Pediatric Plus Home Healthcare Services LLC

The agency failed to ensure policy and procedure was followed to maintain an updated and current log of patients with special needs during emergencies for 1 of 1 home health agency.

The agency failed to create and put into effect emergency preparedness policies and procedures based on the agency’s emergency preparedness plan and facility/community based all hazards assessment conducted for 1 of 1 home health agency.

The agency failed to create and put into effect policies and procedures addressing the medical record documentation process the agency has adopted to preserve, secure, and maintain patient records during an emergency for 1 of 1 home health agency.

The agency failed to maintain documentation of staff emergency preparedness training conducted upon hire for 8 of 10 personnel records reviewed (HHA 1, 2, 3, 4, LPN 1, RN 2, 3, Alternate Clinical Supervisor) and annually for 6 of 10 personnel records reviewed (HHA 1, 2, 3, 4, LPN 1, Alternative…

The agency failed to ensure policy and procedure was followed to conduct an agency-wide training and testing program based on the emergency preparedness plan for 1 of 1 home health agency.

The agency failed to document annual 12 hours of in-service training for 4 of 4 home health aide records reviewed (HHA 1,2,3,4) Findings include: 1. A personnel record review of HHA 1, date of hire 05/22/2023, evidenced a document titled “In-Home Annual Inservice Completion” which included…

The agency failed to ensure an initial RN assessment was completed within 48 hours of referral for 8 of 11 clinical records reviewed (Patient #1, #2, #3, #5, #7, #9, #10, #11).

The Administrator failed to ensure all agency policies and procedures were complete and thoroughly customized to the agency’s operations for 1 of 1 home health agency.

The agency failed to ensure discharge orders from the physician were included in the clinical record for 1 of 2 closed clinical records reviewed (Patient #10).

The agency failed to ensure additional mitigation efforts were enforced for unvaccinated employees to prevent the spread of COVID-19 for 3 of 3 unvaccinated employees reviewed.

The agency failed to include each patient's specific risk for hospitalization/rehospitalization and the interventions to reduce the risk for 7 of 7 clinical records reviewed (Patients 1, 2, 3, 4, 5, 6, and 7).

The agency failed to ensure each patient received services identified in their plan of care (See G572), failed to ensure the plan of care included all of the requirements (See G574), failed to ensure all orders were included incorporated into the plan of care (See G576), failed to ensure orders…

The agency failed to provide skilled nursing services as written on the plan of care for 2 of 9 active records reviewed (Patient 4,7); and for 1 of 2 closed records reviewed.

The agency failed to ensure measures derived from OASIS (Outcome and Assessment Information Set) and other relevant data were included in the design of its program for 1 of 1 agency.

The agency failed to ensure infection control was maintained during a skilled nursing visit for 1 of 3 home visit observations.

The agency failed to ensure one other therapeutic service besides skilled nursing was made available on a visiting basis or under an arrangement for 1 of 1 home health agency.

The agency failed to ensure clinical record documents were completed by the clinician for 2 of 2 closed records reviewed.

The agency failed to take action to protect patients from potential violations while a complaint was investigated for 1 of 1 agency.

The agency failed to ensure completion of an initial assessment within 48 hours of the referral or SOC (start of care) date for 1 of 9 active records reviewed.

The agency failed to ensure a comprehensive assessment was completed within 5 calendar days of the start of care or first home visit for 1 of 9 active clinical records reviewed.

The agency failed to review all medications to identify potential adverse effects in 1 of 9 active records reviewed.

The agency failed to ensure the plan of care included the types of services, supplies, and equipment required for 1 of 3 patient observations (Patient 2); failed to include frequency and duration of visits to be made for 2 of 11 records reviewed (Patient's 2 and 6); failed to include all current…

The agency failed to ensure all orders were included or revised in the plan of care in 4 of 11 records reviewed.

The agency failed to ensure orders were obtained for treatments provided for 1 of 9 active records reviewed.

The agency failed to ensure coordination of care and delivery of care was followed for 1 of 9 active records reviewed.

The agency failed to ensure that a visit schedule was consistent with the most recent plan of care was provided to the patient/caregiver and followed for 4 of 11 records reviewed (Patients 2,3,4,6).

The agency failed to communicate with all physicians involved in the plan of care and other health care practitioners related to the current plan of care for 2 of 11 records reviewed.

The agency failed to ensure nursing services were provided under the supervision of a registered nurse in 2 of 11 records reviewed.