Access Home Health, LLC

The home health agency (HHA) failed to develop, implement, and maintain an ongoing quality assessment and performance improvement (QAPI) program to improve patient safety, health outcomes or quality of care since 03/26/21. This had the potential to affect the safety of services and quality of care…

The agency failed to ensure the EP plan was reviewed and updated at least every two years.

The agency failed to ensure the emergency preparedness (EP) plan included the names and contact information of agency staff and patients' physicians.

The agency failed to complete an exercise of its choice to test of the emergency preparedness (EP) plan.

The agency failed to ensure that patient care was provided as written in the plan of care for one of seven patients (Patient (P) 3) whose blood sugar readings were not reviewed or reported to the physician.

The agency failed to analyze patient adverse events and infection surveillance data that was collected or review this information as a component of a quality assessment and performance improvement (QAPI) program.

The agency failed to (1) use data indicators to identify opportunities for improvement of patient services, and (2) ensure the governing body approved the data collected by the agency.

The governing body failed to ensure a quality assessment performance improvement (QAPI) program was implemented and maintained on an ongoing basis.

The agency failed to ensure staff completed hand hygiene in between glove changes and cleaned equipment during one of three patient (Patient (P) 3) observations.

The agency failed to ensure infection surveillance data was investigated, analyzed, or reviewed as a part of an agency quality assessment and performance improvement (QAPI) program.

The agency failed to complete a discharge summary for two of two discharged patients (Patient (P)1 and P2).

The agency failed to maintain a program for the identification and prevention of infectious and communicable diseases.

The facility failed to ensure the Plan of Care (POC) included Advanced Directives for (P#1-P#7) for (7 of 7) records reviewed and patients interviewed.