Inspection Report
Routine
Deficiencies: 1
Apr 22, 2025
Visit Reason
The purpose of this visit was to conduct a periodic compliance survey on April 22, 2025.
Findings
Rule violations were cited related to the agency's failure to ensure the service agreement included in the client's record contained all required elements, specifically missing frequency and duration, charges for services, and all-inclusive language on client's rights and responsibilities.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The service agreement for Client #1 was incomplete, missing frequency & duration, charges for services, and all-inclusive language on client's rights and responsibilities. | SS= D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A stated during the exit conference that the agency will make all changes. |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 22, 2023
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the May 10, 2023 inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 9
May 10, 2023
Visit Reason
The purpose of this visit was to conduct the initial on-site compliance inspection on May 10, 2023.
Findings
Rule violations were cited related to documentation deficiencies in client referral information, personnel records, tuberculosis screening, employee qualifications, nursing assessments, supervisory visits, and service plan content and timeliness.
Severity Breakdown
D: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to document the referral source and date for two clients. | D |
| Failed to ensure identifying information such as name, address, telephone number, and emergency contact person(s) was obtained for three of four sampled staff. | D |
| Failed to provide documentation of a satisfactory tuberculosis (TB) screening test upon employment and annually thereafter for two of four sampled staff. | D |
| Failed to ensure employee files included documentation of at least an annual performance evaluation for one of four sampled staff. | D |
| Failed to ensure employees providing personal care were qualified as certified nursing assistants (CNA) or had completed required competency tests for one of four sampled employees. | D |
| Failed to ensure regular and/or ongoing assessments of the nursing needs for one of two clients. | D |
| Failed to ensure timely supervisory visits of nursing services for one of two clients. | D |
| Failed to ensure the service plan included specific tasks and directions for one of two clients. | D |
| Failed to ensure the service plan was completed by the service supervisor within seven working days after services were initially provided for one of two clients. | D |
Report Facts
Number of clients sampled: 2
Number of staff sampled: 4
Hire date: Jun 1, 2021
Hire date: Apr 17, 2023
Service plan date: Apr 15, 2023
Client start of care date: Mar 7, 2023
Client service begin date: Apr 18, 2023
Skilled nursing services start date: Jun 10, 2022
Missed supervisory visits: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed during exit interviews, responded to findings | |
| Staff B | Nurse Practitioner | Missing emergency contact, expired TB test, missing annual performance evaluation |
| Staff C | Missing emergency contact information | |
| Staff D | Caregiver | Missing emergency contact, no TB test documentation, not qualified as CNA or completed competency tests |
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