T.L.C. Home Healthcare, Inc

The agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral or discharge from an inpatient facility (refer to G-514); failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health…

The agency failed to develop a plan of care that included objectively measurable goals in 4 of 7 records (MR#s 4, 5, 6 and 7); and failed to ensure the patient received care and services as ordered in the plan of care for 1 (MR #2) record, resulting in the inability to determine the patient's…

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) Program to optimize the agency's patient outcomes (See G-642); failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program to ensure the effectiveness and safety of…

The Agency failed to establish and maintain an agency wide infection control program and policy for the surveillance, identification, prevention, and control of COVID-19 that included a vaccine protocol, written policies and procedures that included implementation of additional precautions to…

The Administrator failed to the Clinical Manager was available during all operating hours (G950); failed to ensure a qualified alternate Administrator, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence (G954); the Clinical Manager…

The Agency failed to provide documented evidence of initial and ongoing training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees and volunteers as appropriate, and failed to maintain documentation of training's, resulting in the…

The Agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency.

The agency failed to develop a plan of care that included objectively measurable goals in 4 of 7 records (MR#s 4, 5, 6 and 7); and failed to ensure the patient received care and services as ordered in the plan of care for 1 (MR #2) record, resulting in the inability to determine the patient's…

The agency failed to provide services as ordered by the physician in 1 of 7 records (MR#7) reviewed, resulting in services not provided as ordered by the physician.

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) Program to optimize the agency's patient outcomes.

The agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program to ensure the effectiveness and safety of services, quality of care, and to identify opportunities for improvement.

The Agency failed to initiate a Performance Improvement Program (PIP) within their QAPI program that focused on high risk, high volume, or problem prone areas, resulting in the potential for agency issues with negative consequences for high risk, high volume, or problem prone areas that could…

The Agency failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement Program (QAPI), that addressed incidence, prevalence, and severity of problems identified amongst the agency's own patient population as areas of focus to improve patient…

The agency failed to conduct a performance improvement project for the year 2023. Findings included: During an interview with the Administrator on 3/3/2023 at 1:00 p.m., the administrator was asked what the agency was working on as their performance improvement project for the year 2023? The…

The Governing Body (GB) failed to ensure a Performance Improvement Program for quality improvement and patient safety is approved by the Governing Body, defined, implemented, maintained, addresses priorities for improved quality of care, patient safety, and that all improvement actions are…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases, including COVID-19, as a part of the agency's Quality Assessment Performance Improvement program, resulting in the potential…

The agency failed to ensure to document and track the COVID-19 vaccination completion, exemption, or temporary delay status for 3 of 6 staff employed by the agency.

The Agency failed to ensure that the individuals who furnished Home Health Aide services on its behalf, met the competency evaluation requirements of this section by ensuring the subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section were evaluated by a…

The agency failed to ensure that 1 (MR #2) of 7 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in…

The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral or discharge from an inpatient facility for 4 (MR's #1, 2, 6, 7) of 4 records reviewed where start of care services were delayed, from a total of 7 sampled records reviewed…

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 4…

The Agency failed to ensure that 6 (MR's #1, 2, 3, 4, 5 and 6) of 6 patients who required assistance with grooming, had the Activities of Daily Living needs adequately met in the patient's home, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, loss of…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 2 (MR's #1, 3) of 7…

The Agency failed to ensure the Comprehensive Assessment was updated and completed at the time of discharge from the agency's services in 1 (MR #1) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in no indication of the patient’s progression towards their identified…

The Agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient in 5 (MR's # 1, 2, 3, 4, 7) of 5 records, from a total of 7 sampled records reviewed, resulting in…

The agency failed to record all patient care orders in the Plan of Care in 1 of 7 (MR#7) records reviewed, resulting in lack of services provided as ordered by the physician.

The physical therapist failed to provide a written copy of the home exercise program prescribed by the physical therapist to aid the patient in performing the prescribed physical therapy exercises between scheduled physical therapy visits in 1 of 2 records reviewed (MR#7) in which Physical Therapy…

The Agency failed to initiate any performance improvement activities within their QAPI program that focused on high risk, high volume, or problem prone areas, resulting in the potential for agency issues with negative consequences for high risk, high volume, or problem prone areas that could affect…

The Agency failed to ensure the Registered Nurse performed re-assessments of the patient's health status and needs in 1 (MR #2) record of a patient with a diagnosis of congestive heart failure, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns…

The Agency failed to ensure Occupational Therapy and Physical Therapy services were provided as ordered for 3 (MR's #1, 2, 3) patients who required Therapy services ordered, from a total of 7 sampled records reviewed, resulting in the potential for decline in physical functioning, and unmet care…

The Agency failed to ensure the clinical record was completed and included detailed Skilled Nursing and Physical Therapy notes for 2 (MR' #2, 3) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns…

The Administrator failed to ensure the Clinical Manager was available at all times during operating hours, resulting in the lack of clinical supervision and oversight and the potential for unmet care needs for the Agency's existing patients.

The Agency failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The Clinical Manager failed to ensure that appropriate disciplines were assigned to provide needed care and services for 3 (MR's #1, 2, 3) patients who required skilled services, from a total of 7 sampled records reviewed, resulting in patients not receiving care in accordance with their identified…

The Clinical Manager failed to ensure the patient's needs were continually assessed for 1 (MR #2) of 1 patient observed during a home visit, who required skilled services and ongoing assessments, from a total 7 sampled records reviewed, resulting in lack of assurance that assessments are performed…

The agency failed to include required information in the Transfer and Discharge Summaries in 1 of 1 (MR# 7) Transfer records and 1 of 2 (MR#6) Discharge records reviewed resulting in a lack of information to ensure continuity of care for the patients transferred from the agency.

The agency failed to ensure services were provided as ordered by the physician for 3 of 7 (MR# 1, 3, 4) records reviewed, resulting in a delay of services and the potential for poor patient outcomes.

The agency failed to ensure that the initial comprehensive assessment visit was made within 48 hours of the date of the referral for 3 of 7 (MR# 2, 6, 7) records reviewed, resulting in a delay in determining the immediate care and support needs of the patient and the potential decline of the…

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 2 of 7 (MR# 3, 6) records reviewed; and failed to ensure the physician was informed of drug…

The agency failed to ensure the plan of care included measurable skilled nursing outcomes and goals for 3 of 7 (MR# 1, 2, 7) records reviewed; failed to ensure the plan of care included the frequency and duration of physical therapy services for 1 of 6 (MR#1) records reviewed with physical therapy…

The nurse failed to coordinate care to ensure the diabetic patient had a glucometer for 1 of 3 (MR#2) patients with primary diagnoses of diabetes, resulting in the patient's inability to monitor blood glucose levels.

The agency failed to ensure that therapy services were provided as ordered in the plan of care for 3 of 6 (MR# 1, 3, 7) records reviewed in which therapy services were provided.

The agency failed to ensure the registered nurse or physical therapist completed an on-site supervisory visit to the patient's home at least every 14 days to supervise the services that were provided by the home health aide for 2 of 3 (MR# 6, 7) records reviewed in which aide services had been…

The agency failed to ensure the clinical record was complete and included clinical notes for 2 of 7 (MR# 1, 4) records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient's health status and progression towards goals.

The agency failed to ensure a discharge summary was completed and sent to the physician within 5 business days of the patient's discharge for 2 of 2 (MR# 6 and 7) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's…