Gentle Shepherd Home Health, Incorporated

The agency failed to ensure development, implementation and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees.

The agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff.

The agency failed to ensure evidence of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for calendar years 2022 and 2023 for all patients and employees.

The agency failed to ensure governing body oversite of: 1. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2022 and 2023; and 3. Agency program evaluation for calendar years 2022 and 2023 effecting all…

The agency failed to: 1. Educate the patient on potential health outcomes related to refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance and; 2. Notify the physician of the patient's continued refusal of and/or missed SN visits prior to the…

The agency failed to ensure documentation of investigation and resolution of a complaint with a patient’s representative/family member for one (Patient #15) of 12 patients.

The agency failed to ensure individualized patient POCs included: 1. Pain reporting parameters for physician notification and related SN goals for five (Patients #2, 4, 6, 10 and 11) of 12 patients and; 2. Identified wound site for SN wound site management and interventions for one (Patients #3) of…

The agency failed to ensure physician orders were a part of the patients’ plans of care for: 1. SN to provide monthly catheter changes and indwelling urinary catheter management for one (Patient #3) of 12 patients; 2. SN to administer daily medications and perform SN interventions to change…

The agency failed to ensure: 1. Physician ordered wound site care dressing materials for two (Patients #3 and #6) of 12 patients and; 2. OT evaluation and treatment plan for one (Patient #6) of 12 patients.

The agency failed to ensure coordination of care with facility care staff for one (Patient #5) of 12 patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure certified home health aide supervisory visits were completed every 14 days for two (Patients #2 and #4) of 12 patients.

The agency failed to ensure SN visit note documentation was complete for three (Patients #3, 5 and #6) of 12 patients.

The agency failed to ensure a completed transfer/discharge summary was provided for one (Patient #10) of 12 patients.

The agency failed to ensure governing body over-site of the operating budget and allocation of resources for fiscal years 2019 and 2020 for 142 patients and all agency staff.

The agency failed to ensure: 1. SN provided wound care as ordered for one (Patient #7); 2. SN visits were conducted as ordered for one (Patient #7); and 3. Occupational Therapy evaluation was completed for one (Patient #10) of 10 patients.

The agency failed to notify the physician of changes in health conditions for one (Patient #5) of 10 patients.

The agency failed to ensure discharge summaries were completed timely and were available for three (Patients #1, #2 and #3) of three patients.

The agency failed to ensure wound care was provided by SN services in accordance with physician orders for one (Pt #2) of seven patients.

The agency failed to ensure SN provided complete clinical documentation for one (Pt #3) of seven patients.