Comforcare Home Care - York

Agency documentation and interview with agency Administrator the agency failed to develop, in writing, an emergency preparedness program based on an all-hazards approach individualized to their specific provider type as required.

The agency failed to ensure that discharge planning was completed and documented in the medical record for one (1) of six (6) records reviewed.

The agency failed to maintain an effective, ongoing data driven QAPI program for one (1) of one (1) program review.

The agency failed to ensure organization, management, and administration of its resources to attain and maintain the highest practicable functional capacity including providing optimal care to achieve the goals and outcomes identified in the patients' plans of care.

The agency failed to ensure medical records that are accurate, complete, and adherent to current clinical record documentation standards of practice.

Agency Administrator the agency failed to ensure the establishment of an emergency plan based on an all-hazards risk assessment for one (1) of one (1) plan reviewed.

Agency Administrator the agency failed to establish an emergency plan based on the agency patient population for one (1) of one (1) plan reviewed.

Agency Administrator the agency failed to establish a relationship with a communitywide emergency management program for one (1) of one (1) plan reviewed.

Agency Administrator the agency failed to develop policies and procedures for an agency-wide emergency preparedness program for one (1) of one (1) plan reviewed.

Agency Administrator the agency failed to ensure a follow-up procedure for on-duty staff to determine a need for services and informing state and/or local officials of any on-duty staff or patients that they are unable to contact for one (1) of one (1) plan reviewed.

Agency Administrator the agency failed to development a procedure for a system of medical documentation that preserves …protects confidentiality…and secures and maintains the availability of records for one (1) of one (1) plan reviewed.

Agency Administrator the agency failed develop a procedure for use of volunteers in an emergency or other emergency staffing strategy for one (1) of one (1) plan reviewed.

Agency Administrator the agency failed to develop an emergency preparedness training and testing program for one (1) of one (1) plan reviewed.

The agency failed to ensure that discharge planning was completed and documented in the medical record for one (1) of six (6) records reviewed.

The agency failed to ensure that discharge summaries and/or transfer summaries were created and maintained in the medical record for one (1) of six (6) records reviewed.

The agency failed to ensure clients had a current plan of care in the medical record for one (1) of six (6) records reviewed.

The agency failed to ensure compliance with the physician's orders for one (1) of one (1) medical record review.

The agency failed to maintain an effective, ongoing data driven QAPI program for one (1) of one (1) program review.

The agency failed to maintain effective, ongoing performance improvement activities for their QAPI program for one (1) of one (1) program review.

The agency failed to ensure staff were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with clients in four (4) of ten (10) files reviewed.

The agency failed to ensure completed documentation demonstrating each staff had satisfactorily completed an initial competency exam for six (6) of ten (10) files reviewed.

The governing body failed to ensure the overall operation of the agency to ensure the agency provided services in a compliant manner through appropriate plans of care and adherence to written policies and procedures.

The Agency administrator failed to ensure the agency adhered to written policies and procedures, was compliant in adhering to all federal, state, and local regulations and provided services in a compliant manner through appropriate plans of care and that staff were complaint in training and health…

The agency failed to ensure the Manager of Care Services fulfilled all job responsibilities for ensuring accurate and complete documentation, care was provided in a compliant manner through appropriate plans of care and staff was competent in their skills for one (1) of one (1) files reviewed.

The agency failed to ensure medical records contained adequate and complete documentation.

The agency failed to ensure medical records contained adequate and complete documentation.

The agency failed to ensure discharge plans were communicated with the client/family and client’s physician in one (1) of six (6) medical records reviewed.

The agency failed to ensure that discharge summaries and/or transfer summaries were created and maintained in the medical record for one (1) of six (6) records reviewed.

Agency Administrator the agency failed to ensure skilled nursing visits were completed as ordered by the physician for one (1) of three (3) records reviewed.

The agency failed to implement, and maintain policies and procedures of an infection control program which has a its goal the prevention and control of infections and communicable diseases.

Agency failed to show evidence agency has a plan or process for vaccine mandate for one hundred and twenty-one (121) employees.

Agency tracking forms agency failed to show employee staff were 100 % vaccinated for one hundred and twenty-five (125) employees providing care to home care patients.

Agency failed to show evidence employee signed job description for aide for one (1) of five (5) files reviewed.

Agency failed to have initial assessment conducted within forty-eight (48) hours {or two (2) days} of date of referral for two (2) of three (3) MR reviewed.

Agency failed to complete the initial assessment within 48 hours of referral for five (5) of ten (10) files reviewed.

Agency failed to include all required elements in the Plan of Care for eight (8) of eight (8) files reviewed.

Staff failed to follow plan of care as ordered for five (5) of (8) files reviewed.

Agency failed to show evidence physician was informed of discharge for two (2) of two (2) discharge records reviewed.

Agency failed to timely supervise the Licensed Practical Nurses (LPN) for six (6) of ten (10) files reviewed.