Servant's Heart Home Health Services, Inc

The home health agency failed to review and update the facility-based and community-based risk assessment every two years (See E0006), failed to ensure an individualized patient emergency plan was developed as part of the comprehensive assessment and kept on file at the agency (See E0017), ailed to…

The home health agency failed to ensure the individualized POC included the frequency and duration of visits to be made, nutritional requirements, all medications, a description of the patient’s risk for emergency department visits and hospital re-admission, and measurable goals identified by the…

The home health agency failed to conduct QAPI meetings at the pre-determined frequency and analyze quality indicators (see G642) and failed to conduct and document performance improvement projects (see G658).

The skilled professional failed to conduct and document a complete wound assessment (See G706) and failed to provide services as indicated in the POC (See G710).

The home health agency failed to ensure all home health aides had successfully completed a competency evaluation prior to furnishing home health services (see G768), the RN failed to create and maintain an aide care plan with detailed instructions to apply non-medicated creams (see G798), and the…

The home health agency failed to review and update the facility-based and community-based risk assessment every two years, which had the potential to affect all active patients and staff.

The home health agency failed to ensure an individualized patient emergency plan was developed as part of the comprehensive assessment for 3 of 7 records reviewed of a patient admitted on or after 4/18/2024 (Patient #3, 4, 5) and failed to ensure an individualized patient emergency plan was kept on…

The home health agency failed to ensure its EP plan identified and implemented a triage classification for all patients, which had the potential to affect all active patients.

The home health agency failed to develop and maintain a communication plan which included the names and contact information for all staff and patients’ physicians, which had the potential to affect all patients and staff.

The home health agency failed to develop and maintain an EP communication plan which included contact information for regional and local EP officials for all counties served, which had the potential to affect all active patients and staff.

The home health agency failed to develop a communication plan which included a method for sharing information and medical documentation with other health providers during an emergency, which had the potential to affect all agency patients.

The home health agency failed to conduct an after-action review of its 2023 EP testing exercise, which had the potential to affect all active patients and staff.

The home health agency failed to conduct QAPI meetings at the pre-determined frequency and failed to evidence analysis of quality indicators, with the potential to affect all patients.

The home health agency failed to conduct and document performance improvement projects (PIP) as part of its QAPI program, which had the potential to affect all active patients.

The home health agency failed to ensure all staff followed infection control policies and best practice for 3 of 4 home visit observations (Patient #1, 2, 4).

The home health agency failed to ensure all home health aides had successfully completed a competency evaluation prior to furnishing home health services for 1 of 2 HHAs observed performing care during a home visit (HHA 1).

The RN failed to create and maintain an aide care plan with detailed instructions to apply non-medicated creams for 2 of 2 records reviewed of a patient receiving HHA services who required the aide to apply a non-medicated cream (Patient #4, 11).

The agency failed to keep clinical records secured when not in use for 2 of 2 locations with paper clinical records and failed to protect patient information while in patients’ homes for 2 of 4 home visit observations (Patients #1 ,2).

The agency failed to provide the name and contact information for the current Administrator for 1 of 1 home visits with a patient handbook available (Patient #3).

The home health agency failed to document its investigation of complaints regarding treatment or care for 1 of 1 complaint documented between 7/07/2024 – 7/07/2025 (Patient #9).

The home health agency failed to ensure an initial assessment to determine a patient’s immediate care and support needs was conducted within 48 hours of referral for 3 of 7 records reviewed of a patient referred on or after March 1, 2024 (Patient #3, 4, 5).

The home health agency failed to ensure the comprehensive assessment included a complete and thorough assessment of Patient’s medical and health needs for 2 of 3 records reviewed of a patient with a wound identified at recertification (Patient #4, 5).

The agency failed to update an assessment within 48 hours following a hospitalization for 1 of 2 home health aide only patients with a hospital discharge (Patient #7).

The home health agency failed to ensure the individualized POC included the frequency and duration of visits to be made, nutritional requirements, all medications, a description of the patient’s risk for emergency department visits and hospital re-admission, and measurable goals identified by the…

The home health agency failed to promptly alert the relevant physician(s)/practitioner(s) to a change in patient condition and service orders not being met for 5 of 5 records reviewed which indicated a change in patient condition and/or service orders not being met (Patient #2, 4, 5, 7, 11).

The home health agency failed to revise the POC to include the patient’s progress towards their goals for 7 of 8 active records reviewed (Patient #1, 2, 3, 5, 6, 7, 11).

The home health agency failed to coordinate care with assisted living facility (ALF) staff for 1 of 2 records reviewed of a patient with a wound who resided in an ALF (Patient #4).

The agency failed to provide a current medication list for 1 of 1 home visits with a patient handbook available (Patient #3).

The home health agency failed to provide a current POC to the patient for 1 of 1 home visit observation where the patient handbook was available (Patient #3).

The skilled professional failed to conduct and document a complete wound assessment for 2 of 2 records reviewed of patient with a wound that worsened (Patient #4, 5).

The LPN failed to provide services as indicated in the POC for 1 of 2 records reviewed of a pediatric patient receiving tube feeding (Patient #9).

The home health agency failed to ensure HHAs performed tasks only within their scope of practice for 1 of 2 home visit observations of an HHA visit (Patient #4).