Inspiring Care at Home

The Governing Body failed to develop, implement, evaluate, and maintain an ongoing, agency-wide QAPI program that measured, analyzed, and tracked measurable and data-driven quality indicators, including adverse events, for health, safety, agency operations, and quality of care (G642); failed to use…

The agency failed to provide initial emergency preparedness training for existing staff for 4 of 4 personnel records reviewed (Administrator/DON, Alternate Administrator/Alternate DON, HHA 1, and HHA 2/Owner).

The agency failed to analyze and document the agency's response to the tabletop drill for 1 of 1 home health agency.

The agency failed to ensure each patient received an OASIS Privacy Notice for 1 of 1 agency admission packets reviewed.

The agency failed to ensure the admission packet contained the state department of health complaint hotline number for 1 of 1 agency admission packet reviewed.

The agency failed to provide services as ordered by the physician for 2 of 4 clinical records reviewed with patients receiving SN and HHA services (Patient #5 and 8) and for 2 of 5 clinical records reviewed with patients receiving wound care (Patient #6 and 12).

The agency failed to ensure the physician was notified of the need to alter the POC for 3 of 5 clinical records with patients receiving wound care (Patient #6, 7, and 12) and for 1 of 1 inactive clinical records reviewed with a patient receiving SN and HHA services (Patient #8).

The agency failed to ensure the HHAs were supervised and included all the necessary elements for 4 of 4 clinical records reviewed with patients receiving HHA services (Patients #1, 4, 5, and 8).

The agency failed to ensure a transfer summary was completed for a patient transferred to another provider for 2 of 2 clinical records reviewed with patients hospitalized (Patient #4 and 8), and failed to ensure a discharge summary was completed and contained all the necessary elements for 5 of 5…