Qcn Home Care

The agency failed to ensure the home health agency was functioning under the supervision of an Administrator who was present and responsible for all day-to-day operations (G948); failed to ensure the Clinical Manager was available at all times during operating hours (G950); and, failed to ensure a…

The agency failed to ensure the home health agency was functioning under the supervision of an Administrator who was present and responsible for all day-to-day operations since 5/30/25, when the administrator left their position.

The Administrator failed to ensure a Clinical Manager was available at all times during operating hours since May of 2025 when the Clinical Manager left.

The agency failed to ensure a qualified alternate, was available to function in the Administrator's absence, resulting in the potential for uncoordinated agency functions.

The agency failed to maintain compliance with this condition of participation.

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that measured, tracked, and analyzed it's quality indicators in order to quantitatively assess outcomes concerning care and services furnished by the agency (See G 642); failed to collect and monitor data…

The agency failed to maintain compliance with this condition of participation.

The agency failed to develop an emergency preparedness plan pertinent to the agency's change of ownership, staffing, and relocation, resulting in the agency's inability to implement appropriate emergency actions.

The agency failed to develop and maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual emergency or disaster.

The agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan.

The agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws, resulting in the agency's inability to ensure the coordination of patient care in the event of an actual emergency.

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 the communication plan.

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 the agency is currently serving, 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 program (QAPI), 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 quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2020, 2021, and 2022 to date, resulting in the agency's…

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 ensure the initial assessment visit was conducted within 48 hours of referral for 3 of 7 (MR's #1, 4, 5) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 2 of 7 (MR's #1, 5) records reviewed, resulting in incomplete clinical information to aide in determining the needs of this patient and for measuring the patient's progress toward…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects such as: side effects, drug interactions, and duplicative drug therapies, and failed to notify the physician as stipulated in 4 (MR’s #1, 3, 4, 5) of 7 sampled records…

The agency failed to ensure the plan of care included measurable outcomes, goals, pertinent safety measures, and reportable parameters for 5 of 7 (MR's #1, 2, 3, 4, 5) records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient…

The agency failed to ensure services were provided as ordered by the physician in 1 of 7 (MR # 4) records reviewed, resulting in the potential to negatively affect the health and well-being of this patient.

The agency failed to ensure the physical therapist performed an assessment of the patient's health status and therapy needs in 1 of 5 (MR# 5) records reviewed with physical therapy services, resulting in a delay in care and the potential for poor patient outcomes for this patient.

The agency failed to ensure that skilled nursing services were provided as ordered by the physician in the plan of care in 1 of 7 (MR# 5 ) records reviewed in which nursing services were ordered, resulting in the potential for poor patient outcomes for this patient.

The agency failed to ensure the skilled nurse communicated with the physician regarding a significant change in status for 2 of 5 (MR# 3, 4) records reviewed with skilled nursing services, resulting in a lack of physician involvement in directing the appropriate care for these patients.

The agency failed to ensure the plan of care included objectively measurable and individualized goals in 7 of 7 records reviewed (MR#s 1, 2, 3, 4, 5, 6 and 7) (G572); failed to ensure the plan of care included all pertinent interventions and safety precautions, for 2 of 7 records reviewed (MR# 1…

The agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 7 of 7 records reviewed (MR #1, 2, 3, 4, 5, 6 and 7) for Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for negative patient…

The agency failed to ensure the emergency preparedness policies and procedures included a process for informing state and local emergency preparedness officials of patients needing evacuation from their residence at any time due to an emergency/disaster situation, this had the potential to affect…

The agency failed to ensure the Emergency Preparedness Plan included procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency and to inform State and local officials of any…

The Agency failed to ensure the communication plan included a method for sharing information and medical documentation for patients under the Agency's care with other providers to maintain continuity of care, resulting in the potential to affect the Agency's ability to provide pertinent patient…

The Agency (HHA) failed to provide documentation for the required annual tabletop and community based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan, resulting in the potential to affect all patients and staff, in the event staff is…

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 7 of 7 records reviewed (MR#s 1, 2, 3, 4, 5, 6 and 7) out of a total of 7 records reviewed, resulting in a potential for failure to measure progress toward achievement of desired outcomes.

The agency failed to provide physical therapy services as ordered by the physician for 1 of 7 records reviewed (MR #5) in which physical therapy was ordered from a total sample of 7 records reviewed, resulting in a decline in patient function and poor outcome for this patient.

The agency failed to ensure their Quality Assessment and Performance Improvement program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care, resulting in the potential for poor patient outcomes for the agency's 25 active…

The agency failed to ensure clinical staff placed a protective barrier between the clinical supply bag and a surface considered contaminated for 2 of 3 patients (MR# 1 and 6) observed during home visits, from a total of 3 home visits surveyed, resulting in the potential for the transmission and…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement program, resulting in the potential spread of infections…

The agency failed to inform the patient, in advance, of the disciplines that will furnish care in 4 of 7 (MR #1, 3, 4 and 7) sampled records, and the proposed visit frequency in 7 of 7 sampled records reviewed (MR's #1, 2, 3, 4, 5, 6, and 7) resulting in all 75 patients treated in the last 12…

The home health agency failed to advise their patients of the names, addresses and telephone numbers of the federally and state funded entities that serve the area where the patient resides, resulting in the potential for unmet patient care needs for all 75 patients serviced by the agency in the…

The agency failed to ensure the registered nurse reviewed patient medications for possible side effects, duplication, and possible drug interactions and informed the physician of any identified problems for 2 of 7 (MR# 1 and 2 ) records reviewed, out of a total of 7 records.

The agency failed to ensure the plan of care included all pertinent interventions and safety precautions, for 2 of 7 records reviewed (MR# 1 and 2), out of a total of 7 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient…

The agency failed to ensure medications and wound treatments were provided only as ordered by the physician for 3 of 7 (MR# 1, 2 and 5) records reviewed, out of a total of 7 records, resulting in the potential for the patient to not be taking medications as directed by the physician and a poor…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 of 7 records reviewed with therapy services (MR #5) from a total sample of 7 records reviewed, resulting in a decline in functional ambulation with a poor outcome.

The Agency (HHA) failed to document actual weights for Congestive Heart Failure patients or obtain pulse oximetry levels in Chronic Obstructive Pulmonary Disease patients in 2 records, from a total of 7 sampled records reviewed (MR's # 3 and 4), resulting in the physician not having a clear and…

The qualified therapists failed to supervise the services that were provided by the therapy assistants for 3 of 3 records reviewed (MR# 3, 4 and 5) with physical therapy assistant services were provided, out of a total of 7 records with therapy services, for a potential for unmet therapy needs.