Good Shepherd Home Health Services

The home health agency (HHA) failed to meet the Condition of Participation of Patient Rights.

The home health agency (HHA) failed to develop a process for cooperation and collaboration with Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency event.

The home health agency (HHA) failed develop procedures to follow up with on-duty staff and patients to determine services that were needed in the event that there was an interruption in services during or due to an emergency and failure to develop a procedure to inform State and local officials of…

The home health agency (HHA) failed to develop a policy that addressed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records during a disaster.

The home health agency (HHA) failed to ensure the HHA's communication plan included contact information for Federal emergency preparedness officials.

The home health agency (HHA) failed to ensure the communication plan included a method for sharing information and medical documentation for patients under the HHA's care with other health providers to maintain the continuity of care and the means of providing information about the general…

The home health agency (HHA) failed to develop a procedure for providing information about the HHA's occupancy, needs, and its ability to assist the authority having jurisdiction, the Incident Command Center, or designee during a disaster.

The home health agency (HHA) failed to ensure all staff received emergency preparedness training annually as required by the agency's policy and failed to maintain documentation of all emergency preparedness training.

The home health agency (HHA) failed to ensure each patient received the home health services that were written in an individualized plan of care which was established by a physician for three (Patient (P) 2, P14, P15) of 13 patients reviewed for notification of the physician of missed visits from a…

The home health agency (HHA) failed to have documentation of the reason quality improvement projects were undertaken and the measurable progress achieved on the projects.

The home health agency (HHA) failed to ensure HHA infection control policies included specific procedures for disinfecting noncritical items and failed to ensure clinical staff used standard precautions to prevent the transmission of infections and communicable diseases as observed during two…

The home health agency (HHA) failed to maintain an agency-wide program for the prevention, control, and investigation of infectious and communicable diseases.

The home health agency failed to provide infection control education to all staff annually in accordance with the HHA's infection control training policy.

The Home Health Agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based electronic medical record (EMR).

The home health agency (HHA) failed to ensure patients were free from verbal, mental, sexual, and physical abuse for one (Patient (P) 8) of one patient whose record was reviewed for a grievance from a sample of four grievances reviewed for the period of 01/01/24 through 12/31/24. The HHA failed to…

The home health agency (HHA) failed to implement its grievance policy by failing to provide written notice to the patient/caregiver of the investigation and resolution of the grievance for four (Patient (P) 5, P6, P7, P8) of four grievances reviewed for the period of 01/01/24 through 12/31/24. This…

The home health agency (HHA) failed to ensure grievances submitted by patients or caregivers were investigated for two (Patient (P) 5, P8) of four grievances reviewed for the period of 01/01/24 through 12/31/24. This deficient practice had the potential to affect all patients/caregivers who…

The home health agency (HHA) failed to implement action to prevent further potential violations, including retaliation, while an allegation of abuse was being investigated for one (Patient (P) 8) of one patient record reviewed for a grievance with an allegation of abuse from a sample of four…

The home health agency (HHA) failed to ensure a registered nurse (RN) conducted an initial assessment to determine the care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status for Medicare patients, within 48 hours of…

The home health agency (HHA) failed to ensure services and treatment were administered only as ordered by the physician for one (Patient (P) 11) of four home visits observed and for three (P1, P9, P15) of 13 patient electronic medical records (EMR) reviewed for implementation of physician orders…

The home health agency (HHA) failed to ensure staff who provided patient care were communicating with others involved in the patient's care to assure patient concerns and patient progress toward the goals identified in the plan of care were communicated for continuity of care for four (Patient (P)…

The home health agency (HHA) failed to ensure each patient and/or caregiver were provided with a copy of written instructions of medications (medication profile) that was kept current with medications in the home for one (Patient (P) 10) of two medication profiles reviewed during four home visits…

The Home Health Agency (HHA) was not in compliance with the rules regarding safeguarding and preventing the risk of loss and/or unauthorized use of patients' protected health information (PHI).

The Home Health Agency (HHA) failed to provide 1 of 3 patients, (Patient (P)8), reviewed during home visits, with a current medication list that included instructions the patient and caregiver could understand.

The facility failed to meet the Condition for Participation (COP) 484.102 for Emergency Preparedness when, the facility failed to develop and implement emergency policies and procedures based on the emergency preparedness plan.

The Home Health Agency (HHA) failed to develop an emergency preparedness plan that included a community based risk assessment, utilizing an all-hazards approach.

Staff interview the Home Health Agency (HHA) failed to develop an emergency preparedness plan that included addressing the patient/client population, including, but not limited to the type of service the agency was able to provide in an emergency and continuity of operations, including delegations…

The Home Health Agency (HHA) failed to develop and implement policies and procedures to inform State and local emergency preparedness officials about the HHA patients clinical condition to facilitate the patient's evacuation and transportation needs during an emergency.

The agency failed to develop and implement an emergency preparedness plan that included notifying the State and local authorities of an on-duty staff that the Home Health Agency (HHA) was unable to be contacted during an emergency.

The Home Health Agency (HHA) failed to develop a policy and procedures addressing a communication plan that included a process for sharing patient information and medical documentation with other health care providers for continuity of care in the event of an emergency.

The agency failed to conduct drills to test the emergency preparedness plan and to include all staff employed or contracted by the Home Health Agency (HHA).

The Home Health Agency (HHA) facility failed to develop an emergency preparedness plan that included initial and annual training for staff.

The agency failed to ensure medical records were complete for 4 of 18 sampled patients (Patient (P)1, P3, P4 and P11).

The agency failed to ensure that Cardio-Pulmonary Resuscitation certification (CPR) was up to date for 1 of 5 sampled contracted Occupational Therapist (OT)8. This deficient practice had the potential to allow staff to care for patients without the proper credentials to provide safe care.

The agency failed to ensure that Cardio-Pulmonary Resuscitation certification (CPR) was up to date for 1 of 5 sampled contracted Physical Therapist (PT)2. The agency further failed to ensure professional licensure was not expired for 2 of 5 sampled contracted PT's, (PT3 and PT10).

The agency failed to ensure that 5 of 5 sampled contracted Physical Therapists (PT), Physical Therapist Assistant (PTA), and Occupational Therapists (OT) (PT2, PT3, OT8, PTA9, and PT10) had attended the agency's in-services and trainings.