Hometown Home Healthcare Inc

The home health agency failed to develop and implement EP policies and procedures to address potential hazards identified in its risk assessment (see E0013), develop and implement EP policies and procedures which indicated the agency’s system of medical documentation during an emergency (see…

The home health agency failed to develop and implement EP policies and procedures to address potential hazards identified in its risk assessment, which had the potential to affect all active patients and employees.

The home health agency failed to develop and implement EP policies and procedures which indicated the agency’s system of medical documentation during an emergency, which had the potential to affect all active patients.

The home health agency failed to develop and implement EP policies and procedures which addressed the use of volunteers in an emergency or other emergency staffing strategies, which had the potential to affect all active patients.

The home health agency failed to develop and maintain an EP communication plan which included names and contact information of staff and patients’ physicians, which had the potential to affect all active patients and staff.

The home health agency failed to develop and maintain an EP communication plan which included contact information for Federal, State, regional, and local EP staff, which had the potential to affect all active patients and staff.

The home health agency failed to develop and maintain a communication plan which included a method for sharing information and medical documentation for patients under agency’s care with other health care providers, which had the potential to affect all active patients.

The home health agency failed to conduct exercises to test its EP plan annually, which had the potential to affect all agency patients and staff.

The home health agency failed to transmit all OASIS assessments within 30 days of the assessment for 1 of 1 transmission on 08/04/2025 (Patient #3).

The home health agency failed to ensure all staff followed agency policies and best practice specific to infection control for 2 of 4 home visit observations conducted (HHA 1, CM).

The home health agency failed to ensure the HHA was accurately documenting which tasks were performed and which were refused by the patient for 1 of 4 active patients who had home visit observations (Patient #4).

The home health agency failed to provide a written notice of the patient’s rights and responsibilities for 1 of 2 home visit observations where the home folder was observed (Patient #4).

The home health agency failed to ensure the Patient received all services ordered in the POC for 1 of 2 active patient records reviewed of patients who received both SN and HHA services (Patient #1).

The home health agency failed to advise the patient nor the patient’s ordering provider that a discharge for cause was being considered for 1 of 1 closed record reviewed of a patient discharged for cause (Patient #9).

The home health agency failed to make and document efforts to resolve the problem which could result in a discharge for cause for 1 of 1 closed record reviewed of a patient discharged for cause (Patient #9).

The home health agency failed to ensure a comprehensive assessment was completed within five days after the SOC for 6 of 6 active patients admitted in 2024 or later (Patient #1, 2, 4, 5, 6, 7).

The home health agency failed to ensure the comprehensive assessment included patient goals for 7 of 8 patient records reviewed where the comprehensive assessment was reviewed for patient goals (Patient #1, 2, 3, 4, 5, 6, 7, 8).

The discharge comprehensive assessment failed to include patient progress toward goals for 3 of 3 closed records reviewed (Patient #8, 9, 10).

The home health agency failed to ensure the POC included ongoing interventions to mitigate the risk of emergency department visits and re-hospitalizations and failed to ensure the POC did not include contradicting service frequencies for 8 of 8 patients whose POCs were reviewed (Patient #1, 2, 3…

The home health agency failed to ensure provider orders were obtained prior to providing services to the patient for 3 of 8 patient records where orders for services were reviewed (Patient #2, 4, 8).

The home health agency failed to ensure verbal order documentation included the date the order was received, time the order was received, and the person who provided the verbal order for 2 of 7 active records reviewed (Patient #6, #7).

The home health agency failed to alert the physician of the need to modify the POC for 3 of 7 active patient records reviewed (Patient #2, 4, 7).

The home health agency failed to ensure the recertification POC included the patient’s progress toward their goals for 7 of 7 active patient records reviewed (Patient #1, 2, 3, 4, 5, 6, 7).

The home health agency failed to ensure all HHAs completed visit documentation according to agency policies and procedures for 1 of 3 active records reviewed of patients who received services from HHA 5 (Patient #6).

The home health agency failed to supervise HHAs at least every 14 days for 2 of 2 active patients who received both SN and HHA services (Patient #1, 2).

The home health agency failed to ensure aide supervisory visit notes included all required information for 6 of 7 patients whose aide supervisory visit notes were reviewed (Patient #1, 2, 4, 5, 6, 8).

The home health agency failed to ensure the SOC date on the POC was accurate for 6 of 6 active patients admitted since the last recertification survey (Patient #1, 2, 4, 5, 6, 7).

The home health agency failed to ensure the discharge summary was sent to the responsible provider for 3 of 3 closed patient records reviewed (Patient #8, 9, 10).

The home health agency failed to ensure the patient received all HHA services as ordered in the plan of care for 4 of 5 records reviewed (Patient #2, 3, 4 and 5).

The home health agency failed to ensure staff followed agency infection control policies and procedures related to hand hygiene for 1 of 1 home visit observation performed (HHA #1).

The home health agency failed to ensure all entries in the clinical record were appropriately authenticated, dated and timed for 4 of 5 patient records reviewed (Patient #2, 3, 4 and 5).

The home health agency failed to ensure the POC included accurate medications the patient is taking for 3 of 4 active records reviewed with SOC in the past 6 months (Patient #1, 2 and 3).

The home health agency failed to document ROC orders were received from the attending practitioner for 1 of 1 active record reviewed with a ROC (Patient #2).

The home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 3 of 4 patient records reviewed who were admitted within the past 6 months (Patient #2, 3 and 4).

The home health agency failed to review the POC with the attending practitioner during the ROC for 1 of 1 active record reviewed with a ROC (Patient #2).

The home health agency failed to ensure the physician or allowed practitioner was promptly notified of the need to alter the POC related to missed visits for 4 of 5 patient records reviewed (Patient #2, 3, 4 and 5).

The home health agency failed to follow their own policy and failed to ensure the Plan of Care was followed for 2 of 2 active clinical records reviewed receiving skilled nursing services (Patient #1 and 9).

The home health agency failed to ensure all clinical records were safeguarded against loss or unauthorized use for 1 of 2 home visit observations (Patient #5) and 1 of 1 clinical manager office observation (Patients #5, #12, #13, and #15).

The agency’s Governing Body failed to approve the frequency and detail of data collection for the agency’s quality analysis and performance improvement (QAPI) program, which had the potential to affect all agency staff and patients.

The home health agency failed to ensure its quality assessment and performance improvement (QAPI) program measured, analyzed, and tracked quality indicators and failed to evidence measurable improvement in quality indicators which would improve patient health outcomes, safety, and quality of care…

The home health agency failed to ensure all staff followed accepted standard precautions and agency policies and procedures to prevent the transmission of infectious and communicable diseases (see G682) and failed to maintain an agency-wide program for the surveillance, identification, prevention…

The home health agency failed to ensure its quality assessment and performance improvement (QAPI) program measured, analyzed, and tracked quality indicators and failed to evidence measurable improvement in quality indicators which would improve patient health outcomes, safety, and quality of care…

The home health agency failed to ensure its quality assessment and performance improvement (QAPI) program conducted at least one performance improvement project (PIP) each calendar year depending on the scope, complexity, and past performance of the agency’s services and operations, which included…

The home health agency’s governing body failed to ensure an ongoing program for its quality improvement and patient safety was maintained, failed to ensure the agency-wide quality assessment and performance improvement (QAPI) efforts addressed priorities for improved quality of care and patient…

The home health agency failed to ensure all staff followed accepted standard precautions and agency policies and procedures to prevent the transmission of infectious and communicable diseases for 1 of 3 staff members observed during a home visit (Home Health Aide #2).

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases which is an integral part of the agency’s quality assessment and performance improvement (QAPI) program, which had the…

The Registered Nurse (RN) failed to prepare a detailed and patient-specific home health aide (HHA) care plan for 2 of 5 active records reviewed (Patient #2 and 5).

The home health agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health and psychosocial status for 2 of 5 active records reviewed (Patients #2 and 5).

The home health agency failed to ensure the comprehensive assessment contained a medication list which included indication for administration for as-needed (PRN) medications for 1 of 5 active records reviewed (Patient #2).

The home health agency failed to ensure the comprehensive assessment completed at the time of discharge accurately reflected the patient’s current wound status for 1 of 1 discharge records reviewed of a patient with a wound (Patient #6).

The agency failed to ensure and follow their own policy and include within the Plan of Care all required elements for 7 of 7 patient records reviewed (Patient #1, 2, 3, 4, 5, 6, and 7).

The home health agency failed to notify the patient’s physician of missed visits according to agency policy and failed to promptly obtain clarification orders for discrepancies regarding the patient’s medications for 2 of 5 active records reviewed (#2, 5).

The home health agency failed to ensure its quality assessment and performance improvement (QAPI) program took actions aimed at performance improvement which focused on high risk, high volume, or problem-prone areas, which had the potential to affect all agency patients and employees.

The agency failed to ensure home health aides provided services as ordered in the care plan for 3 of 5 active patient records reviewed (Patient #2, 3, 4).

The agency failed to ensure all their Infection Control Policies were updated to the latest CDC recommendations for the Corona Virus (COVID-19) pandemic for 1 of 1 agency.

The agency failed to ensure all staff followed infection control policies and standard precautions for 1 of 3 home visits.

The registered nurse (RN) failed to ensure that an aide care plan was completed for each shift for the home health aide (HHA) and failed to ensure that the aide care plan was individualized, and failed to ensure that the aides followed the aide care plan for 3 of 5 records reviewed of patients who…

The agency failed to ensure clinical records were secure at all times to maintain the privacy of patient information in the agency's branch office for 1 of 1 agency.

The registered nurse (RN) failed to ensure the comprehensive assessment was accurate and contained specific current health status for 2 of 7 patient records reviewed (#1,3).

The registered nurse (RN) failed to ensure that the comprehensive assessment contained individual patient strengths for 7 of 7 patient records reviewed (#1, 2, 3, 4, 5, 6, 7).

The agency failed to ensure the plan of care (POC) included measurable goals, home health aide (HHA) visit frequencies, diagnoses, safety measures, specific medication and treatment directions, and durable medical equipment (DME) for 7 of 7 records reviewed (#1, 2, 3, 4, 5, 6, 7).

The agency failed to ensure a written visit schedule was provided to the patient and caregivers for 2 of 3 home visits observed (#2, 3).

The agency failed to ensure that a medication list was provided to the patient and was put into laymans terms that were easy for the patient to understand for 2 of 3 home visits observed (#2,3).

The clinical manager agency failed to ensure all members on the health care team coordinated care with other agencies who also provided care for the patient for 2 of 7 patients reviewed (#3, 7).

The agency failed to ensure all members on the health care team had a written agreement for care with other agencies who provided care for 2 of 7 patient (#3, 7).

The plan of care failed to evidence patient identified-goals for 7 of 7 patient records reviewed (#1, 2, 3, 4, 5, 6, 7).