Help at Home LLC
Inspection 2022-08-15
· Recertification · 57 deficiencies · CMS source report (PDF)The home health agency failed: to develop and maintain an emergency preparedness plan which included a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or…
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The IJ remained unremoved due to the agency's ongoing failure to ensure all plans of care contained wound care orders and failure to coordinate care with other entities to ensure the patients’ needs were met.
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The quality assurance and performance improvement (QAPI) program failed to measure, analyze and track quality indicators and other aspects of performance that enable the agency to assess processes of care, agency services and operations (see tag G642); to monitor the effectiveness and safety of…
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The agency failed to include in its policy a process for tracking and securely documenting the COVID-19 vaccination status of all staff, a process for tracking and documenting the vaccination status of any staff who have obtained any booster doses as recommended by the CDC (Centers for Disease…
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The home health agency failed to ensure the organization and management of the home health agency as follows: the administrator failed to maintain the day-to-day operations of the agency (see tag G0948); the administrator failed to ensure the agency employed qualified personnel (see tag G0952); and…
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The agency failed to ensure the emergency preparedness plan was developed by utilization of a facility-based and community-based risk assessment utilizing an all-hazards approach.
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The agency failed to ensure an emergency preparedness plan was developed and maintained to include a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency.
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The agency failed to develop and implement individualized emergency preparedness plans for the patients which provided appropriate instructions, in the event of an emergency in 2 of 4 home visits.
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The agency failed to ensure a policy included the agency must inform state and local officials of on-duty staff and patients that are unable to be reached in the event of an emergency.
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The agency failed to ensure a policy included a system for medical documentation that preserves patient information, protects patient confidentiality, and secures and maintains availability of records in the event of an emergency.
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The agency failed to ensure a policy included the use of volunteers or other emergency staffing in the event of an emergency.
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The agency failed to ensure the communication plan included names and contact information for patients’ physicians in the event of an emergency.
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The agency failed to develop and maintain an emergency preparedness communication plan which included contact information for Federal and State emergency preparedness officials.
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The agency failed to ensure the communication plan included a method for sharing information and medical documentation for patients under the agency’s care with other health care providers to maintain continuity of care, and in the event of an evacuation, a means of releasing patient information…
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The agency failed to develop and maintain an emergency preparedness communication plan which included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
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The agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures and the communication plan.
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The agency failed to provide and maintain documentation of emergency preparedness training at time of hire and every 2 years for agency personnel.
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The agency failed to conduct exercises to test the emergency plan annually.
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The agency failed to encode and electronically transmit a completed OASIS (Outcome and Assessment Information Set, a comprehensive assessment data collection tool) assessment to the CMS (Centers for Medicare and Medicaid Services) system in 1 of 2 active clinical records reviewed with skilled…
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The agency failed to ensure the OASIS (Outcome and Assessment Information Set, a comprehensive assessment data collection tool) accurately reflected the patient’s status in 1 of 1 active clinical records reviewed with OASIS submissions.
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The agency failed to ensure the comprehensive assessment was updated and revised to include new wounds in 1 of 3 active clinical records reviewed with wounds.
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The agency failed to ensure the discharge/transfer summary included all necessary information pertaining to services received, post-discharge goals of care, and current medications and failed to ensure the summary was sent to the receiving healthcare practitioner in 3 of 3 closed clinical records…
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The agency failed to ensure home health aide services were provided to the patient as directed in the plan of care in 4 of 6 active clinical records reviewed with home health aide services.
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The home health agency failed to measure, analyze and track quality indicators and other aspects of performance that enable the agency to assess processes of care, agency services and operations for all of its locations The findings include: Review of an agency policy revised 1/4/2022, titled…
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The home health agency failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program utilized quality indicator data to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement and failed to ensure the frequency and detail…
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The agency failed to conduct a performance improvement project that reflected the scope, severity and past performance of the agency's services and operations and failed to document the quality improvement project which was conducted, the reasons for conducting the project and the measurable…
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The home health agency failed to ensure all employees practiced standard/universal precautions to prevent the transmission of infections and failed to follow agency infection control policies and procedures in 2 of 4 home visits.
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The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases.
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The agency failed to ensure staff was educated per agency policy on infection control in 12 of 17 personnel records reviewed.
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The home health agency failed to ensure the home health aides had complete, patient-specific written patient care instructions to be performed by the home health aides in 3 of 6 active clinical records reviewed with home health aide services.
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The agency failed to ensure the clinical record was accurate and complete to include the signature, title, and date in 2 of 6 clinical records reviewed with home health aide services.
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The home health agency failed to ensure the patient's protected health information (PHI) was safeguarded against loss or unauthorized use for 1 of 1 random record revealed during the Logansport branch visit tour (#12).
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The agency failed to ensure the patient was provided a written copy of the patient rights in 3 of 6 active clinical records reviewed with home health aide services.
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The agency failed to ensure the patients were provided the name of the administrator to receive complaints in 1 of 2 home visits conducted with the home health aide.
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The agency failed to ensure patients were discharged once goals were met in 1 of 1 closed clinical record reviewed with a discharge reason of goals met.
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The agency failed to ensure complaints made by the patient were documented in 3 of 8 clinical records reviewed with home health aide services.
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The agency failed to ensure the patient’s medication was reviewed to identify any potential adverse effects and drug reactions in 2 of 4 home visits conducted.
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The agency failed to ensure the plan of care was individualized to include medications, frequency of visits, caregiver information, treatments and services, and safety measures in 8 of 8 active clinical records reviewed.
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The agency failed to provide services as only ordered by a physician in 3 of 8 active clinical records reviewed.
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The agency failed to ensure verbal orders were documented and authenticated in 1 of 3 active clinical records reviewed with wounds.
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The agency failed to ensure the plan of care was reviewed by the physician responsible for the plan of care no less than every 60 days in 4 of 8 active clinical records reviewed.
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The agency failed to notify the physician of changes in the patient’s status in 4 of 8 active clinical records reviewed.
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The agency failed to coordinate care with other agencies providing services to the patient in 3 of 3 clinical records reviewed receiving services from another home care agency.
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The agency failed to provide the patient and caregiver in writing with a copy of the visit schedule in 1of 4 home visits conducted.
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The agency failed to provide the patient and caregiver in writing with the treatments to be administered by agency personnel in 2 of 2 home visits conducted with a skilled nurse.
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The agency failed to provide the patient and caregiver in writing with the name and contact information of the clinical manager in 3 of 4 home visits conducted.
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The home health agency failed to ensure the performance improvement activities focused on high risk, high volume, or problem-prone areas.
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The agency failed to ensure the performance improvement activities lead to an immediate correction of any identified problems that directly or potentially threatens the health and safety of patients.
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The skilled nurse failed to provide services as ordered in the plan of care in 4 of 8 active clinical records reviewed.
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The skilled nurse failed to accurately prepare clinical notes in 4 of 8 active clinical records reviewed with wounds.
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The registered nurse (RN) failed to provide supervision of nursing services provided in 1 of 2 active clinical records reviewed with skilled nursing services.
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The home health aide failed to provide services that were ordered by the physician, included in the plan of care, and consistent with the aide care plan in 5 of 6 active clinical records reviewed with home health aide services.
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The home health aide failed to report changes in the patient’s condition to a registered nurse or other appropriate skilled professional in 2 of 3 active clinical records reviewed with wounds.
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The agency failed to ensure the home health aide (HHA) was supervised to ensure the aides furnished care that followed the patient’s plan of care in 4 of 6 active clinical records reviewed with home health aide services.
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The administrator failed to be responsible for the day-to-day operations of the agency.
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The clinical manager failed to ensure the plans of care were implemented in 4 of 6 active clinical records reviewed with home health aide services.
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The agency failed to include clinical notes in the clinical record in 3 of 8 active clinical records reviewed.
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Inspection 2021-05-21
· Complaint, Focused Infection Control, Other-Fed · 12 deficiencies · CMS source report (PDF)The home health agency failed to ensure the plan of care was individualized and followed 5 of 5 records reviewed.
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The home health agency failed to follow accepted standards of practice for screening employees, visitors and patients for COVID-19 in 2 of 2 active patient records reviewed (#1, #2).
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The agency failed to ensure the registered nurse provided a complete care plan for the home health aide [HHA] in 5 of 5 clinical records reviewed (#1, #2, #3, #4, #5).
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The agency failed to ensure all clinical record entries were legible, clear, complete, and appropriately authenticated in 2 of 5 clinical records reviewed (#2, #3).
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The agency failed to ensure the patient was informed of and consented to the changes in the frequency of visits in 1 of 3 discharged records reviewed (#3).
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The agency failed to provide the patient with contact information for other agencies who may be able to provide care in 1 of 3 discharged records reviewed (#3).
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The agency failed to record, track and investigate patient complaints and their resolutions.
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The home health agency failed to meet the patient's needs in 1 of 3 discharged records reviewed (#3).
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The home health agency failed to review identified medication concerns with the physician, in 2 of 3 discharged records reviewed (#3, #4).
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The home health agency failed to ensure the physician was alerted to changes in the patient's condition in 1 of 1 active clinical records reviewed with a hospitalization.
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The home health aide failed to provide services as indicated in the aide care plan in 5 of 5 clinical records reviewed (#1, #2, #3, #4, #5).
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The agency failed to ensure home health aide supervision ensured safe and effective home health aide care in 1 of 1 home visits where the home health aide was observed (#2).
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