Massachusetts Care Services Inc

The HHA failed to establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements, to be reviewed and updated at least annually.

The Home Health Agency (HHA) failed to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program including the HHA's governing body ensuring that the program reflected the complexity of its organization and services; involved all HHA services (including…

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements. . Findings include: The HHA's alternate administrator was interviewed on 9/11/19 at 9:40 A.M. and said the HHA…

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop a written emergency plan including a process for cooperation and collaboration with local, regional, tribal, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of…

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain an emergency preparedness communication plan to comply with all applicable federal, state and local laws to be reviewed and updated at least annually.

The HHA failed to develop, establish and maintain an emergency preparedness communication plan to comply with all applicable federal, state and local laws to be reviewed and updated at least annually.

The HHA failed to develop, establish and maintain an emergency preparedness communication plan to comply with all applicable federal, state and local laws to be reviewed and updated at least annually.

The HHA failed to develop, establish and maintain an emergency preparedness communication plan to comply with all applicable federal, state and local laws to be reviewed and updated at least annually.

The HHA failed to develop, establish and maintain an emergency preparedness communication plan to comply with all applicable federal, state and local laws to be reviewed and updated at least annually.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The HHA failed to ensure the program was capable of showing measurable improvement in indicators for which there was evidence that improvement in those indicators would improve health outcomes, patient safety, and quality of care and the HHA must measure, analyze, and track quality indicators…

The HHA failed to utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program to monitor the effectiveness and safety of services and quality of care; and identify opportunities for improvement with frequency and…

The HHA failed to ensure that there were program activities focused on high risk, high volume, or problem prone areas; consider the incidence, prevalence, and severity of problems in those areas; and lead to an immediate correction of any identified problem that directly or potentially threaten the…

Track Adverse Patient Events

The HHA failed to conduct performance improvement projects including the number and scope of distinct improvement projects conducted annually which reflect the scope, complexity, and past performance of the HHA's services and operations and failed to document the quality improvement projects…

The HHA's governing body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that…

The HHA failed to ensure that a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the agency's quality assessment and performance improvement (QAPI) program was maintained…

The HHA failed to focus on high risk, high volume, or problem-prone areas in the development of the QAPI program.

The HHA failed to consider incidence, prevalence, and severity of problems.

The HHA failed to develop a program that addressed an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.

The HHA failed take actions aimed at performance improvement, and, after implementing those actions, the HHA failed to measure its success and track performance to ensure that improvements are sustained.

The HHA failed to ensure that one patient (Home Visit #1) of 7 patient records reviewed had home visits conducted as ordered by the physician.

The HHA failed to ensure that one employee (G) of 7 employee had documented a training and competency evaluation program completed.

The Home Health Agency (HHA) failed to provide routine supervision by a Registered Nurse (R.N.) to ensure that home health aide services were provided in a safe and effective manner, by conducting an onsite visit to the patient's home no less frequently than every 14 days, Review of the clinical…