Great Lakes Home Healthcare Specialists LLC

The Agency (HHA) failed to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided (G-642), failed to initiate any performance improvement activities within their Quality assessment…

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

The agency failed to ensure cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document the agency's efforts in contacting these officials to engage in planning for…

The agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 17 of 17 records reviewed (MR #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) for Emergency Preparedness out of a total sample of 17 records reviewed, resulting…

The agency failed to have policies and procedures for the use of volunteers and other staffing strategies in its emergency plan, resulting in no directives in the event volunteers are utilized during an actual emergency.

The agency failed to develop and maintain contact information for staff, entities providing services under arrangement, patient's physicians and volunteers, resulting in the lack of essential information in the event of an actual emergency for the agency's current 91 patients.

The agency failed to ensure all staff and individuals providing services under arrangement received initial and annual training in the agency's emergency preparedness program.

The agency failed to ensure participation in an exercise to test the emergency plan at least annually; failed to conduct an additional exercise; and failed to analyze the agency's response to all drills, exercises, and emergency events.

The Agency (HHA) failed to develop a Quality Assessment Performance Improvement (QAPI) program that is at least capable of showing measurable improvements in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

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 develop Performance Improvement activities, as part of the Agency's QAPI (Quality Assessment Performance Improvement) program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the…

The agency failed to ensure a home health aide (HHa) received a minimum of 12 in-service hours each 12 month period for 1 of 1 home health aides employed by the agency for more than 12 months (HHa-4), from a total of 2 HHa personnel files reviewed, resulting in a lack of educational opportunities…

It was noted that the agency failed to ensure the home health aide plan of care included a complete list of ordered safety precautions, durable medical equipment and baseline bowel movement dates in 8 of 9 records reviewed (MR#4, 7, 8, 12, 15, 17, 1, 11); and failed to update an aide care plan…

The agency failed to ensure patients were notified of the addresses and telephone numbers of the federally and stated funded entities that serve the areas in which their patients reside which affected 17 out of 17 records reviewed out of a total sample of 17 records reviewed (MR #1, 2, 3, 4, 5, 6…

The agency failed to inform patients of the right to access and how to access auxiliary aids and language services in 17 of 17 records reviewed out of a total sample of 17 records reviewed (MR #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,1 3, 14, 15, 16 and 17).

The agency failed to ensure the plan of care included patient allergies and medical supplies for 2 of 17 records reviewed (MR# 3, 13), from a total sample of 17 records reviewed, resulting in a potential allergic reaction or discomfort for the patient due to use of incorrect medical supplies.

The agency failed to ensure treatments were provided in accordance with a physician's order in 2 of 14 records in which nursing services were provided beyond the start of care visit out of a total sample of 17 records reviewed (MR #13 and 14), which resulted in the potential for the patient to…

The agency failed to ensure professional staff communicated with the physician regarding patient falls, changes in the patient's health status and the need to alter the ordered visit frequencies in 5 of 17 records reviewed (MR# 5, 8, 9, 13, 14), from a total sample of 17 records reviewed, resulting…

The agency failed to ensure patient's were provided with the frequency of visits for each discipline providing care to the patient in 7 of 17 records reviewed out of a total sample of 17 records reviewed (MR# 5, 6, 7, 8, 15, 16 and 17), which resulted in the patient not having knowledge of the…

The agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status including, actual weights for congestive heart failure patients, blood sugars for diabetics and wound size/appearance in 5 of 17 records reviewed in which nursing…

The agency failed to ensure the staff provided visits at the frequency ordered in the plan of care in 6 of 17 records reviewed out of a total sample of 17 records reviewed (MR #1, 5, 8, 13, 14, 16); and failed to ensure wound care was provided as ordered by the physician in 1 of 3 records reviewed…

The agency failed to ensure the home health aide (HHa) provided services at the frequency ordered on the plan of care (POC) for 3 of 9 patients (MR#1, 8 and 12) in which HHa services were provided, from a total sample of 17 records reviewed, resulting in the patient not receiving services as…

It was noted that the agency failed to ensure an on-site home health aide supervisory visit was provided to the patient's home every 14 days in 5 of 9 records reviewed in which there were home health aide services provided (MR #12, 15, 17, 9, and 11), from a total sample of 17 records reviewed…

The agency failed to ensure the written contract for services included language that ensured the home health agency retained overall responsibility for all services provided and failed to specify how supervision would occur for 1 of 1 contracts reviewed (Contract #1) that provided hourly or per…