Divine Care Home Health Inc

The agency failed to ensure the requested patient roster was updated for eight (Pt #8, 9, 10, 11, 12, 13, 14, and 15) of fifteen patients.

The agency failed to ensure patients received a statement of rights at the time of admission to the agency for care and services for three (Patients #2, 7 and #8) of eight patients.

The agency failed to ensure a resumption of care (updated comprehensive assessment was completed for one (Patient #4) of eight patients.

The agency failed to ensure development of a POC after a comprehensive OASIS assessment for two (Patients #2 and #8) of eight patients.

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure its infection control program included administrative policy and procedures which identified infection control, infection prevention processes and standards for the agency for all patients and staff.

The agency failed to ensure services were provided as ordered on the POC for: 1. PT evaluations were conducted for one (Patient #4) of eight patients; 2. OT evaluations were conducted for one (Patient #4) of eight patients; 3. SN to conduct assessment of patient pain every visit and notify the…

The agency failed to ensure governing body oversite of: 1. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar years 2021 and 2022; and 3. Agency program evaluation for calendar years 2021 and 2022 for all patients…

The agency failed to ensure a completed transfer summary was provided for one (Patient #4) of eight patients.

The agency failed to ensure development and implementation of an agency emergency preparedness program for all patients and employees Emergency Preparedness program administrative records for the agency were requested.

0006 EP RA Based on record review and interview, the agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for all patients and employees.

The agency failed to ensure administrative policies and procedures related to an Emergency Preparedness Plan were in place for all patients and employees.

The agency failed to ensure an emergency preparedness testing and training program was developed, implemented and reviewed/updated at least annually for all patients and employees for all patients and employees Findings: Emergency Preparedness program records for the agency were requested.

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar years 2021 and 2022 for all patients and employees.

The agency failed to ensure completion of a transfer/discharge summary for three (Patients #4, 7 and #8) of eight patients.

The agency failed to ensure development of a POC after a comprehensive OASIS assessment for two (Patients #2 and #8) of eight patients.

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI Program which tracked, analyzed and showed implementation of preventative actions of patient events for all patients and employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program in calendar years 2021 and 2022 for all patients and employees.

The agency failed to ensure governing body oversite of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure its infection control program included administrative policy and procedures which identified infection control, infection prevention processes and standards for the agency for all patients and staff.

The agency failed to ensure its infection control program included surveillance monitoring and reporting and included in QAPI program activities for all patients and staff.

The agency failed to ensure infection control education was: 1) Included in QAPI activities; 2) Showed interventions to reduce future infections; and 3) Provided and/or maintained for all patients and employees.

The agency failed to ensure a care plan for home health aide services was completed for one (Patient #6) of eight patients.

The agency failed to ensure governing body oversite of: 1. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar years 2021 and 2022; and 3. Agency program evaluation for calendar years 2021 and 2022 for all patients…

The agency failed to ensure accurately documented clinical SN visit notes for two (Patients #3 and #4) of eight patients.

The agency failed to ensure it had administrative and clinical policies and procedures in place related to patient clinical records for all patients and employees.

The agency failed to ensure patient paper clinical records were protected from unauthorized access for three (Patients #1, 9 and #10) of 10 patients.

The agency failed to ensure patients received a statement of rights at the time of admission to the agency for care and services for three (Patients #2, 7 and 8) of eight patients.

The agency failed to ensure patients received the contact information for the agency’s administrator at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients.

The agency failed to ensure patients received the notice of discharge and transfer policies for the agency at the time of admission to the agency for three (patients #2, 7 and #8) of eight patients.

The agency failed to ensure patients received informed consent at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients.

The agency failed to ensure patients received informed notice of their right to a complete clinical record and the right to have protected health information for three (Patients #2, 7 and #8) of eight patients.

The agency failed to ensure patients received a statement of billing and complaint processes at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients.

The agency failed to ensure patients received a statement of the grievance processes and OSDH complaint hotline information at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients.

The agency failed to ensure the receipt and subsequent investigation and documentation of related actions of patient complaint, incidence and grievance for all patients and employees.

The agency failed to ensure a recertification assessment was completed for one (Patient #2) of eight patients.

The agency failed to ensure a discharge OASIS assessment was completed for two (Patients #7 and #8) of eight patients.

The agency failed to ensure: 1. An individualized patient POC included SN interventions and goals for one (Patient #3) of eight patients and; 2. An individualized patient POC included pain and weight reporting parameters for one (Patient #6) of eight patients.

The agency failed to ensure an individualized patient POC was reviewed and signed by the physician for one (Patient #6) of eight patients.

The agency failed to ensure an updated POC was completed after a resumption of care comprehensive assessment for one (Patient #4) of eight patients.

The agency failed to ensure patients received the contact information for the agency’s clinical manager at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients.

The agency failed to ensure conduction of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure services were provided as ordered on the POC for: 1. PT evaluations were conducted for one (Patient #4) of eight patients; 2. OT evaluations were conducted for one (Patient #4) of eight patients; 3. SN to conduct assessment of patient pain every visit and notify the…

716Incomplete clinical notes (SNV, etc.) Based on record review and interview, the agency failed to ensure SN visit notes were completed for four (Patients #3, 4, 5 and #6) of eight patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure a clinical manager was available during all operating hours of the agency for all patients and employees.

The agency failed to ensure governing body appointment of an alternate pre-designated person to be available in the absence of the administrator for the agency for all patients and staff.

The agency failed to ensure an administrator or alternate administrator was available during all operating hours for all patients and employees.

The agency failed to ensure a completed transfer summary was provided for one (Patient #4) of eight patients.

The agency failed to show evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to show: 1. the Infection Control Program was included in QAPI activities; and 2. infection control and QAPI activities to reduce future infections and promote learning and preventative measures throughout the agency for all previous and future patients and employees.

The agency failed to show governing body oversight of the program, the agency budget and QAPI program.

The agency failed to ensure patient clinical records were accessible for 17 patients.

The agency failed to ensure development of an agency specific Emergency Preparedness Program for 17 patients and all employees.

The agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 17 patients and all employees.

The agency failed to ensure development, implementation and availability of emergency preparedness policy and procedure to monitor the agency's emergency preparedness plan for 17 patients, future patients, and employees of the agency.

The agency failed ensure an emergency preparedness communication plan development and/or availability for 17 patients, future patients, and employees of the agency.

The agency failed to ensure evidence of an emergency preparedness training and testing program for17 active patients, future patients, and all employees.

The agency failed to show evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to show utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement.

The agency failed to show conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to show the initiation and review of a PIP through their QAPI Program for 17 patients and all employees.

The agency failed to show an ongoing, comprehensive QAPI program was approved by the governing body.

The agency failed to show: 1. the Infection Control Program was included in QAPI activities; and 2. infection control and QAPI activities to reduce future infections and promote learning and preventative measures throughout the agency for all previous and future patients and employees.

The agency failed to show infection control education was: 1) included in QAPI activities; 2) showed interventions to reduce future infections; 3) provided to patients and caregivers for 17 patients; and 4) provided and/or maintained for current and previous employees.

The agency failed to show governing body oversight of the program, the agency budget and QAPI program.

The agency failed to ensure governing body oversight of the program, the agency budget and capital expenditure plan.

The agency failed to show governing body appointment and oversite authority of the administrator.

The agency failed to show the governing body ensured a clinical manager was available during operating hours for 17 current patients.

The agency failed to ensure governing body appointment of a qualified person authorized to act in the absence of the administrator for 17 current patients and all future patients.

The agency failed to ensure patient clinical records were accessible for 17 patients.

The agency failed to provide patient clinical records for 17 patients.

The agency failed to provide patient clinical records for 17 patients.