Hand in Heart Home Health Inc

The CONDITION OF PARTICIPATION (COP) is not met when the Home Health Agency (HHA) failed to: G0572: Ensure the plan of care included all of the durable medical equipment (DME).

The CONDITION OF PARTICIPATION (COP) is not met when the Home Health Agency (HHA) failed to: G0942: Establish a continuous quality program that specifies the detail of data collected and shows verifiable improvement.

The CONDITION OF PARTICIPATION (COP) is not met when the Home Health Agency (HHA) failed to: G1012: Ensure the clinical record accurately reflected the patient's medical condition.

The home health agency (HHA) failed to ensure: Missed skilled home visits were documented in the clinical records (CR) for four of nine sampled patients (Patient 1, 3, 5, and 7).

The home health agency (HHA) failed to provide a plan of care (POC – information identified based upon the patient identified needs and development of appropriate interventions) for three of nine sampled patients (Patients 7, 8, and 9).

The home health agency’s (HHA) governing body (GB) failed to establish a continuous quality program that specified the detail of data collected and show verifiable improvement.

The home health agency (HHA) failed to ensure clinical records for one of nine patients (Patient 3) was retained and not erased.

The home health agency (HHA) failed to ensure communication with the physician was documented in the clinical records for three of nine patients (Patients 5, 7 & 8) when: One patient (Patient 5) refused occupational therapy services (OT).

The home health agency (HHA) failed to ensure accurate documentation of Patient 3’s death.

The home health agency (HHA) failed to review, reconcile, and provide an accurate medication list for one of nine sampled patients (Patient 9).

The agency failed to ensure physician verbal orders were signed timely for one of the nine sampled patients (Patient 4).

The home health agency (HHA) failed to ensure the written visit schedule and frequency of visits provided to the patient were consistent with the most recent plan of care (POC) for one of nine sampled patients (Patient 3).

The home health agency (HHA) failed to ensure: 1. Three of five employees' (Case Manager [CM], Director of Patient Care Services [DPCS] and Certified Home Health Aide [CHHA]) personnel files contained signed job descriptions.

The home health agency (HHA) failed to ensure the governing board (GB) designated an administrator designee.

The home health agency (HHA) failed to ensure that factual information in patient care and services were coordinated among clinicians for one of nine sampled patient (patient 3).

The home health agency (HHA) failed to ensure the clinical record accurately reflected one of three patient's (Patient 3) medical conditions, including vital signs (essential body functions i.e., heartbeat, temperature, blood pressure, breathing rate), cognitive (mental) status, and respiratory…

The home health agency (HHA) failed to ensure the reason for discharge for one of the three sampled patients (patient 3) was accurately documented in the clinical record.

The agency failed to ensure the patient (Patient 1) and Patient 1's family were assisted promptly in arranging a safe and appropriate transfer to another home health agency or other entities when the initial admission assessment cannot be done for Patient 1. This failure resulted in Patient 1 not…

The agency failed to notify the prescriber for approval of changes in the plan of care when an initial assessment for one patient (Patient 1) was not completed within 48 hours of referral.