Principal Home Healthcare

The agency failed to develop an emergency preparedness plan that must be reviewed, updated and included guidance for the Covid-19 pandemic (See E 0004); failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years that included guidance for the Covid-19…

The Agency failed to provide care and services in accordance with the plan of care in 2 (MR#'s 6, 7) records, from a total sample of 7 records reviewed (See G 572); failed to ensure that all care and services were provided only in accordance with the physician's orders for 1 (MR #2) of 1 patient…

The Agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that measured, tracked, and analyzed its quality indicators in order to quantitatively assess outcomes concerning care and services furnished by the Agency (See G 642); failed to provide data collected…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that was incorporated into the Quality Assessment/Performance Improvement program (G-684); failed to provide documented evidence…

The Registered Nurse failed to utilize professional standards of practice during the provision of care and services for 1 (MR #3) of 1 patient observed during a home visit, from a total of 7 sampled records reviewed, resulting in patient inconvenience, inaccurate patient assessment and the…

The Agency failed to ensure a qualified alternate, was authorized in writing by the Administrator and the Governing Body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions (G954); the Clinical Manager failed to ensure patient care was…

The agency failed to ensure the clinical record was complete and included clinical notes for 2 (MR#'s 5, 7) records, from a total of 6 records reviewed in which skilled nursing services were provided (See G-1012); and failed to ensure that discharge and transfer summaries were completed and sent to…

The agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every two years and included strategies to address the Covid-19 global pandemic, resulting in no directions for agency personnel in the event of an actual emergency or disaster.

The Agency failed to develop and update Emergency Preparedness (EP) policies and procedures that were based on an EP plan, risk assessment, and communication plan, resulting in the Agency's inability to implement appropriate emergency actions which could negatively affect the health and safety of…

The agency failed to develop and maintain an emergency preparedness communication plan that is reviewed and updated at least every 2 years and includes contact information for Federal, State, regional, local emergency preparedness officials, and other sources of assistance, resulting in a lack of…

The agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies/procedures, and communication plan, which must be reviewed and updated at least every two years.

The agency failed to provide documentation to fulfill the requirement of participating in a community based full-scale exercise at least once every two years, resulting in the potential for staff and all 4 patients currently receiving services not to be properly prepared in the event of an actual…

The Agency failed to provide care and services in accordance with the plan of care in 2 (MR#'s 6, 7) records, from a total sample of 7 records reviewed, resulting in the potential for decline in physical functioning and unmet care needs.

The agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 4 patients serviced by the agency, resulting in a potential for poor patient outcomes due to the provision of substandard care.

The Agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement (QAPI) program, which had the potential to negatively affect all 4 patients currently…

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the annual performance improvement projects, and the reasons for conducting these projects with measurable progress achieved, resulting in the Agency's inability to show improvement in areas…

The Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect…

The agency failed to develop and maintain a coordinated agency-wide program for the surveillance, identification, prevention, and control of infectious diseases including COVID-19; failed to develop a method to screen visitors and agency staff prior to providing clinical services, and failed to…

The agency failed to provide evidence of infection control education concerning Covid-19 and other communicable disease was provided to any staff employed by the agency, resulting in the potential for the development and spread of the Covid-19 and other infectious agents to staff and all 4 patients…

The Agency failed to establish Vaccine protocol written policies and procedures that included the requirement for all staff to be fully vaccinated against the covid-19 virus; (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for…

The Registered Nurse failed to utilize professional standards of practice during the provision of care and services for 1 (MR #3) of 1 patient observed during a home visit, and failed to ensure the Registered Nurse coordinated care as directed by the physician in 1 (MR#4) record, from a total…

The agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs for all four patients serviced by this agency.

The Agency's Governing Board failed to ensure the appointed Administrator was qualified, in accordance with this requirement, to provide oversight of the Agency's operations, resulting in the absence of qualified leadership and the potential for the rendering of unsafe patient care practices.

The Agency failed to ensure that 1 (MR #3) of 1 patient observed during home visit, was included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 7 sampled records reviewed, resulting lack of…

The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the Agency terminating on-going care for 1 (MR# 1) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services.

The Agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission for 2 (MR #1 and 5) records, from a total of 7 sampled records reviewed, resulting in incomplete clinical information to aide in determining the needs of the…

The Agency failed to ensure the patient's Activity of Daily Living needs, Speech Therapy and Medical Social Work needs were adequately met in the patient's home for 1 (MR #1) patient who required the needed services, from a total of 7 sampled records reviewed, resulting in the potential for poor…

The Agency failed to ensure the Initial Comprehensive Assessment reflected the person(s) availability and willingness to assist 1 (MR #1) of 1 patient with overall care needs, including grooming, from a total of 7 sampled patients reviewed, resulting in the potential for unsupported care, poor…

The Agency failed to ensure that all care and services were provided only in accordance with the Physician's orders for 1 (MR #2) of 1 patient who was recertified for additional services, from a total of 7 sampled records reviewed, resulting in the provision of unauthorized unsafe care and services…

The agency's skilled nursing (SN) and administrative services failed to coordinate and facilitate care as ordered by the physician in 2 (MR#'s 4, 5) records, from a total sample of 7 records reviewed, resulting in the failure of verbal orders being entered into the medical record and the potential…

The Agency failed to provide documented evidence to ensure the plan of care was reviewed and revised by the Physician for 1 (MR #2) of 1 patient who was recertified for additional home care services, from a total of 7 sampled records reviewed, resulting in the potential for the patient not…

The Agency failed to ensure the Physician was promptly notified of the patient's change in condition for 2 (MR#'s 3, 4) patients who displayed clinical findings outside of ordered safety parameters, from a total of 7 sampled records reviewed, resulting in the potential for unidentified, unaddressed…

The agency's skilled nursing (SN) services failed to coordinate and facilitate care as ordered by the physician in 1 (MR#4) record, from a total sample of 7 records reviewed, resulting in the patient's inability to receive ordered services.

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The Agency failed to ensure the Registered Nurse performed baseline assessments and re-assessments of the patient's health status and needs in 1 (MR #1) record of a patient with a diagnosis of Diabetes Mellitus, and 1 (MR #3) of 1 patient observed during a home visit, from a total of 7 sampled…

The Agency failed to ensure the clinical record was completed and included detailed Physical Therapy notes for 1 (MR #2) record with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient care…

The Agency failed to ensure a qualified alternate, was authorized in writing by the Administrator and the Governing Body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The Clinical Manager failed to ensure patient care was coordinated to receive the required and ordered Physical Therapy services for 1 (MR #2) of 1 patient with diagnoses of paralysis and muscle weakness, from a total of 7 sampled records reviewed, resulting in patients not receiving care based on…

The Clinical Manager failed to ensure the patient's needs were continually assessed for 1 (MR #1) of patient who required glucose monitoring; and 1 (MR #3) patient observed during a home visit, who required skilled services and ongoing assessments, from a total 7 sampled records reviewed, resulting…

The agency failed to ensure the clinical record contained skilled nursing clinical notes for 2 (MR#'s 5, 7) records, from a total sample of 6 records reviewed in which skilled nursing services were provided, resulting in a lack of information regarding the health status of this patient.

The agency failed to ensure a discharge summary was completed which provided the patient's health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 2 (MR#'s 4, 6) of 3 discharged records; and failed to ensure a transfer summary was…

The agency failed to provide physical therapy and home health aide services as ordered in the plan of care for 3 of 7 (MR# 1, 2, 5) records reviewed.

The agency failed to advise patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the areas where the patients reside for 1 of 2 (MR# 3) home visits in which the agency's documentation was observed in the home, resulting in a lack of…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine significant drug interactions and duplicate drug therapies in 1 of 7 (MR# 6) records reviewed, resulting in the potential for harmful medication effects for the 4 patients currently serviced…

The agency failed to ensure the comprehensive assessment was updated and revised within 48 hours of the patient's return home post discharge from a hospital for 1 of 3 (MR#1) records reviewed in which care had been resumed following hospitalization, resulting in the delay of home health services…

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 3 of 3 (MR# 5, 6, 7) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status…