Academy Home Care, Inc

The agency failed to develop and maintain an emergency preparedness plan that included a hazard risk assessment that must be reviewed and updated at least annually (Refer to E-006); failed to develop and implement policies and procedures for the agency that are based on a risk assessment and…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that measures, tracks and analyzes it's quality indicators in order to assess the processes of care and services provided by the agency, resulting in the inability to improve patient care with…

The agency failed to document an agency wide infection control program to prevent and control the spread of infections and communicable diseases (G-684), resulting in the potential for the spread of infections and communicable disease to staff and patients of the agency.

The agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency's provision of home health services…

The agency failed to develop and maintain an emergency preparedness plan that included a hazard risk assessment and must be reviewed and updated at least annually.

The agency failed to develop and implement Emergency Preparedness policies and procedures for the agency based on a risk assessment and communication plan that are reviewed and updated at least every 2 years.

The agency failed to develop a written emergency communication plan that included information on how the facility coordinates patient care within the facility, across healthcare providers, and with the state and local public health departments to support coordination of care for the care of the…

The facility failed to develop and maintain an emergency preparedness communication plan that included a primary and alternate means for communicating with staff and Federal, State, Tribal, Regional, and local Emergency Preparedness Officials, resulting in the lack of essential information being…

The Agency failed to develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section.

The agency failed to develop, document and ensure participation of staff in the Agency's Emergency Preparedness training program to ensure staff are educated on the agency policies and procedures in preparation for an emergency event.

The Agency failed to provide documentation for the required annual tabletop and community based full-scale exercise nor any documentation of an actual event that would qualify as a test of the emergency plan, resulting in the potential to negatively affect all patients and staff in the event of an…

The agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential for unmet care needs.

The agency failed to document what data they would collect and monitor for their Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no…

The Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for…

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

The home health agency failed to have an active Governing Body that met at least annually and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans and its…

The Agency (HHA) failed to include contact information for the Home Health Agency's Administrator in the agency's Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns or complaints.

The agency's Governing Body had appointed an administrator to oversee agency operations, resulting in the potential for negative patient outcomes.