Compassionate Care Home Care Service, Inc

The agency failed to ensure their emergency plan was based on both a facility-based and community-based hazard risk assessment, resulting in the potential for being unprepared to respond effectively in the event of an emergency (See E0006); failed to contact and collaborate with local, tribal…

The home health agency failed to inform the patients of the business address of the agency to use as a reference in mailing letters of complaints for the agency, (Refer to G-0414); failed to inform the patient, in writing, of the specific visit frequency for the skilled nurse (Refer to G-0434)…

The Agency (HHA) failed to ensure the initial comprehensive assessment was completed no later than 5 calendar days after the start of care (Refer to G-0520); failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past…

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals (Refer to G-0572); failed to include frequency and duration of visits for the Registered Nurse/Licensed Practical Nurse (RN/LPN) and failed to include patient specific interventions with parameters…

The Home Health Agency failed to ensure the Governing Body assumed full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and it's operational plans and it's quality…

The agency failed to ensure their emergency plan was based on both a facility-based and community-based hazard risk assessment, resulting in the potential for being unprepared to respond effectively in the event of an emergency.

The agency failed to contact and collaborate with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency.

The agency failed to develop, implement, review and update the policies and procedures for the emergency preparedness plan, that was based on the risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section, for a potential for the staff to be…

The agency failed to develop and maintain a communication plan for the emergency preparedness plan affecting all patients served by the agency including staff, resulting in the facility not being able to communicate effectively with facility staff, volunteers, other health care providers and…

The agency failed to develop and maintain a communication plan for emergency preparedness, including names and contact information for staff, community, state and federal entities providing services, patients' physicians and volunteers, affecting all patients served and staff, resulting in the…

The agency failed to ensure the emergency preparedness communication plan complied with Federal, State and local laws and was reviewed and updated every 2 years, resulting in the potential for staff being unprepared to respond effectively in the event of an actual emergency, which had the potential…

The agency failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least every 2 years (2018 and 2019), resulting in the potential for staff being unprepared to respond effectively in the event of an actual emergency, which had the…

The agency failed to ensure initial training in emergency preparedness policies and procedures was provided to all employees for 2018, 2019 and 2020; failed to maintain documentation of emergency preparedness training provided to all staff for 2018, 2019 and 2020; and failed to demonstrate staff…

The agency failed to perform testing of their emergency preparedness program as required for 2018 and 2019 and failed to analyze the staff's response to and maintain documentation of all drills, and the tabletop exercise dated 2/24/2020, and failed to revise the emergency plan, as needed, affecting…

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments…

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 2 of 2 records reviewed (MR#s 1 and 2) from a total of 2 sampled records reviewed, resulting in a potential for failure to measure progress toward achievement of desired outcomes.

The agency failed to ensure the home health aide competency evaluation was completed by observing the aide's performance of the tasks with a patient prior to being deemed competent to perform aide services for 1 of 1 aide (Aide #1), from a total sample of 1 aide personnel file reviewed, resulting…

The agency failed to inform the state agency of the change in address, when if occurred December 2018. Findings include: During an interview on 2/24/2020 at 11 AM it was queried what date did the agency move to the current address, the Administrator #1 replied, "We moved her in December 2018." It…

The Home Health Agency failed to ensure the Governing Body assumed full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and it's operational plans and it's quality…

The agency failed to ensure that all entries in the medical record were legible and authenticated by a signature, date and title for 1 of 2 sampled records reviewed (MR#1), resulting in a lack of validation as to the correctness of the entries in the medical record.

The home health agency failed to inform the patients of the business address of the agency to use as a reference in mailing letters of complaints for the agency, resulting in a potential for unaddressed patient concerns or complaints for 2 of 2 active patients (MR#s 1 and 2) from a total patient…

The agency failed to inform the patient, in writing, of the specific visit frequency for the skilled nurse for 2 of 2 records reviewed (M.R. #1 and 2) with skilled nursing services, of a total of 2 records reviewed, for a potential of unmet nursing needs.

The agency failed to inform the patient/caregiver before care was initiated of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient in 1 of 2 records reviewed (MR# 1)…

The home health agency failed to advise their patients of the names, addresses and telephone numbers of the federally and state funded entities that serve the area in which each patient resides, resulting in the potential for unmet patient care needs for the 2 patients currently served by the…

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 2 records reviewed (MR #1) resulting in the potential for unidentified patient needs.

The Agency failed to ensure the patient's Activities of Daily Living {ADLs} needs were adequately met in the patient's home by the home health agency while providing services for this patient in 1 of 2 sampled records reviewed (MR# 1) resulting in potential for poor hygiene, psychological decline…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 2 records (MR#s 1 and 2) from a total of 2 sampled records reviewed, resulting in the potential for harmful medication effects for all 16…

The agency failed to ensure the comprehensive assessment accurately reflected the primary caregivers willingness, ability, and availability to provide care for 1 of 2 patients (MR#1) assessed as needing assistance with activities of daily living, resulting in the potential for poor hygiene…

The agency failed to document the frequency and duration of visits for the Registered Nurse and Licensed Practical Nurse (RN/LPN); and failed to identify patient specific interventions with parameters on the plan of care in 2 of 2 sampled records reviewed.

The agency failed to ensure medications were provided only as ordered by the physician for 1 of 2 sampled records reviewed (MR# 1), resulting in the potential for the provision of inappropriate care and services.

The registered nurse failed to complete the Start of Care assessment and include assessment of the Influenza and Pneumococcal vaccines to determine contraindications and adverse reactions of the vaccine for 2 of 2 patients records reviewed (M.R. #1 and 2), of a total patient records reviewed of 2…

The Agency (HHA) failed to include contact information for the Home Health Agency's Clinical Manager on the Plan of Care in one of two records reviewed (MR# 1), resulting in the potential for unaddressed patient concerns.

The Home Health Agency failed to ensure the Governing Body appointed the administrator's position, for a potential of lack in management for all the staff.

The Administrator and the Governing Body failed to identify in writing an alternate administrator and an alternate Clinical Manager, for a potential of a lack of oversight and management of patient care services and the staff.