Extracare Home Health Services

The agency failed to ensure the comprehensive assessment reflected the patient’s status for 1 (P-5) of 7 patient records reviewed (G528); failed to ensure the comprehensive assessment included the patient’s strengths, goals, or preferences for 1 (P-5) of 7 patient records reviewed (G530); failed to…

The agency failed to ensure the plan of care included patient-specific measurable goals and outcomes for 1 (P-4) of 7 patient records reviewed (G572); failed to ensure the plan of care included all the required elements to provide quality and safety in patient care for 4 (P4, P-5, P-6, & P-7) of 7…

The agency failed to ensure its Quality Assessment and Performance Improvement (QAPI) program documented actions to measure, track and analyze quality indicators for improvement of patient care services (See G 642); failed to develop a program of relevant data collection used to monitor safety and…

The agency failed to develop an infection control program that monitored staff's performance regarding any of the six accepted standard infection control practices to prevent the transmission of infections and communicable diseases (See G 682); failed to ensure the infection control program was…

The Agency failed to ensure that the Clinical Manager and or the designated alternate was available during all operating hours (G950); failed to ensure the oversight of the coordination of referrals for 1 (P-4) of 7 patient records reviewed (G964); the continued assessment of patient care needs for…

The agency failed to maintain Emergency Preparedness policies and procedures that had been reviewed and updated at least every 2 years, resulting in the potential for poor patient outcomes during a disaster if staff are ill-prepared.

The agency failed to develop and maintain an inclusive Communication Plan, resulting in the inability to communicate with staff and officials in the event of an actual disaster and uncoordinated care for all patients serviced by this agency in the event of a facility emergency or disaster.

The agency failed to develop and maintain an emergency preparedness Communication Plan that complied with Federal, State and local laws to include required subject areas and had been reviewed and updated at least every 2 years, resulting in lack of an effective communication plan and the potential…

The agency failed to ensure the comprehensive assessment was updated and revised for 1 (P-1) of 1 patient who was recertified for continued services, resulting in the lack of information in determining the care and support needs of the patient.

The agency failed to ensure that the plan of care (POC) included objective measurable goals specific to the needs of the patient in 1 (P-4) of 7 patient records reviewed.

The agency failed to identify any measurable improvement indicators for its Quality Assessment and Performance Improvement (QAPI) program since 2021, resulting in the potential for repeated unmet patient outcomes, poor safety for patients, and provision of substandard care.

The agency failed to develop a data collection program that utilized quality indicators and failed to document its Governing Body's (GB) approval of the frequency and detail of the data collection for the Quality Assessment Performance Improvement (QAPI) program since 2021, resulting in the…

The agency failed to initiate any performance improvement activities with its Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the provision of substandard care and unmet patient care needs.

The agency failed to develop performance improvement activities, as part of the Agency's Quality Assessment Performance Improvement (QAPI) program, to track and trend adverse patient events, analyzing the cause and implementing preventive interventions, resulting in the potential for the rendering…

The agency failed to conduct any performance improvement projects (PIP) as required since 2021, resulting in the lack of quality improvement measures intended for patient care services.

The agency failed to ensure its Governing Body (GB) was involved in the Quality Assessment and Performance Improvement (QAPI) program since 2021, resulting in the lack of oversight concerning the quality of patient care services rendered.

The agency failed to utilize infection control standards of practice during the provision of care for 2 (P-2, P-6) of 2 patients observed during home visits, resulting in the potential for the development and spread of infection.

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of infections, and failed to ensure the infection control program was an integral part of the agency's Quality Assessment Performance Improvement (QAPI) program, resulting in the…

The agency failed to provide documented evidence that infection control (IC) education was provided to all staff utilized by the agency, and failed to show IC education was instructed to patients/caregivers within the IC program since 2021, resulting in the potential for the development and spread…

The agency failed to ensure the physical therapist (PT) adequately assessed and monitored the needs of the patient in 1 (P-7) of 7 patient records reviewed, resulting in unrecognized clinical needs and the potential for poor outcomes.

The agency failed to ensure the registered nurse prepared clear, written patient care instructions found on the home health aide (HHa) plan of care for 1 (P-7) of 1 patient with ordered HHa services, resulting in the potential for the provision of unsafe care and unmet care needs.

The agency failed to ensure at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs.

The agency failed to ensure all entries contained in the clinical record were clear and legible, resulting in the potential for lack of continuity of care and unmet patient care needs.

The agency failed to honor the right to refuse care/treatment during therapy and ensure inclusion of overall planning of care for 1 (P-2) of 1 patient observed during a home visit, resulting in the potential for missed visits and unmet care needs.

The agency failed to ensure the patient received the Notice of Medicare Non-Coverage (NOMNC) in advance of terminating home care services for 2 (P-1, P-7) of 2 patients, resulting in patients not having the right to dispute the termination of Medicare covered services.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-5, P-6) of 7 patient records reviewed, resulting in incomplete clinical information used to develop a plan of care based on the needs of the patient.

The agency failed to ensure the comprehensive assessment included the patient’s strengths, goals, or preferences for 1 (P-5) of 7 patient records reviewed, preventing the patient and caregiver to actively participate in the development of the plan of care.

The agency failed to ensure the comprehensive assessment documented discharge needs and discipline of services for 1 (P-5) of 7 patient records reviewed.

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, and failed to ensure the physician was notified of the identified drug interactions for 6 (P-1, P-2, P-3, P-5, P-6, P-7) of 6 patients, resulting in the potential for…

The agency failed to ensure the comprehensive assessment identified the patient’s primary caregiver for 1 (P-5) of 7 patient records reviewed, resulting in the potential of unmet needs.

The agency failed to ensure the plan of care included all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of 6 (P-1, P-3, P-4, P-5, P-6, P-7) of 6 patients, resulting in patients not receiving care specific to their…

The agency failed to ensure the plan of care (POC) included all patient care orders for 1 (P-4) of 7 patient records reviewed, resulting in the potential for unmet needs.

The agency failed to ensure care and services were provided only as ordered by the Physician for 4 (P-1, P-2, P-3, P-7) of 4 patients, resulting in the patients not receiving services in accordance with their identified needs.

The agency failed to ensure the plan of care (POC) was reviewed and revised by the physician for 1 (P-4) of 7 patient records reviewed.

The agency failed to provide current written medication information, schedule, and instructions for 1 (P-4) of 3 patients observed, resulting in the potential of poor patient outcomes.

The agency failed to ensure the name and contact information of the Clinical Manager was provided for 1 (P-4) of 3 patients observed.

The agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that instituted actions for the purpose of collecting performance improvement data and failed to implement a process to re-evaluate subsequent data to determine if intended improvements are sustained.

The agency failed to ensure that the clinical manager and or the designated alternate were available during all operating hours.

The agency failed to ensure that the Clinical Manager and or the designated alternate coordinated referrals for 1 (P-4) of 7 patient records reviewed, resulting in the potential of unidentified health concerns and unmet care needs.

The agency failed to ensure the Clinical Manager and or the designated alternate provided oversight of the continued assessment of patient care needs by ensuring a comprehensive assessment was completed with all the required elements for 1 (P-5) of 7 patients records reviewed, resulting in the lack…

The agency failed to ensure the Clinical Manager and or the designated alternate provided oversight of the development of an individualized plan of care in 1 (P-4) of 7 records reviewed, resulting in the potential of unmet patient care needs.

The agency failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, and forwarded to the Physician within 5 days of the date of discharge for 3 (P-1, P-3, P-7) of 3 patients who were discharged from the agency's services, resulting…

The agency failed to ensure a Registered Nurse or Physical Therapist performed an initial assessment of the patient within 48 hours of the referral date in 1 (MR #7) of 7 records reviewed out of a total sample of 7 records reviewed.

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 5…

The agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 7 of 7 records reviewed (MR#’s 1-7) for Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for negative patient outcomes in the event…

The Agency failed to ensure a registered nurse performed a timely review of the patient's medication list in 3 (MR's #1, 4, 5) of 6 records reviewed with therapy only services ordered from a total sample of 7 records, resulting in the potential for harmful medication effects for all 6 patients…

The Agency failed to ensure the plan of care (POC) covered all pertinent interventions with reportable parameters for 2 (MR's # 3, 4) of 7 total sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes for all…

The agency failed to maintain a record of referral for services for 1 of 7 (MR# 3) records reviewed, resulting in unmet record maintenance and availability.

The Agency failed to ensure a discharge summary was complete, provided the patient's health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 3 (MR's #2, 6, 7) of 3 closed records; and failed to ensure a transfer summary was sent to…

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 Physical Therapist failed to provide services in accordance with the Plan of Care for 3 (MR's #1, 2, and 4) of 7 records with Physical Therapy services ordered, from a total of 7 sampled records reviewed, resulting in the potential for decline in physical functioning and unmet care needs.

The Agency (HHA) failed to ensure that all entries in the medical record were legible in 4 of 7 records in which Skilled Nursing (SN) services and/or Physical Therapy were provided, from a total sample of 7 sampled records reviewed (MR#s 4, 5, 6, and 7), resulting in difficulty deciphering the care…

The agency failed to ensure that clinical records were safeguarded against loss or unauthorized use and visit notes were stored in a secured area in 1 of 7 records reviewed (MR # 4), resulting in the potential for compromise of protected health information for all patients serviced by the agency.

The Agency failed to ensure that the initial comprehensive assessment visit was made within 48 hours of the date of referral for 1 record (MR #1), from a total of 7 records reviewed, resulting in the delay of needed care and services and the potential for decline in health status.

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 6 (MR's #1, 3, 4, 5, 6, 7) records, from a total of 7 sampled records reviewed, resulting in patients not receiving…

The agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status and needs in 2 of 7 records reviewed in which nursing services were provided out of a total sample of 7 records reviewed (MR#s 5 and 7), which resulted in the potential…

The Agency failed to ensure Occupational Therapy and Medical social Work services were provided for 1 record (MR #2), from a total of 7 records review, resulting in the potential for physical and psychological decline and unmet care needs.

The Agency failed to ensure the clinical record was complete and included a Comprehensive Discharge assessment and Discharge Summary that accurately captured the status of the patient at the time of discharge for 3 (MR #s 1, 5, and 7) of 3 discharged records, from a total of 7 sampled records…