Phoenix Home Health Agency, LLC

The agency failed to ensure the emergency preparedness testing and training program was followed for all employees.

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events from 05/12/23 to 12/31/23 for all patients and employees.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI activities included follow-up for self-monitoring for outcomes, improved care, services and operations for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program for 01/30/23 to 01/03/25 for all patients and employees.

The agency failed to ensure the Infection Control Program surveillance data was included in QAPI program activities for all patients and employees.

The agency failed to ensure governing body oversite of the agency’s program evaluations, operating budgets, and capital expenditure plans for calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure advance beneficiary notice and/or HHCOC notice was provided to one (Patient #7) of 20 patients.

The agency failed to ensure individualized patient POC included: 1. SN catheter treatment/interventions or last changed/treatment due date for suprapubic catheter management for one (Patient #1) of 20 patients; 2. Identified a wound site for wound care management for one (Patient #7) of 20…

The agency failed to ensure physician orders were a part of the patients’ POCs for SN to administer medications for two (Patients #11 and #17) of 20 patients.

The agency failed to ensure: 1. CHHA conducted visit frequency as ordered on the POC for one (Patient #2) of 20 patients; 2. PT conducted visit frequency as ordered on the POC for one (Patient #3) of 20 patients; 3. SN conducted visit frequency as ordered on the POC for two (Patients #3 and #4) of…

The agency failed to ensure SN and OT visit note documentation was completed within 24 hours of the visit for two (Patients #3 and #6) of 20 patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure clinical visit note documentation was completed for one (Patient # 2) of 20 patients.

The agency failed to ensure completed transfer/discharge summaries were provided to receiving service providers for five (Patients #1, 5, 6, 7 and #8) of 20 patients.

The agency failed to ensure the Infection Control Program included interventions to reduce future infections and promote learning and preventative measures throughout the agency for all 124 patients and all staff.

The agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all 124 patients and all employees.

The agency failed to develop an individualized plan of care for two (Patients #1 and 7) of seven patients.

The agency failed to ensure performance improvement projects showed data collection and measurable progress made towards the chosen performance improvement projects.