Inspection Report
Routine
Deficiencies: 1
Jan 28, 2025
Visit Reason
The purpose of this visit was to conduct a periodic compliance survey on January 28, 2025.
Findings
Rule violations were cited related to supervisory home visits for personal care services. Specifically, supervisory visit forms for one of two sampled clients failed to include all required elements.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Client supervisory visits for personal care services failed to include all required elements for one of two sampled clients (Client #2). | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding supervisory visit deficiencies and stated the agency will make all updates and changes. |
Inspection Report
Routine
Deficiencies: 5
Jun 15, 2023
Visit Reason
The purpose of this visit was to conduct a periodic inspection on June 15, 2023.
Findings
Rule violations were cited as a result of this inspection. Deficiencies were found related to incomplete service agreements, missing annual performance evaluations for staff, inadequate staff qualifications, incomplete supervisory home visits, and incomplete service plans lacking pertinent client information.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a description of services needed as stated by client or responsible party for two of three sampled clients. | D |
| Failed to ensure employee files included documentation of at least an annual performance evaluation for two of five sampled staff. | D |
| Failed to ensure employees providing personal care were qualified as certified nursing assistants or completed required competency tests for two of five sampled employees. | D |
| Failed to ensure supervisory home visits included all required elements for one of three sampled clients. | D |
| Failed to ensure service plans included pertinent diagnoses, medications and treatments, equipment needs, and diet and nutritional needs for three sampled clients. | D |
Report Facts
Number of sampled clients with missing service description: 2
Number of sampled staff missing annual performance evaluations: 2
Number of sampled employees lacking required qualifications: 2
Supervisory home visit frequency requirement: 122
Number of sampled clients with incomplete supervisory visits: 1
Number of sampled clients with incomplete service plans: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed during exit, acknowledged deficiencies and inability to locate evaluations or qualifications | |
| Staff B | Registered Nurse | Missing 2022 annual performance evaluation |
| Staff C | Personal Care Assistant | Missing 2022 annual performance evaluation |
| Staff D | Incomplete personal care assistant test and missing qualifications | |
| Staff E | Missing qualifications |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 22, 2022
Visit Reason
The purpose of this visit was to conduct a follow up inspection to the January 4, 2022 inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 10
Jan 4, 2022
Visit Reason
The purpose of this visit was to conduct a periodic inspection of the facility to assess compliance with applicable regulations.
Findings
The inspection identified multiple deficiencies related to service agreements, personnel records, supervision of services, service plans, and supervisory home visits. Deficiencies included improper verbiage in service agreements, missing documentation of TB screening and job descriptions for staff, lack of supervisory signatures on client task sheets, incomplete service plans, and failure to conduct required supervisory home visits.
Severity Breakdown
SS= D: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Service agreements failed to include expected frequency and duration of services for two clients. | SS= D |
| Service agreements failed to include charges and billing/payment mechanisms for two clients. | SS= D |
| Personnel records lacked documentation of satisfactory TB screening for one staff member. | SS= D |
| Personnel records lacked job descriptions for two staff members. | SS= D |
| Personnel records lacked documentation of annual written evaluations for three staff members. | SS= D |
| Services were not supervised by qualified staff as evidenced by missing supervisory signatures on client task sheets for four clients. | SS= D |
| Initial service plan was not completed by an appropriate supervisor for one client. | SS= D |
| Supervisory home visits were not made at least every 92 days for two clients. | SS= D |
| Supervisory home visits were not made at least every 122 days for one client. | SS= D |
| Service plans lacked detailed descriptions of functional limitations and discharge plans for four clients. | SS= D |
Report Facts
Number of sampled clients with service agreement deficiencies: 4
Number of sampled staff with personnel record deficiencies: 7
Number of clients missing supervisory home visits every 92 days: 2
Number of clients missing supervisory home visits every 122 days: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Acknowledged improper verbiage in service agreements and missing supervisory visits during exit interviews | |
| Staff B | Registered Nurse | Missing annual written evaluation documentation |
| Staff C | Missing job description in personnel file | |
| Staff D | Personal Care Assistant | Expired TB screening and missing annual evaluation documentation |
| Staff E | Certified Nursing Assistant | Missing annual evaluation documentation |
| Staff F | Missing job description in personnel file | |
| Staff G | Unaware of supervisory signature requirements on task sheets |
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