Seraphic Springs Healthcare

The home health agency failed to ensure an individualized plan of care was reviewed and signed timely by the physician for 1 patient (#7), out of a total sample of 8 patients.

The agency failed to ensure clinical documentation was completed and appropriately authenticated and dated in accordance with currently accepted standards of practice for 2 patients (#7 and #3), out of a total sample of 8 patients.

The Agency failed to ensure a substantiated allegation of abuse (misappropriation: wrongful temporary or permanent use of a patient's belongings or money without such patient's consent) was reported to the Department of Public Health for 1 patient (#8), out of a total sample of 8 patients.

The home health agency failed to ensure that services and treatments were administered only as ordered by a physician or allowed practitioner for 1 patient (#3), out of a total sample of 8 patients.

The home health agency failed to ensure that the physician ordered plan of care was followed for 1 patient (#4) out of a total of 8 sampled patients.

The home health agency failed to ensure a completed discharge summary was sent to the physician within 5 business days of the patient’s discharge from the agency as required for 1 patient (#7), out of a total sample of 8 patients.

The agency failed to ensure that a QAPI program was developed which reflected the complexity of the HHA's organization, focused on indicators related to improved outcomes, including the use of emergent care services and hospital admissions and readmissions and takes action to address the HHA's…

The agency failed to ensure the QAPI program was capable of showing measurable improvement in indicators and failed to measure, analyze and track quality indicators.

The agency failed to utilize quality indicator data in the design of its program.

The agency failed to ensure that the HHA's performance improvement activities focused on high risk, high volume, or problem-prone areas.

The agency failed to ensure that the performance improvement activities were tracked.

The agency failed to ensure that there was an ongoing program for quality improvement and patient safety, address priorities for improved quality of care, make clear expectations for patient safety and any findings of fraud or waste are appropriately address.

Infection control practices were not followed to prevent the transmission of infection and communicable diseases.

The HHA failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases.

The agency failed to ensure that the HHA's performance improvement activities focused on high risk, high volume or problem-prone areas.

The agency failed to ensure that the HHA's performance improvement activities must consider incidence, prevalence, and severity of problems in those areas.

The agency failed to ensure that the HHA's performance improvement activities led to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.

The agency failed to ensure that the HHA took action aimed at performance improvement and tracked performance to ensure that improvements are sustained.

The agency failed to ensure that services were provided according to the plan of care for 1 (HV#3) of 7 records reviewed.