Excellacare Skilled Services

The Agency failed to develop an emergency preparedness (EP) plan that must be reviewed, and updated, resulting in lack of direction for Agency personnel (See E 0004); failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years that included guidance for…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program, (G-642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, (G-644); failed to document the quality improvement…

The agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every two years, resulting in no directions for agency personnel in the event of an actual emergency or disaster.

The agency failed to develop and update an Emergency Preparedness (EP) plan within the last 3 years that utilized and incorporated a facility and community-based all-hazards risk assessments, resulting in the potential for being unprepared to respond effectively during an actual or simulated…

The agency failed to develop and maintain an Emergency Preparedness communication plan that integrated specific roles, tasks and responsibilities of its staff in the event of an actual or simulated emergency, resulting in the agency's inability to ensure the coordination of patient care during an…

The agency failed to provide documentation that it had maintained an emergency preparedness (EP) training and testing program that utilized an all-hazard risk assessment, EP policies/procedures, or an EP communication plan, resulting in the potential for staff and all 4 active patients not to be…

The agency failed to provide documentation that it had conducted exercises to test its emergency plan (EP) annually, by way of a tabletop and community based full-scale exercise required every two years, and failed to conduct an additional exercise at least every two years opposite the year of the…

The agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 4 active patients, resulting in a potential for poor patient outcomes due to the provision of substandard care.

The agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care, and identify opportunities for improvement by the quality assessment and performance improvement program, which had the potential to negatively affect all patients serviced by the agency…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2023, 2024 and 2025 calendar years, resulting in the…

The agency failed to ensure that 7 (Patient/P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 patients were appropriately informed of intended discipline visit frequencies, and failed to attain patient and staff signatures in 1 (P-7) of 7 completed home care admission consents reviewed, resulting in a…

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 4 (Patient P-1, P-3, P-4, P-7), and failed to date the Notice of Medicare Provider Non-Coverage for 1 patient (P-2) out of 7 total…

The Home Health Agency (HHA) failed to inform their patients of the names, addresses and phone numbers of the Federally funded and State funded entities, resulting in failure to maintain the patients' informational rights and provide access to community resources and services for 4 of 4 active…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 3 (Patient P-1, P-5, P-6) of 3 records reviewed with congestive heart failure, out of a total sample of 7 records reviewed, resulting in missing clinical information that is…

The agency failed to ensure the patient’s clinical record documented all medications with a completed reconciliation for 1 (Patient/P-7) of 7 records reviewed.

The agency failed to ensure the Plan of Care (POC) covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient in 1 (Patient/P-5) of 7 records reviewed, out of a total sample records of 7 reviewed, resulting in the potential…

The agency failed to coordinate care to meet the needs of the patient in 1 (Patient/P-6) of 2 records reviewed with congestive heart failure, out of a total sample of 7 records reviewed, resulting in the potential for poor clinical outcomes.

The agency failed to document blood glucose levels as ordered for 1 (Patient/P-3) of 4 records reviewed with diabetes, out of a total sample of 7 records reviewed, resulting in the potential for physical decline and unmet care needs in all 2 active patients with diabetes.

The agency failed to ensure the patient and caregiver were provided with medication administration and wound care teaching and instructions for 1 (Patient/P-7) of 7 records reviewed, for a potential of missed medication and improper wound care resulting in the potential of unmet care needs.

The agency failed to ensure clinical notes were accurate for 1 (P-7) patient, and that clinical notes were submitted for 1 (P-1) patient of 7 total records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to send the discharge summary of care provided by skilled nursing (SN) within 5 days of discharge as required in 4 (Patient P-2, P-4, P-6, P-7) of 7 records reviewed, out of a total sample of 7 records reviewed, resulting in the physician not having timely clinical information…

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, and history of events leading to current home care needs in 2…

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 1 of 2 (MR# 6) records reviewed with therapy only services.

The agency failed to ensure visit notes were documented in the record for 3 of 7 records (MR# 4, 5 and 7) reviewed, resulting in no documented evidence of the patient's current health status from clinician visits.

The agency failed to update its Emergency Preparedness plan to include plans to address the global pandemic (Covid-19), resulting in staff being ill-prepared to address the crisis and the potential for poor patient outcomes for the agency's 13 patients.

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening visitors and all 18 staff employed by this agency and those (14 staff) who were granted clinical privileges, resulting in the…

The Agency failed to provide documented evidence that Covid-19 infection control education was provided to all 18 staff employed by the agency staff, 14 of which were granted clinical privileges, resulting in the potential for the development and spread of the Covid-19 infection to staff and all 13…

The agency failed to ensure the initial comprehensive assessment visit was made within 48 hours of the date of the referral for 1 of 8 (MR# 1) records reviewed, resulting in a delay in determining the immediate care and support needs of the patient and the potential decline of the patient's health…

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy; failed to ensure the physician was informed of major/severe drug interactions for 3 of 8 (MR's #2…

The agency failed to ensure the plan of care included measurable skilled nursing outcomes and goals for 3 of 8 (MR#s 4, 6, and 7) records reviewed, and failed to include pertinent safety measures in 1 of 8 (MR #4) records reviewed, resulting in the potential for poor patient outcomes due to a lack…

The agency failed to ensure the supervisory visit by the registered nurse accurately reflected aide services for 1 of 2 (MR#2) records reviewed in which aide services were provided, resulting in a lack of aide supervision.

The agency failed to ensure that home health aide visit notes were completed and included in the clinical record for 1 of 2 (MR# 2) records reviewed in which aide services were provided, resulting in the physician not having a clear and concise clinical picture of the patient's health status and…