Serenity Home Health Care Agency, LLC

The agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the agency contracting all patient services.

The agency failed to ensure the registered nurse conducted the initial assessment visit within 48 hours of referral, and determine the immediate care needs of the patient for 2 of 7 (MR's #1 and 2) records reviewed (See G514); failed to ensure the comprehensive assessment accurately reflected the…

The agency failed to ensure the plan of care included all pertinent diagnoses, patient-specific safety measures, allergies, parameters, and interventions for 3 of 7 (MR# 1, 4 and 7) records reviewed (G 575); failed to ensure services were provided only as ordered by the physician in 4 of 7 (MR's…

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 document the…

The Agency failed to ensure that skilled nursing services, physical therapy services, and medical social worker services were provided at the frequency ordered by the physician for 6 of 7 (MR's #1, 3, 4, 5, 6, and 7) records reviewed (see G710); and failed to ensure skilled professionals prepared…

The Home Health Agency failed to ensure the Governing Body assumed full legal authority and responsibility for the agency's overall management and daily operations (See G942) and failed to ensure that at least one qualifying service was provided directly by agency employees (See G982).

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

The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all patient's physician, which had the potential to negatively affect the health and safety of the 49 patients currently serviced by this agency, resulting in the lack of…

The agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 256 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 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, which had the potential to negatively affect all patients serviced by the agency…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2019 and 2020 calendar years, resulting in the Agency's…

Based record review and 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…

We'll have to change on how we do our business then." The Governing Body failed to ensure the Agency's daily operation plan concerning administrative and supervisory functions were not delegated to another organization.

The administrator failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for all services to be provided by contracted staff.

The agency failed to furnish home health aide services as needed in 1 of 3 (MR# 1) records reviewed with aide services ordered, resulting in an unnecessary financial burden placed on the patient.

The agency failed to ensure the registered nurse conducted the initial assessment visit within 48 hours of referral, and determine the immediate care needs of the patient for 2 of 7 (MR's #1 and 2) records reviewed in which Skilled Nursing services were ordered, resulting in a delay in needed care…

We need to work on that." Based on document review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 6 of 7 (MR's #1, 3, and 4) records reviewed, resulting in incomplete clinical information to aid in determining the…

The agency failed to update the patients Medication Profile to reflect the current medication changes.

The agency failed to ensure the plan of care included all pertinent diagnoses, patient-specific safety measures, allergies, parameters, and interventions for 3 of 7 (MR# 1, 4 and 7) records reviewed, resulting in the patient not receiving care based on specific individual needs and the potential…

The agency failed to ensure services were provided only as ordered by the physician in 4 of 7 (MR's #1, 5, 6, and 7) records reviewed, resulting in the potential to negatively affect this patient.

Additionally, for this patient the physical therapist failed to document in the clinical record an evaluation and plan of care for this patient after the 4/2/21 start of care assessment by the registered nurse.

When queried why the POC was not implemented as directed, RN#1 stated, "It's absolutely my fault, I was supposed to coordinate with the LPN (Licensed Practical Nurse), and I didn't follow-up.

The agency failed to ensure skilled professionals prepared clinical notes for 6 of 7 (MR's# 1, 3, 4, 5, 6, and 7), records reviewed, resulting in the physician not having a complete clinical picture of the patient's health status and progress toward goals during the period of care.

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 5 and 7) with home health aide services, for a potential of unmet and unsafe patient care.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 1 of 1 (MR# 5) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status at the…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19, resulting in the potential spread of a contagious viral infection between agency staff and the agency's 25 current patients.

The agency failed to provide education of the COVID-19 virus for 18 of 21 employees and 4 of 6 patients/caregivers (MR #3, 4, 5 and 6) resulting in the potential spread of a contagious viral infection between agency staff and the agency's 25 current patients.

The Agency failed to establish an emergency plan that included an all-hazards risk assessment, and subsequent strategies for addressing events identified by the risk assessment at both the facility-based and community-based levels, resulting in the potential to deter the Agency's ability to provide…

The Agency's emergency preparedness plan failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document the agency's efforts to…

The Agency failed to implement in the Emergency Preparedness policy the use of volunteers and other emergency staffing strategies to address surge needs encountered during an emergency, resulting in the potential for the interruption in needed care and services for 32 of 32 patients currently…

The Agency (HHA) failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws regarding agency staff, contracted services, patient physicians, other healthcare facilities, and volunteers that had been reviewed and updated at least…

The facility failed to develop and maintain an emergency preparedness communication plan that enlisted a primary and alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency preparedness officials, resulting in the potential to affect the Agency's…

The agency failed to ensure the Quality Assessment Performance Improvement (QAPI) program demonstrated measurable improvement in quality of care indicators by measuring, analyzing and tracking quality indicators for patient care which had the potential to affect 32 of 32 active patients out of a…

The agency failed to ensure the Quality Assessment Performance Improvement (QAPI) program developed and utilize data elements to monitor the effectiveness, quality and safety of patient care services to identify areas for improvement, which had the potential to affect 32 of 32 active patients out…

The agency failed to ensure that the infection control program was integrated into the Quality Assessment Performance Improvement (QAPI) program which had the potential to affect 32 of 32 active patients out of a total of 164 patents admitted in the past 12 months, resulting in the potential for…

The home health aide plan of care did not include safety precautions for the aide to follow in 3 of 3 records reviewed in which home health aide services were provided out of a total sample of 7 records reviewed (MR #1, 5 and 6), resulting in potential injury to patient's during the provision of…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status and included the events leading to current home care needs in 4 of 7 records reviewed (MR# 4, 5, 6 and 7), from a total sample of 7 records reviewed, resulting in incomplete clinical…

The agency failed to ensure staff provided services in accordance with the plan of care in 2 out of 3 records reviewed in which the patient had a diagnosis of diabetes out of a total sample of 7 records reviewed, resulting in the potential for patient's to have complications from elevated blood…