Family Care Choice & Services, Inc

The Agency (HHA) failed to develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually (See E0004); failed to incorporate the use of volunteers or other staffing strategies to address surge needs during an emergency (See E0024); Based on interview, the…

The agency failed to ensure the plan of care included safety precautions for 3 of 7 records, (MR#s 2, 3, 6), failed to ensure visits were provided as ordered for 2 of 7 records, (MR#s 1, 5), (See G572), failed to provide services in 1 of 1 record (MR#6), where home health aide (HHa) services were…

The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program to optimize patient outcomes, (See G642); failed to collect and monitor data for the QAPI program in 2020, 2021, and 2022, (See G644); failed to initiate any performance improvement activities within their…

The agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases, (See G682); and failed to maintain a functioning infection control program for 2020, 2021 and 2022 (G-684), resulting in the…

The agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency's provision of home health services…

The agency failed to develop, review, and update the EP plan at least every two years.

The agency's (HHA) Emergency Preparedness (EP) plan, policies and procedures, failed to address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge…

The agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least every two years.

The agency (HHA) failed to develop and maintain an emergency preparedness communication plan that included an alternate means for communicating with agency staff, Federal, State, tribal, regional, and local emergency preparedness officials, resulting in the lack of essential information in the…

Failed to conduct exercises to test, at least every two years, the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the clinic's response…

The Home Health Agency (HHA) failed to ensure orders on the plan of care (POC) were followed for 2 records (MR# 1,5), failed to document a POC/485 in the patient record for 2 records (MR# 2,3), failed to ensure safety precautions were included on the POC for 3 records (MR# 2, 3, 6), and failed to…

The home health agency failed to ensure the physician orders were followed in 1 of 1 records (MR# 6) where home health aide (HHa) and physical therapy (PT) services were ordered, from a total of 7 records reviewed, resulting in the potential for unmet patient care needs.

The Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators for 2020, 2021, and 2022, in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential for unmet care needs.

The agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, resulting in the potential for ineffective…

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency (HHA) failed to track adverse patient events, analyze their causes, and implement preventative actions within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for patient issues to go unresolved and affect all patients served by the agency.

The Agency (HHA) failed to conduct any performance improvement projects within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for patient and agency issues to go unresolved and affect all patients served by the agency.

The Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for…

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 staff employed by the agency including staff who were granted clinical privileges, resulting in the potential…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement program, resulting in the potential spread of infections…

The home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans, and…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required; failed to have a skilled nurse review the medications; and failed to ensure the physician was…

The agency failed to ensure treatments were provided in accordance with a physician's order in 1 of 3 records reviewed (MR # 3) in which occupational therapy (OT) services were provided, from a total of 7 records reviewed, resulting in the potential for the patient to receive inappropriate…

The agency failed to inform the physician that ordered services were not provided for 1 of 7 records reviewed (MR #6) in which home health aide (HHa) and physical therapy (PT) services were ordered, from a total of 7 records reviewed, resulting in the potential for unmet patient care needs.

The Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas, resulting in the potential for agency issues to go unresolved in high risk, high volume or…

The agency failed to communicate with the physician involved with the plan of care (POC) in 4 of 7 discharge records reviewed (MR# 1, 2, 3, 5), from a total sample of 7 records, resulting in the potential for inappropriate care and unmet care needs, Findings include: MR#1: The start of care (SOC)…

The agency failed to have a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, to assume the same responsibilities and obligations as the administrator, in the administrator's absence.

The agency failed to assure the development, implementation, and updates of the individualized plan of care for 2 of 7 records (MR# 2, 3) from a total of 7 records reviewed, resulting in the potential for inappropriate care and unmet care needs.

The agency failed to include discharge summaries in the patient record and failed to document submission to the physician in 7 of 7 records (MR #'s 1, 2, 3, 4, 5, 6, 7) who were discharged from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care…

The agency failed to contact and collaborate with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency (See E0009); failed to ensure the Emergency Preparedness Plan included procedures to follow up with on-duty…

The agency failed to maintain compliance with this condition of participation.

The agency failed to contact and collaborate with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency.

The agency failed to ensure the Emergency Preparedness Plan included procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency and to inform State and local officials of any…

The agency failed to address the use of volunteers and other emergency staffing strategies in the Emergency Preparedness plan, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, which could…

The agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State and local laws.

The agency failed to provide documentation for the required annual tabletop and community based full-scale exercises or any documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff not being properly prepared for an actual emergency.

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 8 of 8 records reviewed (MR#s 1, 2, 3, 4, 5, 6, 7 and 8), failed to provide services within the accepted timeframe for 1 of 8 records (MR #6), failed to follow the plan of care for visits…

The Agency (HHA) failed to provide documented evidence that infection control education was provided to all staff employed by the agency and who were granted clinical privileges, resulting in the potential for the development and spread of infection.

The agency failed to ensure patient records were safeguarded against loss or unauthorized use for more than 100 patient records, from a total of more than 100 patient records observed unsecured.

The agency failed to ensure the comprehensive assessment included baseline information detailing the patient's current health at the time of admission for 1 of 8 (MR# 7) records reviewed, resulting in incomplete clinical information to assist in determining the needs of the patient.

The agency failed to ensure the registered nurse reviewed patient medications for possible side effects, duplication, and possible drug interactions and informed the physician of any identified problems for 3 of 8 (MR#'s 2, 6, and 8) records reviewed, out of a total of 8 records.

The agency failed to ensure a qualified alternate administrator was authorized in writing by the Administrator and approved by the Governing Body, to function in the Administrator's absence, resulting in a lack of organization and direction of the agency's ongoing functions to assure the…

The agency failed to ensure that discharge and transfer summaries were complete, provided the patient's current health status at the time of discharge and transfer, documented progress toward goals, provided an updated medication list and were sent to the physician in 5 of 5 records (MR #'s 3, 4…