Care in Action Home Healthcare Agency LLC

The home health agency (HHA) failed to select the indicators that it would utilize in its QAPI program based upon identified adverse or negative patient outcomes or agency processes that the HHA wished to monitor and measure (G642); failed to collect and use data to monitor the effectiveness and…

The home health agency (HHA) failed to ensure adherence to home health aide qualification (G754); failed to provide evidence of the content and duration of home health aide classroom and supervised practical training (G760); failed to maintain documentation that demonstrates that the requirements…

The home health agency (HHA) failed to ensure that the EPP was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

The home health agency (HHA) failed to ensure that the EPP contained a communication process in the event of a disaster or need to activate the disaster/emergency plan.

The home health agency (HHA) failed to conduct exercises to test the emergency plan (EP) at least annually.

The home health agency (HHA) failed to select the indicators that it would utilize in its QAPI program based upon identified adverse or negative patient outcomes or agency processes that the HHA wished to monitor and measure.

The home health agency (HHA) failed to utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program and failed to collect data to monitor the effectiveness and safety of services and quality of care, identify…

The home health agency (HHA) failed to provide evidence that the QAPI program focused on high risk, high volume, or problem-prone areas, and considered the incidence, prevalence, and severity of problems in those areas.

The home health agency (HHA) failed to select the indicators that it would utilize in its QAPI program based upon identified adverse or negative patient outcomes or agency processes that the HHA wished to monitor and measure.

Failed to have one performance improvement project either in development, on-going or completed each calendar year in 2023, 2024 or 2025. Findings include: HHA Policy QAP-001.1 Quality Assessment and Performance Improvement (QAPI) Program reviewed on July 1, 2025 at approximately 1:30 PM states in…

The home health agency (HHA) failed to assure that the governing body assumed overall responsibility for ensuring that the QAPI program reflected the complexity of the HHA and its services, involved all services (including those provided under contract or arrangement), focused on indicators related…

The home health agency (HHA) failed to utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program and failed to collect data to monitor the effectiveness and safety of services and quality of care, identify…

The agency failed to demonstrate the presence of: The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section.

The HHA failed to assure that an initial assessment was completed by the registered nurse (RN) within forty-eight (48) hours of the referral for three (3) of four (4) CR's reviewed: CR#2, CR#3 and CR#4. Findings include: The HHA's Policy Guidelines for Assessment PC-019.1 reviewed on June 30, 2025…

The HHA failed to ensure that an accurate review of the current medications that the patient was using was conducted for two (2) of four (4) CR's reviewed: CR#1 and CR#3. Findings include: The HHA's Policy PC-019.1 Guidelines for Assessment reviewed on July 1, 2025 at 2:00 PM reads in part, "The…

The HHA failed to assure that medications and services provided to patients were ordered by a physician or allowed practitioner and documented in the CR.

The HHA failed to prepare and provide to the patient written information regarding the patient's medication regimen as based on the results of the medication review and physician orders.

The home health agency (HHA) failed to utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program and failed to collect data to monitor the effectiveness and safety of services and quality of care, identify…

The agency failed to demonstrate the presence of the following: HHA initial competency including 75 hours of classroom training for one (1) of seven (7) files reviewed: PF# 5. Findings includes: A review of policies conducted on July 01, 2025 starting at 2:15 PM revealed following: A policy titled…

The agency failed to demonstrate the presence of the following: Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services for one (1) of seven (7) files reviewed…

The agency failed to follow its policy regarding New Employee Orientation and the documentation of required trainings.

The agency failed to maintain documentation that demonstrates home health aide (aide) competency was determined by direct observation and the results of those observations for one (1) of one (1) aide PF reviewed: PF#5. A review of policies conducted on July 01, 2025 starting at 2:15 PM revealed…

The home health agency (HHA) failed to provide evidence that registered nurse (RN) supervisory visits were conducted at least every two (2) weeks for patients receiving home health aide (aide) services for two (2) of four (4) CR’s reviewed: CR#3 and CR#4. Findings include: A review of policies…

The HHA failed to assure that criminal background checks, child abuse clearance, FBI clearance, a signed position description, competency assessments, Hepatitis B vaccination/declination, tuberculosis testing, and/or a TB risk assessment was completed upon hire for seven (7) of seven (7) PF's…

The HHA failed to assure that clinical notes were present and/or completed in a timely manner.

The agency failed to update comprehensive assessments at least every 60 days for two, (2), of seven (7) Clinical Records, (CR), reviewed.

The agency failed to maintain standards for completion of the comprehensive assessment for (2), of seven (7) Clinical Records, (CR), reviewed.