Rehoboth McKinley Christian Home Care Services

The facility failed to develop a communication plan that includes contact information of needed personnel in the event of an emergency.

The agency failed to have a health certificate for all staff having contact with patient/clients stating that the employee is free from Tuberculosis (TB) (a serious infection, usually of the lungs caused by the bacteria Mycobacterium tuberculosis (species of bacteria) and is spread when you breathe…

The facility failed to ensure and retain orientation and training for 2 (S3, S4) out of 9 staff (s) reviewed (S1 through S9) providing care.

The facility failed to ensure a Registered Nurse (RN) conducted an initial assessment to determine the immediate care and support within 48 hours from receiving a referral for home care services for 1 (P (patient) 6) out of 7 Patients sampled.

The agency failed to ensure that patient goals were individualized to specifically meet individual patient needs for six (Pt # 1- #6) of seven patients.

The agency failed to ensure that Plan of Care (POC) goals were measurable for five (Pt #2, #3, #4, #5, #6) of seven patients.

The home health agency failed to maintain an effective, ongoing, agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) program that reflected the complexity of its organization and services, potentially resulting in patients receiving poor quality of care (See G0642).

The agency failed to maintain an agency-wide program for infection control and prevention that included a method of identifying infectious and communicable disease problems and a plan for implementation of appropriate actions.

The agency failed to provide at least 12 hours of in-service training to Home Health aide (HHA) for one employee ( # 4).

The hospice failed to maintain documentation of governing body engagement in the home health program and daily operation.

The agency failed to have a written emergency preparedness plan.

The agency failed to ensure that patient goals were individualized to specifically meet individual patient needs for six (Pt # 1- #6) of seven patients.

The agency failed to ensure that Plan of Care (POC) goals were measurable for five (Pt #2, #3, #4, #5, #6) of seven patients.

The home health agency failed to maintain an effective, ongoing, agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) program that reflected the complexity of its organization and services, potentially resulting in patients receiving poor quality of care.

The home health agency failed to document the use of quality indicator data in the design of their QAPI program per their Plan of Care (POC).

The home health agency failed to implement and evaluate Performance Improvement Projects for 2016 and 2017. This failed practice has the potential to result in poor quality of care for all current and future patients.

The agency failed to maintain an agency-wide program for infection control and prevention that included a method of identifying infectious and communicable disease problems and a plan for implementation of appropriate actions.

The home health agency failed to maintain an agency-wide program for infection control and integrate the infection control program into Quality Assessment Performance Improvement (QAPI).

The agency failed to ensure that Physical Therapy Assistants (PTA) were supervised for three ( Pt #2, Pt #5, and Pt #6 ) of five patients that received physical therapy services.

The agency failed to provide at least 12 hours of in-service training to Home Health aide (HHA) for one employee (# 4).

The agency failed to ensure that plan of care instructions were provided to the Home Health Aide (HHA) for one (Pt #1) of four patients with orders for services and one (Pt# 2) of one patients with no orders for HHA services.

The agency failed to maintain documentation of governing body engagement in the home health program and daily operation.

The agency failed to ensure that patient goals were measurable for six (Pt # 1- #6) of seven patients.

The agency failed to ensure that the comprehensive assessment included review of all medications for three (Pt # 1, #2, and #5) of seven patients for potential adverse effects, duplicate therapy and drug interactions.

The agency failed to ensure that Plan of Care (POC) developed for the patients contained frequency and duration of visits to be made, measurable outcomes and goals for five (Pt #2, #3, #4, #5, #6) of seven patients.

The home health agency failed to maintain evidence of a QAPI program that focused on high risk, high volume, or problem-prone areas.

The agency failed to ensure that 10 (Employee #1 -#10) of 10 were provided in-service training specific to home health services.

The agency failed to ensure that the Home Health Aide (HHA) provided services in accordance with the Plan of Care.

The agency failed to appoint a person responsible for the agency and maintain documentation of governing body oversight of the home health program.