Supportive Home Health Care, LLC

The agency failed to develop an emergency preparedness plan (see E0004); failed to develop an emergency preparedness communication plan (see E0029); and failed to develop and maintain an emergency preparedness training and testing program (see E0036).

The agency failed to ensure that each patient receiving home health services had an individualized written plan of care that was established, periodically reviewed, and signed by a doctor in 2 of 7 (Patient #’s 2, and 6) records reviewed (see G572); failed to ensure the plan of care included…

The agency failed to maintain compliance with this condition of participation.

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement program (See G 684); and failed to provide infection control…

The agency failed to ensure the registered nurse prepared written patient care instructions that included reportable weight parameters, safety parameters, and skin care instructions for 1 of 1 (P-7) records reviewed (see G798); failed to ensure the aide provided care as instructed for 1 of 1 (P-7)…

The agency failed to ensure the governing body assumed full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans and its quality assessment and…

The agency failed to develop an emergency preparedness plan, resulting in the potential to negatively affect the health and safety of the agency's 8 current patients in the event of an actual agency or community-based emergency.

The agency failed to develop an emergency preparedness communication plan, resulting in the inability to coordinate patient care for the agency's 8 current patients in the event of an agency-based emergency or community disaster.

The agency failed to develop and maintain an emergency preparedness training and testing program, resulting in the potential to negatively affect the health and safety of the agency's 8 current patients.

The agency failed to ensure that each patient receiving home health services had an individualized written plan of care that was established, periodically reviewed, and signed by a doctor in 2 of 7 (Patient #'s 2, and 6) records reviewed resulting in the inability of the agency to identify and…

The agency failed to ensure conformance to the physician orders in the plan of care for 2 (Patient #5, 7) of 7 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs.

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program which could show measurable improvement in health outcomes, patient safety, and quality of care by collecting, measuring, analyzing, and tracking quality indicators resulting in a lack of evidence of the…

The agency failed to collect and utilize quality indicator data and other relevant agency data for the design of a Quality Assessment and Performance Improvement (QAPI) program, resulting in the potential for poor quality outcomes for the 44 patients admitted to the agency in the past 12 months.

The agency failed to conduct performance improvement projects from 2021 through 2023, resulting in no coordinated efforts to improve patient outcomes for the 44 patients admitted to the agency in the past 12 months.

The governing body failed to ensure the agency developed, implemented, and maintained an agency-wide, data driven Quality Assessment and Performance Improvement (QAPI) program from 2021 through 2023 resulting in a lack of oversight by the governing body to ensure patient safety and quality of care…

The agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program in 2021 through 2023, resulting in the potential…

The agency failed to provide documented evidence that infection control education was provided to any of the 9 health care personnel contracted by the agency for patient care resulting in the potential for the development and spread of infection.

The agency failed to ensure the registered nurse prepared written patient care instructions that included reportable weight parameters, safety parameters, and skin care instructions for 1 of 1 (P-7) records reviewed in which aide services were provided, resulting in a lack of direction regarding…

The agency failed to ensure the governing body assumed full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and it's operational plans and it's quality assessment and…

The agency failed to ensure 2 of 2 contracts (Contractor-1, Contractor-2) met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that receive contracted services.

The agency failed to ensure at least one qualifying service was provided directly by agency employees, resulting in the potential for an interruption in continuity of care and unmet care needs.

The agency failed to ensure patients were informed of the Administrator's name to receive complaints, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect the quality of care for the agency's 8 current patients.

The agency failed to ensure the patient was able to participate in, be informed about, and consent or refuse care in advance of and during treatment in 3 of 7 (Patient #’s 1, 2, and 3) records reviewed potentially resulting in those patients being uninformed of the planned services and care that…

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 1 of 7 (Patient #4) records reviewed, and failed to ensure a registered nurse conducted an initial assessment visit to determine immediate care needs within 48 hours of returning home in 1 of 7…

The agency failed to ensure the comprehensive assessment was completed within 5 calendar days for 1 of 7 (P-6) records reviewed, resulting in a lack of information to direct and support the care needs for this patient.

The agency failed to ensure the comprehensive assessment to determine eligibility for the Medicare home health benefit was completed by the registered nurse in 1 (Patient #4) of 7 records reviewed, resulting in the potential for a patient who is ineligible for benefits to be admitted to home care…

The agency failed to ensure the comprehensive assessment included a review of all medications taken by the patient for potential adverse effects, drug reactions, and duplicative drug therapy in 7 of 7 (Patient #’s 1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in the potential for undetected or…

The agency failed to ensure the comprehensive assessment was updated and revised in 1 (Patient #4) of 7 records reviewed at discharge from care, resulting in the lack of updated information to determine the continuing care needs of the patient and no record of the patient's progress towards the…

The agency failed to ensure the plan of care included appropriate patient-specific interventions in 2 (Patient #'s 1 and 5) of 7 records reviewed, resulting in the potential for the patient to not receive care specific to their needs and the inability to determine the patient's progress towards…

The agency failed to ensure all patient care orders were recorded in the plan of care for 1 of 7 (Patient # 2) records reviewed resulting in a lack of physician oversight and input regarding the patient's plan of care and the potential for services not provided as ordered.

The agency failed to ensure all services, and treatments were administered only as ordered by a physician in 2 of 7 (Patient #2, 7) records reviewed resulting in potential to provide ineffective or harmful care for this patient.

The agency failed to ensure patients were provided written information with the correct name of the agency's clinical manager, resulting in a lack of information to enable the 8 current patients to contact the clinical manager.

The agency failed to ensure skilled professionals performed assessments of the patient's health status and needs in 2 of 7 (P-6, 7) records reviewed with multiple disciplines ordered, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient…

The agency failed to ensure services of the skilled professionals were provided as indicated by the physician in the plan of care in 4 (Patient # 1, 2, 4, and 7) of 7 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs.

The agency failed to ensure the aide provided care as instructed for 1 of 1 (P-7) records reviewed in which aide services were provided, resulting in the potential for poor patient outcomes.

The agency failed to ensure documentation of an annual on-site visit to observe and assess the aide while performing care for 1 of 1 (Staff C) aides contracted by the agency, resulting in a lack of supervision and oversight of the care provided by this aide.

The agency failed to ensure the Administrator was appointed by and reported to the governing body, resulting in no definitive lines of authority, lack of oversight of patient care and operations of the agency, and the potential for poor patient outcomes.

The agency failed to ensure the clinical manager provided oversight and coordination of patient care services and personnel for 1 of 7 (P-6) records reviewed, resulting in a potential decline in physical functioning, lack of assistance with personal care needs, and the potential for poor patient…

The agency failed to ensure the clinical manager assured the development of plans of care for 1 of 7 (P-6) records reviewed, resulting in a potential decline in physical functioning, lack of assistance with personal care needs, and the potential for poor patient outcomes.

The agency failed to ensure contracts for services indicated the agency maintains overall responsibility for the services provided under arrangement for 2 of 2 (Contractor-1, Contractor-2) contracts reviewed, resulting in a lack of overall responsibility by the agency for the services provided…

The agency failed to ensure that the primary home health agency is responsible for patient care services for 2 of 2 (Contractor-1, Contractor-2) contracts reviewed, resulting in a lack of overall responsibility by the agency for patient care services.

The agency failed to ensure the clinical record contained a complete comprehensive assessment for 1 of 7 (P-6) records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient.

The agency failed to ensure the clinical record contained all interventions, medication administration, treatments, services, and responses to those interventions in 2 of 7 (Patient # 1, 7) records reviewed resulting in an incomplete record and the lack of patient's health status for care needs to…

The agency failed to send a completed discharge summary to the primary care provider within 5 business days after discharge in 1 of 7 (Patient #1) records reviewed resulting in the potential for unidentified continuing health care concerns and unmet care needs.

The Registered Nurse failed to prepare clearly written patient care instructions and include all safety measures on the aide's care plan in 3 of 3 records reviewed in which Home Health Aide services were provided (MR's #2, 4, and 6), from a total sample of 7 records reviewed, resulting in the…

The agency failed to advise patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the areas where the patients reside for 2 of 3 (MR#'s 1, and 3) home visits in which the agency's documentation was observed in the home, resulting in a lack…

The agency failed to ensure the registered nurse conducted a review of the patient's medications for significant potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy; and failed to ensure the physician was informed of major/severe drug interactions for 3 of…

The Home Health Agency failed to ensure the goals on the plan of care were measurable and the plan of care included patient specific/measurable interventions and goals that were based on patient needs in 6 of 7 records reviewed (MR#s 1, 2, 4, 5, 6, and 7), from a total sample of 7 records reviewed…

The agency failed to ensure transfer summaries were sent within 2 business days to the receiving facility/physician, and failed to include the patient's status, specific care provided and progress/outcomes toward goals in for 3 of 3 (MR#'s 5, 6, and 7) records reviewed in which the patient was…