Community Home Care Services Inc

The home health agency failed to ensure: the plan of care was individualized to meet the patient needs (see tag G0570), the plan of care was followed by all agency staff as directed by the primary care physician (see tag G0572), the plan of care contained all required elements for their patients…

The administrator failed to: ensure the organizational structure was readily identifiable and included the lines of authority and services provided; appoint in writing a qualified administrator in conjunction with the Governing Body in the administrator’s absence; ensure the accuracy of public…

The agency failed to provide an updated and revised comprehensive assessment as a patient condition warranted in 1 of 1 clinical record reviewed of a home visit of a patient with a wound (Patient #2).

The agency failed to ensure the discharge planning was followed per agency policy in 1 of 1 closed record reviewed.

The agency failed to provide discharge summary to the receiving health care practitioner to ensure a safe and effective transition of care in 2 of 2 closed clinical records reviewed (Patient #6, 7).

The agency failed to evidence services were provided as directed in the plan of care in 4 of 7 clinical records reviewed.

The agency failed to ensure the Governing Body approved the frequency and detail of the data collection of the quality assurance performance improvement (QAPI) program.

The agency failed to ensure the quality assurance performance improvement (QAPI) program’s performance improvement activities focused on high risk and problem-prone areas.

The agency failed to follow accepted standards of practice to prevent the transmission of infections in 2 of 2 clinical records reviewed with home visits with a registered nurse (RN).

The agency failed to protect clinical records from loss or unauthorized use in one of one agency.

The agency failed to provide the name and contact information of the administrator in 1 of 2 home visits with a registered nurse.

The agency failed to ensure the patient was informed about and consented to the type and frequency of care provided in advance of and during treatment in 5 of 7 records reviewed (Patient #1, 3, 4, 5, 6).

The agency failed to conduct an initial assessment within 48 hours of patient referral in 3 of 5 active clinical records reviewed (Patient #2, 3, 4) and 1 of 2 closed clinical records reviewed (Patient #7).

The comprehensive assessment failed to include the complete current health status of the patient in 4 of 7 records reviewed (Patient #1, 4, 5, 6).

The agency failed to provide a comprehensive assessment that accurately reflects the patient’s status including a review of all medications and side effects in 2 of 5 active clinical records reviewed (Patients #2, 3).

The agency failed to provide a comprehensive assessment that accurately reflected the patient’s status to include an assessment of the patient’s primary caregiver’s willingness, ability, and availability to provide care in 3 of 5 active clinical records reviewed.

The agency failed to ensure the plan of care included all necessary components in 7 of 7 records reviewed (Patient #1, 2, 3, 4, 5, 6, 7).

The agency failed to provide services only as ordered by a physician in 5 of 7 clinical records reviewed.

The agency failed to ensure the plan of care was reviewed by the physician at least every 60 days in 2 of 3 active clinical records reviewed with more than 1 certification period.

The agency failed to promptly alert physicians to any changes in the patient’s condition that suggest outcomes are not being achieved in 4 of 7 clinical records reviewed (Patient #2, 4, 6, and 7).

The agency failed to ensure the plan of care was revised to include relevant changes in 2 of 5 active clinical records reviewed.

The agency failed to integrate all services provided directly or under arrangement to assure coordination of care provided by all disciplines in 4 of 5 active clinical records reviewed.

The agency failed to provide the patient and caregiver with a copy of written instructions outlining the visit schedule in 3 of 3 clinical records reviewed with home visits.

The agency failed to provide the patient and caregiver with a copy of a writing instructions outlining the patient medication list and instructions in 3 of 3 clinical records reviewed with home visits.

The agency failed to provide the patient with written information about services and treatments to be provided in 1 of 1 home visits with physical therapy observed (Patient #1) and 1 of 1 home visit observation with skilled nurse services Patient #2).

The agency failed to ensure the agency provided in writing to the patient the name and contact information of the case manager in 1 of 2 home visits with a registered nurse.

Physical therapist failed to provide the services as directed in the plan of care in 5 of 7 clinical records reviewed.

The skilled nurse failed to prepare clinical notes accurately and/or timely in 1 of 2 home visits with a registered nurse (RN) (Patient #3) and in 1 of 2 active clinical records reviewed with physical therapy (PT) services (Patient #4).

The agency failed to ensure services were provided in accordance with current clinical practice guidelines and professional standards of practice in 2 of 7 records reviewed (Patient #1, 5).

The agency failed to ensure each patient record included all physician orders in 3 of 7 records reviewed (Patient #1, 2, 6).

The agency failed to develop and maintain an emergency preparedness communication plan which included names and contact information for all staff.

The agency failed to ensure the OASIS data was complete, accurate, and reflected the patient’s current status in 1 of 6 clinical records reviewed.

The administrator failed to ensure day-to-day operations were followed according to agency policy.

The home health agency failed to ensure: the plan of care was reviewed by the physician, individualized and followed by all agency staff (See tag G0572); the plan of care included all required information / elements for the treatment of the patient (See tag G0574); services and treatment were…

The quality assurance and performance improvement (QAPI) program failed to show measurable improvement in indicators for which there was evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care (see tag G642); failed to use quality indicator…

The skilled professional failed to ensure the following: failed to provide ongoing interdisciplinary involvement of all skilled professionals involved in the patient's care (See tag G0706); failed to provide the services as indicated in the plan of care (See tag G0710); failed to provide the…

The home health agency failed to ensure: the organizational structure was set forth, in writing, including lines of authority and services furnished (see tag G0940), the administrator was responsible for all day-to-day operations of the agency (see tag G0948), the administrator employed qualified…

The agency failed to ensure the emergency preparedness plan was based on and included a documented facility-based and community-based risk assessment utilizing an all-hazards approach.

The agency failed to ensure an emergency preparedness plan included a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency.

The agency failed to develop and implement individualized emergency preparedness plans for the patients which provided appropriate instructions, in the event of an emergency, in 6 of 7 clinical records reviewed.

The agency failed to develop and maintain an emergency preparedness communication plan which included names and contact information for wound clinics providing services to 2 of 2 clinical records reviewed receiving wound clinic services.

The agency failed to develop and maintain an emergency preparedness communication plan which included contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance.

The agency failed to provide and maintain documentation of initial training and every 2 years in emergency preparedness policies and procedures to all new and existing staff and failed to demonstrate staff knowledge of emergency procedures.

The agency failed to conduct exercises to test the emergency plan annually.

The agency failed to ensure the OASIS was completed, accurate and reflected the patient's current status in 5 of 7 clinical records reviewed.

The agency failed to update the comprehensive assessment as frequently as the patient’s condition warrants due to a major decline in the patient’s health status in 3 of 4 active clinical records reviewed who received skilled services from a licensed practical nurse (LPN).

The agency failed to ensure the patients received an individualized, written plan of care which was established, reviewed and signed by a physician and failed to ensure the patient received the services as directed in the plan of care in 7 of 7 clinical records reviewed.

The agency failed to ensure conformance with physician’s orders in 1 of 2 active records reviewed with occupational therapy services.

The home health agency failed to show measurable improvement in indicators for which there was evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care.

The home health agency failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program utilized quality indicator data to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement and failed to ensure the frequency and detail…

The agency failed to ensure the performance improvement activities tracked adverse patient events, analyzed their causes and implemented preventative actions in 2 of 2 clinical records reviewed with falls.

The agency's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented and maintained and agency-wide quality assessment and performance improvement (QAPI) efforts which addressed priorities for improved quality of care and patient safety…

The agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in 2 of 2 home visits with a skilled nurse . (#1, #5) The findings include: 4. During an observation on 8/11/2021, at 1:00 PM…

The agency failed to provide infection control education in 4 of 7 active personnel records reviewed providing direct patient care.

The home health agency failed to ensure the home health aides had complete, patient-specific written patient care instructions to be performed by the home health aides in 2 of 2 clinical records reviewed with home health aide services.

The agency failed to ensure all clinical records were clear, legible and appropriately authenticated in 6 of 7 clinical records reviewed.

The home health agency failed to ensure all clinical records and patient information were safeguarded against loss or unauthorized use.

The agency failed to ensure the patient was provided written notice of the patient’s rights and responsibilities in advance of furnishing care to the patient in 2 of 5 active clinical records reviewed.

The agency failed to ensure the patient participated in, was informed about, and consented to in advance of treatment the care to be furnished, establishing and revising the plan of care, the disciplines that would furnish the care, the frequency of visits, expected outcomes of care and any changes…

The agency failed to ensure the patient received all services as outlined in the plan of care for 3 of 3 active clinical records reviewed with wounds.

The home health agency failed to ensure the primary care physician was informed of and agreed the patient had met their outcome/goals in 1 of 1 closed record reviewed with a discharge due to goals met.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health and functional status in 3 of 5 clinical records reviewed with wounds.

The home health agency failed to ensure all patient medications were reviewed by a registered nurse to identify any potential drug interactions, adverse effects and drug reactions in 5 of 7 clinical records reviewed.

The agency failed to ensure the written individualized plan of care included safety measures, and medications in 6 of 7 clinical records reviewed.

The agency failed to ensure treatments and services were provided as ordered by a physician in 3 of 3 active clinical records reviewed with wounds.

The agency failed to ensure the clinician receiving verbal orders documented the order, signed, dated and timed the order and failed to ensure the physician signed and dated the verbal order in 1 of 3 clinical records with anticoagulant (a class of medication used to thin the blood to treat and/or…

The agency failed to ensure the physician reviewed the plan of care at least every 60 days in 3 of 3 clinical records reviewed with more than 1 certification period.

The agency failed to promptly alert the physician to changes in the patient's condition or needs that suggested that outcomes were not being achieved and/or alert the physician the plan of care should be altered in 5 of 7 clinical records reviewed.

The home health agency failed to revise the plan of care to reflect current health status, medications and nursing needs in 5 of 5 active clinical records reviewed.

The agency failed to ensure the patient and physician were communicated with regarding revisions to the plan of care related to the plans for the patient’s discharge in 2 of 2 closed clinical records reviewed.

The agency failed to communicate with all physicians involved in the plan of care in 1 of 1 home visit with a registered nurse.

The agency failed to coordinate care of services provided to the patient in 4 of 5 active clinical records reviewed.

The agency failed to provide a written visit schedule to the patient/caregiver in 4 of 4 home visits conducted.

The agency failed to provide the patient and caregiver written medication schedule and instructions in 4 of 4 home visits.

The agency failed to provide the patient with written instructions for the name and contact information for the clinical manager in 4 of 4 home visits.

The home health agency failed to ensure the performance improvement activities focused on high risk, high volume, or problem-prone areas.

The home health agency failed to ensure the performance improvement activities considered incidence, prevalence and severity of problems.

The home health agency failed to take actions aimed at performance improvement, and after implementing those actions, the agency must measure its success and track performance to ensure improvements are sustained.

The skilled nurse failed to provide an ongoing assessment of the patient in 2 of 3 active clinical records reviewed with wounds.

The skilled professional failed to provide services as ordered by the physician in the plan of care in 3 of 3 active clinical records reviewed with wounds.

The registered nurse failed to provide patient and caregiver education in 2 of 3 clinical records reviewed receiving anticoagulation (a class of medication used to thin the blood to prevent/treat blood clots) therapy.

The registered nurse failed to prepare clinical notes in 1 of 1 home visit with a registered nurse.

All licensed professionals providing services on behalf of the agency failed to participate in agency-sponsored in-service training in 2 of 3 active personnel records for skilled nurses providing direct patient care (Employee H, Employee L) and 2 of 2 closed personnel records reviewed.

The agency administrator failed to be responsible for all day-to-day operations of the agency.

The administrator failed to ensure the agency employed qualified personnel for 11 of 14 personnel records reviewed.

The home health agency failed to ensure a pre-designated person was authorized in writing by the administrator and governing body to assume the same responsibilities as the administrator when the administrator was unavailable.

The clinical manager failed to provide oversight of patient and personnel assignments.

The clinical manager failed to provide oversight of coordination of patient care.

The clinical manager failed to provide oversight of the development, implementation and update of the individualized plan of care.

The agency failed to ensure all services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice in 1 of 1 home visit with a registered nurse.

The agency failed to ensure the clinical record included a completed discharge summary that was sent to the physician within 5 days of the patient’s discharge in 2 of 2 closed clinical records reviewed.