Holistic Home Care Home Health, LLC

The agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) for the agency was developed and implemented for all patients and employees.

The agency failed to ensure development, implementation and maintenance of processes and contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials since emergency preparedness plan requirement date of…

The agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to current employee contact information for the agency since emergency preparedness plan requirement date of 11/15/17, for all patients and employees.

The agency failed to ensure the emergency preparedness annual testing and training program was followed for all employees.

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were completed from 05/12/23 to 03/04/25 for all patients and employees.

The agency failed to ensure utilization of QAPI quality indicator data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure performance improvement project documentation for the agency in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure infection prevention practices in the storage of clean and sterile supplies stored on a wire shelving rack against a wall inside of the agency for all patients and employees.

The agency failed to ensure the Infection Control Program surveillance data was included in QAPI program activities for calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure paper clinical records were securely stored for all patients.

The agency failed to ensure advance beneficiary notice and/or HHCOC notice were provided to one (Patient #8) of eight patients.

The agency failed to ensure a medication profile was updated for ordered medications for one (Patient #1) of eight patients.

The agency failed to ensure individualized patient POC included: 1. SN visit frequency and duration of services for two (Patients #1 and #7) of eight patients.

The agency failed to ensure physician orders were a part of the patients’ POCs for two (Patients #2 and #7) of eight patients.

The agency failed to ensure care was coordinated between the agency and physician for three (Patients #4, 5 and #8) of eight patients.

The agency failed to ensure SN assess and monitored the patients pain level every visit and reported pain levels greater than 5 of 10 to the physician for one (Patients #3) of eight 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 a completed discharge summary was provided to receiving service providers for one (Patient #6) of eight patients.

The agency failed to conduct a risk assessment of potential hazards or Hazard Vulnerability Assessment (HVA) at least every two years for the facility, geographical region or community which had the potential to place 35 current patients and staff at risk of not addressing or meeting their needs…

The agency failed to conduct emergency preparedness drills and/or exercises to test the emergency plan based on risk assessment of the facility, patient, staff and community needs which had the potential to place all patients and staff at risk during an actual disaster or weather related event.

The agency failed to identify all medications the patient was currently taking for one (Patient #3) of seven records reviewed.