Valerie Home Health Care Services, Inc

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 3 of 7 (MR 2, 4, 6) records reviewed (refer to G514); failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on the…

The agency failed to ensure the plan of care included frequency and duration of visits, interventions, treatments, measurable outcomes, and goals for 7 of 7 (MR 1, 2, 3, 4, 5, 6, 7) records reviewed (refer to G574); failed to ensure the physical therapist notify the physician of findings that fell…

The agency failed to develop a Quality Assessment Performance Improvement (QAPI) program to optimize patient outcomes.

The agency failed to ensure the update to the comprehensive assessment warranted recertification for an additional episode of care for 1 of 2 (MR 7) records reviewed in which patient care was recertified for additional episodes of care, resulting in the provision of home care services to a…

The agency failed to ensure the physical therapist notify the physician of findings that fell outside the parameters ordered in the patient’s plan of care in 1 of 4 (MR 6) records reviewed with physical therapy services, resulting in the potential for physical decline and unmet care needs for this…

0642: Based on record reviewed and Interview, 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 track adverse patient events, analyze their causes, and implement preventive actions.

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 ensure to document and track the COVID-19 vaccination completion, exemption, or temporary delay status for 1 of 8 (HHA-H) staff that provide patient care for the agency.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 3 of 7 (MR 2, 4, 6) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients.

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

The agency failed to ensure the physician was informed of any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 1 of 7 (MR 7) records reviewed, resulting in the potential for harmful medication effects for this patient.

The agency failed to ensure the comprehensive assessment at discharge indicated the patient had met the care plan goals for 3 of 5 (MR 2, 4, 6) discharge records reviewed, resulting in the patient being discharged from the agency before meeting the care plan goals.

The agency failed to ensure the plan of care included frequency and duration of visits, interventions, treatments, measurable outcomes, and goals for 7 of 7 (MR 1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to…

The agency failed to ensure the physician was notified of significant changes in the condition of the patient for 2 of 7 (MR 4, 7) records reviewed, resulting in the potential for poor patient outcomes for these patients.

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 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 ensure skilled professionals performed assessments of the patient's health status and needs in 2 of 4 (MR 5, 6) records reviewed with multiple disciplines, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes.

The agency failed to ensure the nurse provided services as ordered by the physician in the plan of care for 2 of 7 (MR 4, 7) records reviewed, resulting in the potential for poor patient outcomes for these patients.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of discharge for 4 of 5 (MR 3, 4, 5, 6) discharge records reviewed; and failed to include required information in the Transfer Summary in 1 of 2 (MR 3) Transfer records reviewed resulting in a lack of…

The agency failed to update/revise the Emergency Preparedness Plan to include the monitoring and prevention of the Corona Virus Disease, for a potential spread of a major Pandemic disease to all 9 employees and all patients served by the agency from 3/1/2020 to 7/7/2020. Findings include: During…

The agency failed to update the Emergency Preparedness Plan to include COVID-19 and provide in-service training on the update for 9 of 9 active employees and all patients receiving services from 3/1/2020 to 7/7/2020 resulting in the potential spread of a contagious infection between agency staff…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to provide infection control training to all employees for the COVID-19 from 3/1/2020 to 7/7/2020; and failed to develop a method of screening visitors and…

The Agency failed to provide documented evidence that COVID-19 infection control education was provided to all 9 staff employed by the agency staff, resulting in the potential for the development and spread of the COVID-19 infection to staff and all patients serviced by this agency from 3/1/2020 to…

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, measurable data to use as a baseline for future assessments…

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

The Agency failed to include contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed concerns for all patients serviced by this agency.

The Agency failed to advise their patients of the names, addresses and telephone numbers of federally funded and state-funded entities that serve the area where the patient resides, resulting in the potential for unmet patient care needs.

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 3 records (MR's #5, 6, 7) from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all 5…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, failed to include all functional limitations, and objectively measurable goals specific to the needs of the patient for 7 (MR's #1, 2, 3, 4, 5, 6 and 7) records, from a total of 7 sampled…

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status and needs in 1 (MR #6) of 1 record of a patient with a diagnosis of congestive heart failure, from of a total sample of 7 records reviewed resulting in the potential for…

The Agency failed to ensure Physical Therapy services were provided as ordered, for 1 (MR #6) of 3 records with Physical Therapy services ordered, from a total of 7 records reviewed, resulting in the potential for decline in physical functioning, and unmet care needs.

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 1 of 3 (MR# 4) records reviewed in which the patient was discharged from the agency from a total of 7 sampled records reviewed, resulting in the physician…