Saint Elizabeth Home Care (Cathleen Naughton Associates)

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure the QAPI program is data-driven, involves all services, and is reviewed by the governing body.

This Element is NOT MET as evidenced by: Based on staff interview it has been determined that the HHA failed to ensure the organizational structure, including lines of authority, responsibilities and relationships including services furnished is reflective accurately on the HHA organizational chart.

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure that information contained in the clinical record is accurate and adheres to current clinical record documentation standards of practice for 1 of 2 patients…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure that each patient receives the home health services that are written in the plan of care for 5 of 7 care plans reviewed, Patient ID#s 1, 2, 4, 5, and 7.…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure the QAPI program includes infectious and communicable diseases and measures the collected data to evaluate procedures, interventions for measurement, and…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure the frequency and detail of the data collection must be approved by the HHA’s governing body.

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the HHA’s governing body failed to review QAPI and assume overall responsibility for ensuring that the QAPI program reflects the complexity of the HHA and its services, involves all…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the HHA’s governing body failed to review QAPI and assume overall responsibility for ensuring that the QAPI program reflects the complexity of the HHA and its services, involves all…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the HHA failed to ensure the quality assessment and performance improvement program (QAPI) is reviewed by the governing body.

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to measure its success and track performance to ensure the improvements implemented in QAPI are sustained.

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure that nursing communicated with the physician involved in the plan of care for 1 of 2 patients reviewed relative to surgical wound orders, Patient ID #8.…

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the QAPI program lacked evidence of having input and participation of every skilled professional which includes contribution with all phases of the HHA’s QAPI program.

This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the HHA failed to pre-designate a qualified, person who is authorized in writing by the Administrator and governing body to assume the same responsibilities and obligations as the…

The Condition of Participation: Quality assessment and performance improvement has not been met relative to; the agency failed to develop, implement, and maintain an effective, ongoing HHA wide, data driven Quality Assessment and Performance Improvement (QAPI) program.

The agency failed to meet the conditions of participation for skilled professional services, relative to medical social work services as required.

The agency failed to ensure that drugs, services, and treatments are administered only as ordered by a physician for 4 out of 7 clients observed during home visits, Client ID #s 1, 2, 3 and 6. Findings are as follows: 1. Record review for Client ID # 1, revealed the current medications on the…

The Home Health Agency has failed to complete a comprehensive assessment of all ordered medications the client is currently taking for 5 of 6 clients observed during home visits (ID #'s 1, 2, 3, 6, & 9).