Victory Home Health, LLC

The agency failed to ensure weights were obtained as ordered for two (Patient #2 and 6) of 11 patients.

The agency failed to ensure coordination of care for the management of pain for one (Patient #2) of 11 patients.

The agency failed to ensure the accuracy of the primary diagnosis documented on skilled nurse assessments for one (Patient #2) of 11 patients.

The agency failed to ensure coordination of care was provided for one (Patient #6) of 11 patients.

The agency failed to ensure its QAPI Program showed measurable improvement in indicators related to improved agency services.

The agency failed to ensure emergency drills were completed for all employees and 27 current patients.

The agency failed to ensure: 1. physical therapy frequencies were completed as ordered for one (Pt #2) of 17 patients; 2. skilled nurse visit frequencies were completed as ordered for two (Pt #3 and 5) of 17 patients; Findings: Pt #2 A review of the plan of care dated 06/26/20 to 08/24/20 showed…

The agency failed to ensure its QAPI Program showed measurable improvement in indicators related to improved agency services.

The agency failed to ensure quality indicators were analyzed.

The agency failed to ensure implementation and evaluation of PIPs for all employees and 431 patients on service during the calendar year of 2018, 2019 and the first three quarters of 2020. This failed practice had the potential to place the agency, all patients and all employees at risk for…

The agency failed to ensure an ongoing, comprehensive QAPI program was approved by the governing body.

The agency failed to ensure the Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for 431 patients and all staff.

The agency failed to ensure governing body oversight of this agencies budget, QAPI program and PIPs and infection control program for all employees and patients of the agency during calendar years 2018, 2019 and January through November 1, 2020.. Findings: A review of governing body minutes for…

The agency failed to ensure the initial assessment was performed within 48 hours of the referral for one (Pt #1) of 17 patients.

The agency failed to ensure POC orders included: 1) blood glucose parameters for one (Pt #12) of 17 patients; 2) interventions for hypoglycemia or hyperglycemia for one (Pt #13) of 17 patients.