Four Seasons Home Health Care

The agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for the identified potential hazards (E0006); failed to ensure its Emergency Preparedness policies and procedures had…

The agency failed to ensure the patient and legal representative was provided with written notice of rights and information on transfer and discharge policies that was given in a manner that could be understood (G412); failed to provide the patient and legal representative with the Administrator's…

The agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for the identified potential hazards, resulting in the potential for lack of preparedness and poor patient and staff…

The agency failed to ensure its Emergency Preparedness policies and procedures had been reviewed and updated at least every 2 years, resulting in the potential for ineffective staff responses and poor patient outcomes in the event of a disaster.

The agency failed to develop and maintain a communication plan for emergency preparedness, resulting in the inability to effectively communicate with staff and local and state officials, uncoordinated care and unmet care needs for all patients serviced by this agency in the event of a facility…

The agency failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws, resulting in the potential for lack of effective communication and the interruption in the provision of needed care and services in the event of an emergency or…

The agency failed to establish and effective Emergency Preparedness training and testing program that was based on policies and procedures, a risk assessment from an all-hazards approach and a communication plan that had been reviewed and updated at least every 2 years.

The agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared…

The agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency.

The agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 15 active patients, resulting in a potential for poor patient outcomes due to the provision of substandard care.

The agency failed to ensure its skilled discipline utilized infection control standards of practice during the provision of care for 1 (P-1) of 1 patient observed during a home visit, resulting in the potential for the development and spread of infection.

The agency failed to provide documented evidence of initial infection control education for 1 of 9 sampled staff members, including those employed through an arranged contract, which has the potential to negatively impact the safety and well-being of all 60 patients serviced by the agency in the…

The agency failed to ensure its HHa (home health aide) services had the required 12 hours of in-services during each 12-month period for 2 (HHa-1 and HHa-2) of 2 HHa personnel files reviewed, resulting in a lack of educational training and the potential for unmet patient care needs.

The agency failed to ensure that 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 for all patients serviced by this agency.

The agency failed to ensure the patient and legal representative was provided with written notice of rights and information on transfer and discharge policies that was given in a manner that could be understood for 1 (P-1) of 1 patient observed during a home visit with visual and auditory…

The agency failed to provide the patient and legal representative with the Administrator's full contact information in a manner that could be understood by 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairments, resulting in the potential for unaddressed concerns and…

The agency failed to obtain the patient's or legal representative's signature as confirmation of receipt of notice of rights for 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairments.

The agency failed to ensure the patient or legal representative was provided with information regarding his right to lodge a complaint with the agency for 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairments.

The agency failed to ensure that 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairment, and his legal representative was including in the overall planning of care; and, failed to ensure that 1 (Patient/P-7) patient was included in their overall planning of care…

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 1…

The agency failed to ensure the patient's activity of daily living needs were adequately met in the patient's home for 1 (P-2) of 1 patient who required assistance with grooming, resulting in the potential for low self-esteem, poor hygiene and unmet care needs.

The agency failed to ensure the patient’s clinical record documented all medications with a complete reconciliation and interactions for 2 (Patient/P-3 and P-7) of 7 records reviewed.

The agency failed to ensure the plan of care (POC) included patient specific measurable goals in 4 (Patient/P-3, P-4, P-5, P-6) of 7 records; and failed to ensure the POC provided clear instructions concerning safety precautions when drinking fluids in 1 (P-3) of 1 record reviewed with dysphagia…

The agency failed to ensure that Physical Therapy services were provided at the ordered frequency for 1 (P-2) of 6 patients who required therapy services and, failed to ensure that speech therapy (ST) performed an initial evaluation as ordered for 1 (Patient/P-3) of 2 records reviewed with speech…

The agency failed to ensure the Physician was promptly notified of a significant change in condition for 1 (P-1) of 1 patient observed during a home visit with complaints of abdominal discomfort, resulting the potential for unidentified, untreated health concerns and unmet patient care needs.

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the patient admission folder/patient handbook, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure that services were provided as ordered by the Physician and in the Plan of Care for 1 (P-1) of 2 patients who required Speech Therapy services, resulting in the potential for worsening health conditions and unmet patient care needs.

The agency failed to ensure the clinical record was complete, including assessments, communication notes and evaluations for 1 (Patient/P-3) of 1 record reviewed with ER (emergency room) admission, resulting in an incomplete depiction of the patient's health status, and the potential for unmet care…

The agency failed to send the discharge summary of care, within 5 days of discharge as required, in 2 (Patient/P-3 and P-6) of 3 records with discharge, resulting in the physician not having timely clinical information concerning the outcomes of home care services provided and the potential for…

The agency failed to ensure the Aide Care Plan included the functional limitation of hearing in 1 of 1 record with aide services, out of a total of 7 records reviewed, resulting in the inability of the aide to be aware that the patient could not hear conversations while the aide provided services…

The agency failed to ensure the registered nurse conducted the initial assessment visits and resumption of care visits within 48 hours of referral to determine the immediate care needs of the patient, including homebound status, for 3 of 7 (MR# 1, 2, and 4) records reviewed in which Skilled Nursing…

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 the plan of care included interventions for each discipline providing services, measurable outcomes, pertinent safety precautions, reportable blood sugar, weight and pain parameters, and allergies in 7 of 7 records reviewed (MR #s 1, 2, 3, 4, 5, 6, and 7), resulting in…

The Agency failed to ensure a discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals in 2 (MR# 1 and 2) of 2 closed records, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care…

The agency failed to maintain a coordinated agency-wide surveillance program for the identification and prevention of COVID-19, resulting in the potential development and spread of a contagious viral infection between agency staff and the agency's 32 current patients.

The agency failed to document education of the COVID-19 virus for 1 of 4 patients (MR# 3) resulting in the potential spread of a contagious viral infection between agency staff and the agency's 100 current patients.

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 3 of 7 records reviewed (M.R.#s 1, 2, 3), resulting in the potential for a POC not meeting the patient's needs, possibly affecting all patients serviced by the Agency.

The agency failed to ensure the home health aide (HHa) plan of care (POC) included safety precautions in 2 of 3 records reviewed (MR# 1, 2) with HHa services ordered, resulting in the potential for injury to all patients receiving aide services.

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 the plan of care included all safety measures to prevent injury and the use of a condom catheter in 2 of 7 records reviewed out of a total sample of 14 active patients (MR #2, 4 ), which resultednin the potential for patient injury.

The agency failed to enure the LPN provided wound care only as ordered by the physician in 1 of 1 records reviewed out of a total sample of 14 active patients in which the patient was treated for wounds (MR #4) which resulted in the potential for deteriorating wound status.

The agency failed to ensure the physical therapist made an on-site visit to the patient's home at least every 14 days to supervise the services that were provided by the home health aide for 1 of 1 (MR#6) records reviewed in which physical therapy supervised aide services, resulting in a lack of…