Excellence Home Health Care Agency Inc

The facility failed to ensure Patient 6’s discharge summary entered into the Outcome and Assessment Information Set (OASIS - a data collection system used by home health agencies (HHAs) to collect and report patient information) accurately reflected services the patient received by the HHA when the…

The facility failed to ensure background checks were performed on three of six sampled staff upon hire Registered Nurse 1 [RN 1], Assistant Administrator [ASST ADMIN] and Physical Therapist 1 [PT 1]).

The facility failed to ensure Electronic Medical Records (EMR) for one of seven sampled patients (Patient 4) was accurate when an occupational therapy assessment (an assessment of an individuals in terms of their specific physical or mental difficulties, to determine how they are functioning at…

The agency failed to provide training to contracted staff on the emergency preparedness policies and procedures and “Emergency Operational Plan” for 14 of 14 months reviewed, in a universe of 32 patients.

The agency failed to ensure 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) were evaluated for…

The agency failed to ensure staff followed the agency’s policy and procedure and professionally accepted infection control practices for one of seven sampled patients (Patient 3) when the Registered Nurse (RN 2) did not follow clean bag technique (a set of procedures to follow to prevent the…

The agency failed to maintain an infection control program when four employees' vaccination status was not tracked and policies and procedures were not developed to address contingency plans for staff that refused a COVID 19 vaccination, for four of four months reviewed, in a universe of 32…

The agency failed to ensure that all medications were recorded in initial assessment for one of seven sampled patients (Patient 2).

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: A.

The agency failed to ensure that the Condition of Participation: G 680 484.70: Infection prevention and control was in compliance when: A.

The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts to maintain an integrated response during a disaster or emergency, for 13 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13).

The agency failed to develop individual patient emergency preparedness plans based on and included in the patients' comprehensive assessments for 13 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13).

The agency failed to implement procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for 13 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13).

The agency failed to ensure a procedure was implemented to maintain availability of clinical documentation of patients' clinical records during a disaster or emergency, for 13 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12 and 13).

The agency failed to implement 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 13 of 13 sampled patients…

The agency failed to provide training to contracted staff on the emergency preparedness policies and procedures and "Emergency Operational Plan" for 13 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13).

The agency failed to implement policy and procedures on conducting 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…

The agency failed to ensure the plan of care was reviewed and signed by a physician within 30 days of the patient's start of care for two of 13 sampled patients (Patients 6 and 10).

The agency failed to 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 undertaken…

The agency failed to follow accepted standards of practice for three of 13 sampled patients (Patients 11, 12 and 13) when a Clostridium difficile (C diff.-a bacteria that infects the colon) infection was suspected and contact precautions (procedures applied to a specified patient known or suspected…

The agency failed to maintain an infection control program that was integrated into the agency's Quality Assessment Performance Improvement (QAPI) program in order to identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, for 13 of 13 sampled…

The agency failed to ensure a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for four of 13 sampled patients (Patients 4, 5, 8 and 10).