Lady of Fatima Health Services, Inc.

The agency failed to maintain documentation for review/update of the emergency preparedness plan with all required elements annually until 2019 and every two (2) years thereafter.

The agency failed to base the emergency preparedness plan on/or to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

The agency failed to develop an emergency plan that addressed patient population, including, but not limited to, persons at-risk; the types of services the agency had the ability to provide in an emergency; and continuity of operations, including delegation of authority and succession plans.

The agency failed to demonstrate that the emergency preparedness communication plan included the Names and Contact Information for the following: Staff, Entities providing services under arrangement, Patients' physicians and Volunteers.

The agency failed to establish and maintain an emergency preparedness communication plan that included contact information for local/regional/state/federal emergency preparedness staff.

The agency failed to develop and maintain an emergency preparedness plan training and testing program that was reviewed and updated at least every two (2) years, which includes the time period prior to the Covid-19 pandemic.

The agency failed to ensure visits or a treatment or service as required by the plan of care was conducted as ordered for one (1) of one (1) clinical records (CR) reviewed, (CR#3).

The agency failed to demonstrate the presence of the following: Infection control education provided to staff at periodic intervals consistent with accepted standards of practice.

The agency failed to appoint an alternate administrator and alternate supervising nurse and failed to review and approve the agency's policies and procedures annually in accordance with its policy.

The agency failed to ensure that a reassessment occurred within the last five (5) days of every sixty (60) day recertification period for one (1) of three (3) CRs reviewed, (CR#1).

The agency failed to file clinical notes in accordance with its policy for three (3) of three (3) CRs reviewed, (CR #1, 2, and 3).

The agency failed to conduct Licensed Practical Nurse (LPN) supervisory visits in accordance with its policy for one (1) of three (3) CRs reviewed, (CR #1).

The agency failed to follow its policies to provide documentation of the following: signed job descriptions for three (3) of three (3) PFs reviewed, (PF #1, 2, and 3); Federal Bureau of Investigations (FBI) background check for one (1) of three (3) PFs reviewed, (PF #2); current CPR certification…

The supervising nurse and/or alternate supervising nurse were not available during operational hours Findings include: Upon arrival to agency on May 27, 2025, at approximately 9:15 AM, this surveyor announced that she was there to conduct the Medicare recertification survey and asked if the…

The supervising nurse and/or alternate supervising nurse were not available during operational hours.

The agency failed to complete and/or submit to the physician a discharge summary for two (2) of two (2) discharged CRs, (CR #2 and 3).

The agency failed to ensure a Home Health Aide, (HHA), received 12 Hours of in-service during each 12 month period.

The agency failed to provide supervision and performance evaluations for the License Practical Nurses, (LPN), working in the community for two (2) of two (2) License Practical Nurses' Personnel Files, (PF), reviewed.

The agency failed to to document an individualized care plan, with pertinent diagnosis, frequency and duration of visits made, Prognosis, all medications and treatments, and all orders for, two, (2), of three, (3), Clinical Files,(CF), reviewed.

The agency failed to ensure a Home Health Aide, (HHA), received 12 Hours of in-service during each 12 month period, or to demonstrate that a training program exists for required training.

The agency failed to implement, evaluate and maintain an effective, ongoing, Home Health Agency-wide, data-driven QAPI program.

The agency failed to organize, manage and administer its resources to attain and maintain the highest practicable functional capacity including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing and rehabilitative…

The facility failed update the emergency preparedness plan's names and contact information for agency staff.

The agency failed to include documentation of any unannounced drills, tabletop exercise, emergency drills or participate in a full-scale community-based exercise.

The Facility failed to follow their policy regarding transmitting OASIS (Outcome Assessment Information Set) Transfer Assessments for two (2) of four (4) clinical records (CR) examined.

Agency failed to have QAPI program showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

Agency failed to utilize quality indicator data, including measures derived from OASIS (The Outcome and Assessment Information Set), where applicable, and other relevant data, in the design of its program; failed to use the data to- (i) monitor the effectiveness and safety of services and quality…

The agency failed to maintain documentation to demonstrate performance improvement projects conducted annually at the HHA (home health agency).

The agency's governing body failed to define and implement an ongoing QAPI (quality assessment and program improvement) program for the purpose of quality improvement and patient safety; failed to ensure the HHA's (home health agency) QAPI efforts addressed priorities for improved quality of care…

The agency failed to ensure a CLIA waiver was obtained prior to drawing blood glucose levels for diagnostic purposes for two (2) of four (4) clinical records (CR) reviewed.

The governing body did not assume full legal authority and responsibility for the agency's overall management and operation and its quality assessment and performance improvement program.

In reviewing the Pennsylvania Deparment of State Online Licensing System Verification service on 6/18/19 at approximately 1:45 P.M with the office manager it was revealed that the Adminstrator/supervising nurse failed to start the renewal license application until 5/15/19 (after license was already…

The agency failed to ensure the licensed practical nurse (LPN) to be registered in the state where practicing for one (1) of three (3) LPN files.

An interview with the office manager the agency failed to ensure weekly wound measurements were obtained for one (1) of four (4) clinical records reviewed (CR# 3) and the agency failed to communicate with the physician regarding change in patient's condition for one (1) out of four (4) clinical…

An interview with the office manager the agency failed to ensure a registered nurse to complete the initial evaluation assessment for two (2) of four (4) clinical records reviewed (CR #1 & 4) and The agency failed to ensure a registered nurse complete the recertification assessment for three (3) of…

The agency failed to ensure that a comprehensive assessment included a review of all medications that the patient was currently using in order to identify any potential adverse effects, drug reactions, significant side effects, significant drug interactions, ineffective drug therapy and…

The agency failed to ensure that a written summary report was completed and sent to the attending physician at least every 60 days for four (4) of four (4) clinical records (CR) reviewed (CR# 1, 2, 3 & 4).

The agency failed to ensure a visit frequency was listed on the Plan of Care, for three (3) out of four (4) clinical records reviewed (CR #1, 2, & 3) and Findings include: Agency policy titled "Patient plan of care" was reviewed on 6/19/19 at approximately 12:00 P.M. which stated, "The Plan of Care…

The agency failed to ensure all nursing visit documentation was maintain in the chart/the physician was notified of any missed visits for four (4) out of four (4) clinical records reviewed.

In reviewing the Pennsylvania Deparment of State Online Licensing System Verification service on 6/18/19 at approximately 1:45 P.M with the office manager it was revealed that the Adminstrator/supervising nurse failed to start the renewal license application until 5/15/19 (after license was already…

The agency administrator failed to follow the agency's personnel requirements of orientation, job description, criminal background checks, annual performance evaluations, and failed to have each a current license maintained for each individual holding a professional license and the agency did not…

The agency failed to ensure a qualified person shall be authorized in writing to act in the absence of the administrator and the adminstrator.

The agency failed to ensure a qualified person shall be authorized in writing to act in the absence of the administrator and the adminstrator.

The agency failed to ensure that a transfer summary was completed within 2 business days of becoming aware of an unplanned transfer if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer for two (2) of two (2) clinical records (CR) of…