Mareli Home Care, LLC

The Agency failed to develop an emergency preparedness plan that must be reviewed, updated, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The agency failed to have a Quality Assurance Performance Improvement program that measured, tracked and analyzed quality indicator data for the purpose of showing improvement in health outcomes, patient safety and quality of care (See G642); failed to collect and use quality indicator data to…

The Physical Therapist failed to utilize professional standards during ambulation for 1 (MR #2) of 1 patient observed during a Therapy home visit, resulting in the potential for fall with injury (G704); failed to ensure the Physical Therapist performed reassessments of a patient's oxygen level for…

The Agency failed to develop an emergency preparedness plan that must be reviewed, updated, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor patient and staff…

The Agency failed to develop and maintain a communication plan for emergency preparedness that included strategies for the global Covid-19 pandemic, resulting in the inability to communicate with staff and officials in the event of an actual disaster, and the potential for uncoordinated care for…

The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 12 patients currently…

The Agency failed to provide evidence of initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared…

The Agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency.

The agency failed to have a Quality Assurance Performance Improvement program that measured, tracked and analyzed quality indicator data for the purpose of showing improvement in health outcomes, patient safety and quality of care that had the potential to affect all 50 patients served in the past…

The agency failed to collect and use quality indicator data to monitor the effectiveness and safety of services, and identify opportunities for improvement which affected all 50 patients admitted for services in the past 12 months, resulting in the potential for poor patient outcomes or patient…

The agency failed to have any performance improvement projects documented, with the reason the project was selected and the measurable progress achieved, as part of their QAPI program which had the potential to negatively affect all 50 patients admitted in the past 12 months, resulting in the…

The Physical Therapist failed to utilize professional standards during ambulation for 1 (MR #2) of 1 patient observed during a Therapy home visit, resulting in the potential for fall with injury.

The Agency failed to ensure that patient records were safeguarded against loss, theft or misuse resulting in the potential for theft and unauthorized use of protected health information for all current and past patients serviced by this agency. findings include: On 9/29/21 at 9:50 a.m., upon…

The Agency failed to include contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed concerns for all patients serviced by this agency.

The registered nurse failed to review the patients medications and complete a drug regime review in 1 of 1 records in which the patient was admitted by a Physical Therapist out of a total sample of 7 records reviewed (MR #4), resulting in the potential for adverse medication reactions.

The Agency failed to ensure the plan of care included all treatments, services, reportable parameters and measurable goals in order to meet the needs of the patient for 6 (MR's #2, 3, 4, 5, 6, and 7) records, from a total of 7 sampled records reviewed, resulting in the potential for unmet patient…

The agency failed to have an ongoing Quality Assessment Performance Improvement program that was based on high risk, high volume and problem prone areas which had the potential to affect all 50 patients admitted in the past 12 months, resulting in the potential for poor patient outcomes and patient…

The agency failed to have an ongoing Quality Assessment Performance Improvement program that considered incidence, prevalence and severity of problems identified, which had the potential to affect all 50 patients admitted for services in the past 12 months, resulting in poor patient outcomes and…

The agency failed to have a Quality Assessment Performance Improvement program that would ensure an immediate correction of any identified problem that would directly or potentially threaten the health or safety of patients, which had the potential to affect all 50 patients admitted for services in…

The agency failed to document any actions taken to improve performance, measurement and tracking of quality indicator data to ensure improvements are sustained which had the potential to affect all 50 patients admitted in the past 12 months, resulting in the potential for poor patient outcomes or…

The agency failed to ensure the Physical Therapist performed reassessments of a patient's oxygen level for 1 (MR #2) of 1 patient observed during a therapy home visit; and failed to ensure the Registered Nurse performed re-assessments of the patient's edema in 1 (MR #3) of 1 record of a patient…

The Agency failed to ensure Occupational Therapy services were provided for 1 (MR #3) of 1 patient in which Occupational Therapy services were ordered, resulting in the potential for physical decline, and unmet care needs.

The agency failed to ensure that a discharge summary was completed, detailed the course of care and the status at the time of discharge for 2 (MR #1 and #4) of 2 patients who were discharged from the agency, resulting in lack of the clear clinical picture needed by the Physician in order to…