Carepine Home Health, LLC

The agency failed to maintain an effective, ongoing, agency-wide, data-driven QAPI (quality assessment and performance improvement) program.

The agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the agency to assess processes of care, agency services, and operations, for one (1) out of one (1) QAPI documentation data reviewed (Data Review #1).

The agency failed to utilize data to monitor the effectiveness and safety of services and quality of care/identify opportunities for improvement for one (1) out of one (1) QAPI documentation data reviewed (Data Review #1).

The agency failed to ensure a program that focuses on high risk, high volume, or problem-prone areas was utilized for one (1) out of one (1) QAPI documentation data reviewed (Data review #1).

The agency failed to conduct performance improvement projects annually for one (1) out of one (1) QAPI documentation reviewed (Documentation Review #1).

The agency failed to conduct TB testing and/or TB education, per policy, for six (6) out of eight (8) employee files (EFs) initial documentation reviewed (EF#1 - EF#3, EF#5, EF#7, EF#8).

The agency failed to ensure the election/designation of Governing Body members, per policy, for one (1) of one (1) interviews conducted (Interview #1).

The agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for six (6) of seventeen (17) clinical record (CR) referrals reviewed (CR#1, CR#4, CR#5, CR#6, CR#9, CR#12).

Agency failed to ensure patient plan of care/treatments were signed by the physician within (30) days of the start of care, per policy, for two (2) of seventeen (17) clinical records (CR) reviewed (CR#4, CR#10).

Agency failed to ensure a written summary report for each patient was sent to the attending physician at least every 60 days for seven (7) of seven (7) clinical records (CR) recertification periods reviewed (CR#4 - CR#7, CR#9 - CR#11).

The agency failed to ensure home health aides completed a minimum of 75 hours of classroom and supervised practical training, per policy, for two (2) of two (2) employee files (EF) reviewed (EF#7, EF#8).

Agency failed to ensure a registered nurse conducted a supervisory visit to the patient's residence at least every 2 weeks for one (1) of two (2) clinical records (CR) receiving home health aide services reviewed (CR#12).

Agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient's discharge or transfer…

The agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for three (3) of three (3) clinical record (CR) referrals reviewed (CR#1 - CR#3) and failed to ensure a registered…

The agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for eleven (11) of seventeen (17) clinical record referrals reviewed (CR#1 - CR#4, CR#6, CR#8, CR#12 - CR#15…

The agency failed to ensure that everyone entering the health care facility is screened and triaged for COVID-19 and for one (1) of one (1) observations (Observation #1) and failed to maintain a coordinated agency-wide program for the surveillance of communicable disease by failing to ensure all…