Excel Care Home Health Services Inc

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the…

The agency failed to ensure that the Condition of Participation: G 640 484.65 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview, and record review, the agency failed to measure and analyze quality indicators (a measurable element of the…

The agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2022 and 2023 years reviewed, in a universe of 23 patients.

The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2022 and 2023 years reviewed, in a universe of 23 patients.

The agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2022 and 2023 years reviewed, in a universe of 23 patients.

The agency failed to implement a procedure to provide for emergency staffing during a disaster or emergency, for the 2022 and 2023 years reviewed, in a universe of 23 patients.

The agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the 2022 and 2023 years…

The agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2022 and 2023 years reviewed, in a universe of 23 patients.

The agency failed to provide training to all staff, as well as contracted staff, on the agency’s Emergency Preparedness Program, for the 2022 and 2023 years reviewed, in a universe of 23 patients.

The agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “boots on the…

The agency failed to measure and analyze quality indicators (a measurable element of the agency’s practice that can be used to assess the quality of care provided) to assess the agency’s processes of care, services, and operations, from January 1, 2022, to December 14, 2023, in a universe of 23…

The agency failed to use quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency’s services.

The agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had…

The agency’s Governing Body (GB) failed to provide oversight for its Quality Assessment and Performance Improvement (QAPI) Program from January 1, 2022, to December 14, 2023, in a universe of 23 patients when: 1. Based on interview, and record review, the agency failed to measure and analyze…

The Governing Body (GB) failed to operate and manage the agency from January 1, 2022, to December 11, 2023, in a universe of 23 patients when a current California Department of Public Health (CDPH) Laboratory Registration was not maintained.

The agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for three of seven sampled patients (Patients 3, 4, and 7).