Lifeline Home Health Inc

The agency failed to assure that the Emergency Preparedness Plan (EPP) was reviewed and updated every two (2) years.

The agency failed to demonstrate that the EPP was developed using a facility-based and community-based all-hazards risk assessment approach.

The agency failed to demonstrate that emergency preparedness training was provided every two (2) years for eight (8) of twelve (12) PF's reviewed: PF#1, PF#2, PF#3, PF#5, PF#6, PF#7, PF#9, and PF#10. Findings include: The agency owner, in an interview conducted on August 15, 2023 at approximately…

The agency failed to provide evidence that the emergency preparedness plan was tested annually.

The agency failed to transmit OASIS (Outcome and Assessment Information Set) Reports to the CMS (Centers for Medicare and Medicaid Services) system.

The home health agency (HHA) failed to assure that a comprehensive assessment was documented by a registered nurse for one (1) of four (4) records reviewed: CR#2. Findings Include: A review of the home health agency's policy - Professional and Ancillary Services - was conducted on August 17, 2023…

The home health agency (HHA) failed to assure that the comprehensive assessment accurately reflected the patient's status and included minimal information pertinent to the assessment.

The HHA failed to demonstrate the involvement in and responsibilities of the governing body in the quality assurance performance improvement program (QAPI).

The agency failed to demonstrate the presence of systematic data collection and monitoring for infections, and failed to present the results of the data collection to the governing body.

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 demonstrate the presence of the following: · A minimum of 75 hours of classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a…

The agency failed to demonstrate the presence of the following: The HHA (Home Health Aide) 12 hours in-service training during each 12-month period for three (3) of four (4) files reviewed: PF# 9, 10, 12. Findings include: A review of personnel files (PF) was conducted on August 15, 2023, starting…

The home health agency (HHA) failed to demonstrate that one of the two services provided by the HHA (Skilled Nursing and Home Health Aide) was a direct service.

The agency failed to provide the patient with the names, addresses and telephone numbers of the following Federally funded and State funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center…

The agency failed to complete a comprehensive assessment within five (5) days of the end of the certification period for four (4) of four (4) CR's reviewed: CR#1, CR#2, CR#3, and CR#4. Findings Include: A review of the following policy - Professional Plan of Care - conducted on August 17, 2023…

Code §601.31 Acceptance of Patients, Plan of Treatment and Medical Supervision (d)Conformance with Physician Orders, and an interview with the administrator and agency owner, the home health agency (HHA) failed to assure authentication of verbal orders within thirty (30) days from receipt of the…

The home health agency (HHA) failed to assure that the plan of care was reviewed and revised by the physician no less frequently than once every sixty (60) days.

The agency failed to demonstrate the presence of the following: · Initial competency evaluation for five (5) of twelve (12) files reviewed: PF# 4, 8, 9, 11, 12. · Annual competency evaluation for five (5) of twelve (12) files reviewed: PF# 1, 2, 3, 5, 7. · Annual performance evaluation for four (4)…

The home health agency (HHA) failed to maintain a clinical record that included all of the clinical notes for two (2) of four (4) CR's reviewed: CR#2 and CR#4. Findings include: A review of the home health agency's (HHA) policy manual conducted on August 17, 2023 at 10:00 AM found a policy titled…