Personal Care Concepts Inc

The home health agency failed to develop and maintain an EP plan which included strategies for addressing emergency events identified by the hazards risk assessment (see Tag E0006), type of services the agency would have the ability to provide in an emergency (see tag E0007), a process to…

The home health agency failed to ensure the POC was established and reviewed with the physician at SOC and recertification (See G572); failed to ensure the POC included measures to address all safety concerns, patient-specific interventions, measurable outcomes and goals; and failed to clearly…

The home health agency failed to ensure the HHA performed the required competency skills evaluation tasks with a patient or pseudo patient (See G768); the RN failed to prepare written care instructions for the HHA which clearly delineated when similar tasks were to be performed (See G798); and…

The home health agency failed to develop an EP plan which included strategies for addressing emergency events identified by the hazards risk assessment, with the potential to affect all agency patients and staff.

The home health agency failed to develop and maintain an emergency preparedness plan which included the type of services the agency would have the ability to provide in an emergency, with the potential to affect all agency patients and staff.

The home health agency failed to develop and maintain an emergency preparedness plan which included a process to collaborate with state, tribal, and federal officials’ efforts to maintain an integrated response during a disaster or emergency, with the potential to affect all agency patients and…

The home health agency failed to develop and implement EP policies and procedures which addressed a system for medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, with the potential to affect…

The home health agency failed to develop and implement EP policies and procedures which addressed the use of volunteers in an emergency or other emergency staffing strategies, with the potential to affect all agency patients and staff.

The home health agency failed to develop and implement EP policies and procedures which addressed the use of volunteers in an emergency or other emergency staffing strategies, with the potential to affect all agency patients and staff.

The home health agency failed to develop and maintain an EP communication plan which included names and contact information for all patients’ physicians, with the potential to affect all agency patients and staff.

The home health agency failed to develop and maintain an EP communication plan which included alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency management agencies, with the potential to affect all agency patients and staff.

The home health agency failed to develop and maintain an EP communication plan which included a method for sharing information and medical documentation for patients under the agency’s care with other health providers to maintain the continuity of care, with the potential to affect all agency…

The home health agency failed to conduct a variety of exercises to test the emergency plan annually and failed to document an after-action review of the testing exercise, which had the potential to affect all agency patients and staff.

The agency failed to ensure the POC was established and reviewed by the attending physician/practitioner for 5 of 7 patient records reviewed (Patient 1, 3, 5, 6 and 7).

The home health agency failed to document and conduct a performance improvement project(s) approved by the QAPI committee, which had the potential to affect all agency patients and employees.

The agency failed to ensure employees followed standards of practice for hand hygiene to reduce the spread of infections for 1 of 1 home visit observation with the HHA (HHA 2).

The home health agency failed to ensure the HHA performed the required competency skills evaluation tasks with a patient or pseudo patient (person acting as a patient) for 4 of 4 new hired HHA’s in the past year (HHA 2, 3, 4 and 5).

The RN failed to prepare written care instructions for the HHA which clearly delineated when similar tasks were to be performed for 1 of 3 active records reviewed of patients receiving HHA services (Patient #4).

The home health agency failed to ensure OASIS transmissions were submitted on time for 1 of 1 agency.

The home health agency failed to ensure the patient received all visits as ordered for 1 of 2 records reviewed of patients receiving home health aide, attendant care, and homemaker services (Patient #4).

The home health agency failed to collaborate with the patient and physician regarding possible discharge for cause/ noncompliance for 1 of 1 discharge for cause/noncompliance patient record reviewed (Patient #7).

The home health agency failed to make efforts to resolve the problem in the patient home for 1 of 1 discharge for cause/noncompliance patient record reviewed (Patient #7).

The home health agency failed to provide the patient with contact information for other home health agencies who may be able to provide care for 1 of 1 discharge for cause/noncompliance patient record reviewed (Patient #7).

The home health agency failed to document the efforts made to resolve the problem for 1 of 1 discharge for cause/noncompliance patient record reviewed (Patient #7).

The home health agency failed to conduct an initial assessment to determine the patient's immediate care and support needs within 48 hours of referral for 1 of 2 discharged records reviewed (Patients #7).

The home health agency failed to ensure an accurate review of all medications for 4 of 4 records reviewed with home visit observations (Patient #1, 2, 3 and 5).

The home health agency failed to ensure the POC included patient-specific interventions, measurable outcomes and goals for 6 of 7 patient records reviewed (Patient #1, 2, 3, 5, 6 and 7).

The home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 1 of 1 active patient records reviewed with SN only services (Patient #1) and 2 of 2 discharged records reviewed (Patient #6 and 7).

The home health agency failed to ensure all verbal orders were signed by the ordering provider within 30 days for 1 of 1 active records reviewed with Person H listed as the attending physician (Patient #3).

The skilled nurse failed to document an assessment of the patient's pain for 1 of 1 records reviewed of a patient diagnosed with dementia (Patient #2) and failed to document their assessment of a wound for 1 of 1 record reviewed of a patient with an active wound (Patient #3).

The SN failed to provide services as ordered in the POC for 2 of 2 patient records reviewed with multiple daily SN visits ordered (Patient #1 and 2).

The home health agency failed to ensure all SN visit note documentation was completed accurately for 1 of 1 active patient record reviewed who received SN visits to set up the medications (Patient #1).

The home health agency failed to ensure the HHA provided services according to HHA training for 1 of 1 home visit observation with HHA (Patient #5) and failed to ensure the HHA followed the aide care plan or notified the agency of a need to alter the aide care plan for 1 of 4 active records…

The clinical record failed to include accurate HHA supervisory clinical notes for 1 of 1 patient with a home visit observation with an HHA (Patient #5) and failed to ensure visit documentation was entered accurately for 1 of 1 patient record reviewed with HHA, ATTC and HMK services (Patient #4).

The home health agency failed to submit the discharge summary to the physician within 5 days of discharge for 1 of 1 discharge for cause record reviewed (Patient #7).

The agency failed to ensure the home health aide (HHA) care plan was specific to the needs of the patient for 3 of 4 active record reviews with orders for HHA services (Patient #3, 6, and 7).

The agency failed to ensure patient’s clinical records would be made available to the patient, free of charge, upon request, at the next home visit or within 4 business days (whichever came first) for 1 of 1 agency.

The agency failed to ensure it provided all patients with the name, address, and telephone number of the QIO (Quality Improvement Organization that manages all beneficiary complaints and quality of care reviews) for 1 of 1 agency, with the potential to affect all patients of the agency.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current psychosocial and functional status for 1 of 2 active records reviewed that received skilled nursing services (Patient #5).

The agency’s home health aide (HHA) training program failed to include training regarding adequate nutrition intake, with the potential to harm all patients receiving HHA services, for 1 of 1 agency.

The agency failed to ensure the home health aide (HHA) followed the plan of care for 1 of 2 non-skilled active records reviewed with orders for home health aide services only (Patient #7).

The agency failed to ensure staff followed infection control policies and procedures for 2 of 3 home visit observations (# 2 and # 4).

The agency failed to ensure verbal orders orders were accepted only by personnel authorized to do so by applicable state laws and regulations in 1 of 10 records reviewed.