Reflex Home Care, LLC

The Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status and the events that let to the need for home care for 7 (MR# 1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of…

The Agency failed to provide care and services in accordance with the plan of care in 5 (MR's # 2, 3, 4, 5 and 7) of 6 records reviewed for provision of services, from a total of 7 records reviewed, resulting in the potential for decline in physical functioning and unmet care needs (G572); failed…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program, (refer to G-642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, (refer to G-644); failed to initiate any…

The Agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide's performance of the required tasks with a patient…

The agency failed to ensure the clinical record was complete and included all clinical notes and complete medical record for 2 records (MR# 1 and 2) from a total of 7 sampled records (G1012); the Physical Therapist failed to accurately document the patient's responses, (specifically elevated pain…

The Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to include in its emergency plan, the procedures needed to follow-up with staff and patients to determine services that are needed in the event services are interrupted due to an emergency, and to inform state and local authorities of any on-duty staff or patients that the Agency…

The Agency failed to develop an Emergency Preparedness policy/Plan, that included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs during the COVID-19 crisis, resulting in the potential for the interruption in needed care and services for…

The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 39 patients currently…

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency's emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster.

The Agency failed to ensure all contracted staff received initial and annual training in the Agency's emergency preparedness program, including training on the Covid-19 pandemic, resulting in staff being ill-prepared in the event of an actual disaster or emergency.

The Agency failed to provide documentation for the required community based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being unprepared in the event of an actual emergency.

The Agency failed to provide care and services in accordance with the plan of care in 5 (MR's # 2, 3, 4, 5 and 7) of 6 records reviewed for provision of services, from a total 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 109 patients that were admitted during the past 12 months, resulting in a potential for poor patient outcomes due to the provision of…

The agency failed to monitor data for the Quality Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the governing body approved the QAPI…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2017, 2018 and 2019 calendar years, resulting in the Agency's…

Based interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control of infectious and communicable diseases including Covid-19, and failed to develop a method of screening all field staff employed by this agency, and those granted clinical…

The agency failed to adequately assess and monitor the needs of 1 (MR #6) of 1 patient observed during a Physical Therapy home visit, from a total sample of 7 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs.

The Agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide's performance of the required tasks with a patient…

The agency failed to ensure that 2 (HHa #1 and HHa #2) of 3 Home Health Aide files reviewed, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to providing care in 2 of 3 records (MR# 2) in which Home Health Aide services were ordered, resulting in the potential to…

The agency failed to ensure patients were informed of the Administrator's name and business contact information, resulting in the potential for patient complaints or concerns to go unaddressed which could affect the quality of care for the agency's 39 current patients.

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 2 (MR# 3, and 5) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status and the events that led to the need for home care for 7 (MR# 1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 4 of 7…

The agency failed to ensure the plan of care was individualized to the patient's identified needs for 2 of 7 records reviewed (MR#'s 1 and 3), resulting in an inaccurate plan of care and the potential for poor patient outcomes.

The Agency failed to ensure that all drugs, care, and services were provided only in accordance with Physician's orders for 1 (MR #6) of 3 records in which a home visit was conducted, from a total of 7 records reviewed, resulting in the potential for the provision of unsafe, unauthorized care and…

The agency failed to ensure the Physician was promptly notified of elevated blood pressure readings, and elevated pain levels outside of the reportable parameters, for 1 (MR #6) of 3 patients observed during a Physical Therapy home visit, resulting in the potential for unidentified, untreated…

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 Home Health Agency (HHA) failed to develop a QAPI (Quality Assessment Performance Improvement) program that focused on high risk, high volume or problem-prone areas of the agency, to monitor the agency's improvement in these areas resulting in the agency's inability to improve in patient care…

The Agency failed to maintain documentation of the required 12 hours of annual Home Health Aide in-services for 2 (HHa's #1 and 2) of 3 Home Health aide files reviewed, resulting in lack of evidence of ongoing education and training and the potential for the provision of unsafe care for all…

The registered nurse failed to supervise the home health aides' services no less frequently than every 14 days for 2 of 3 records reviewed (MR 2 and 3) with home health aide services, for a potential of unmet and unsafe patient care.

The Agency failed to ensure the skilled discipline made an annual onsite observation visit at the patient's residence to observe the care being provided, for 2 (HHa #1 and HHa #2) of 3 Home Health Aide files reviewed, resulting in the potential for the provision of substandard care and unmet care…

The agency failed to ensure the Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the lack of oversight of patient care and operations of the agency, affecting all 109 patients admitted to the agency within the past 12 months…

The Agency failed to ensure the Clinical Manager coordinated patient care in 1 (MR#4) of 1 record in which the Licensed Practical Nurse completed visits after the Registered Nurse completed a discipline discharge, resulting in the potential for the provision of care inconsistent with the plan of…

The agency failed to ensure the clinical record was complete and included clinical notes for 2 (MR#'s 2, 9) of 7 records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient's health status and progression towards goals, and incomplete clinical record…

The Physical Therapist failed to accurately document the patient's responses, (specifically elevated pain levels and blood pressure readings), before and after therapy services were rendered, for 1 (MR #6) of 1 patient observed during a therapy home visit, from a total of 7 sampled records…

The Agency failed to ensure a discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 2 (MR# 3 and 5), of 2 closed records, from a total of 7 records reviewed…