical Manager was available…

The Home Health Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care…

The Agency failed to ensure a Clinical Manager was available during all operating hours, to provide oversight of all patient care services and personnel, for a potential of unmet health care and medical needs and a lack of medical supervision to the clinical personnel.

The Home Health Agency failed to ensure all disciplines entries, in the medical records, were legible, clear and authenticated with the date of completion and time for 7 of 9 records reviewed (M.R. #1, 2, 3, 4, 5, 6 and 9), for a potential of unidentifiable author of a document and unauthorized…

The Agency failed to provide documented evidence of the appointment of the Administrator that reported to the Board of Directors.

The Administrator failed to be responsible for all day-to-day operation of the Home Health Agency, resulting in a lack of supervision of the clinical staff and daily operations.

The Agency failed to ensure a Clinical Manager was available during all operating hours, for a potential of unmet health care and medical needs and a lack of medical supervision.

The Home Health Agency (HHA) failed to ensure a qualified alternate was authorized, in writing by the Administrator and the Governing Body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The Agency (HHA) failed to ensure the initial comprehensive assessment was completed no later than 5 calendar days after the start of care in 1 record, from a total of 7 records reviewed (MR #3) resulting in the potential for unidentified patient needs (G520); failed to conduct a patient-specific…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program, (refer to G 0642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, (refer to G0644); failed to initiate any…

The Home Health Agency (HHA) failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases (refer to G-0682); maintain an active infection control program for 2017 and 2018, as part of the HHA's…

The Agency (HHA): failed to maintain sufficient documentation that demonstrated the required training for this section was met for 1 of 1 Home Health Aides (HHa #1) employed by this Agency, resulting in the potential for the rendering of substandard care and unmet care needs (G766); failed to…

The Agency failed to develop and maintain an emergency preparedness program that included the required elements, that must be reviewed, and updated at least annually, resulting in the potential for the Agency's inability to provide safe patient care in the event of an actual emergency.

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 1…

The agency failed to ensure patient visits were provided as ordered on the Plan of Care (POC) for Home Health aide (HHa) services for 1 of 7 records reviewed (MR #4) out of a total of 7 sampled records reviewed, resulting in the potential for unmet care needs.

The Agency (HHA) failed to develop a Quality Assessment Performance Improvement (QAPI) program that is at least capable of showing measurable improvements 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 collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the…

The Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, addressed priorities for improved quality of care and patient safety and was evaluated for…

The Agency (HHA) failed to ensure the Home Health Aide (HHa #1) followed accepted Infection Control standards of practice during the provision of a shower for 1 patient observed during a home visit, from a total sample of 7 sampled records reviewed (MR #1), resulting in the potential for…

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

The Agency (HHA) failed to provide documented evidence that infection control education was provided to all staff employed by the agency and who were granted clinical privileges, resulting in the potential for the development and spread of infection.

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

The agency failed to ensure the RN (registered nurse) prepared written patient care instructions alerting the home health aide (HHa) to the safety precautions that were applicable to each patient, for 4 of 4 records reviewed (MR#'s 1, 3, 4, 6) in which HHa services were provided, from a total…

The home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans and…

The agency (HHA) failed to ensure that clinical records were safeguarded against loss or unauthorized use, resulting in the potential for compromise of protected health information for all patients serviced by the agency.

The Agency (HHA) failed to include contact information for the Home Health Agency's Administrator in the agency's Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns or complaints.

The home health agency failed to advise the patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the area where the patient resides, resulting in the potential for patient needs being unmet.

The Agency (HHA) failed to ensure the initial comprehensive assessment was completed no later than 5 calendar days after the start of care in 1 record, from a total of 7 records reviewed (MR #3) resulting in the potential for unidentified patient needs.

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 4 records…

The Agency (HHA) failed to conduct a Resumption of Care (ROC) assessment within 48 hours of the patients discharge from a hospital, and assess the patient's updated needs related to hospitalization in 1 of 1 records in which the patient was transferred to and discharged from a hospital stay, from a…

The Agency (HHA) failed to ensure the physician was promptly notified of the patient's fall for 1 of 1 patient identified at risk for falls, from a total of 7 sampled records reviewed (MR #1), resulting in the potential for unidentified, underlying injuries and poor patient outcomes.

The Agency (HHA) failed to ensure the physician was promptly notified of the patient's fall for 1 of 1 patient identified at risk for falls, from a total of 7 sampled records reviewed (MR #1), resulting in the potential for unidentified, underlying injuries and poor patient outcomes.

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas, resulting in the potential for agency issues to go unresolved in high risk, high volume or…

The agency (HHA) failed to ensure that nursing services were administered in accordance with the plan of care (POC) in 1 of 1 record that required urinary catheter care, and failed to provide SN, Physical Therapy, Occupational Therapy, and Home Health Aide (HHa) services as order for 2 records with…

The Agency (HHA) failed to maintain sufficient documentation that demonstrated the required training for this section was met for 1 of 1 Home Health Aides (HHa #1) employed by this Agency, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency (HHA) failed to ensure on-site supervisory visits to the patient's home were made in order to supervise the care provided by the Home Health Aide for 1 of 4 records with Home Health Aide services ordered, from a total of 7 records reviewed (MR #1) resulting in the potential for the…

The Agency failed to ensure the Administrator was appointment by the Governing Body.

The Agency (HHA) failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The Agency (HHA) failed to ensure the clinical record was complete and included assessments and clinical notes in 3 records, from a total of 7 sampled records reviewed (MR's #4, 5 and 1), resulting in the physician not having a clear and concise clinical picture of the patient's health status and…

The Agency (HHA) failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician in 1 of 2 closed/discharged records, from a total of 7 records reviewed (MR #2), resulting in the…