Accessible Healthcare, LLC

The agency failed to ensure a review of the Emergency Preparedness Plan at least every two years.

The agency failed to ensure policies and procedures for Emergency Preparedness were developed using their Hazard Vulnerability Assessment.

The agency failed to ensure the staff emergency contact information was reviewed and updated as needed at least every two years.

The agency failed to ensure completion of annual exercises of their Emergency Preparedness Plan (EP Plan).This failure had the potential to negatively impact the agency’s ability to evaluate the staff's skills and readiness needed in the event of an actual emergency, placing all 26 patients…

The agency failed to ensure the assigned clinicians followed the plan of care as ordered for four of nine patients sampled (Patient (P)1 P2, P8, and P9).

The agency failed to ensure that a qualified person was designated to act as Administrator in the absence of the Administrator.

The agency failed to have documentation of an effective, ongoing Quality Assessment and Performance Improvement (QAPI) program focusing on improved outcomes with measurable indicators that is reviewed and approved by the Governing Body.

The agency failed to maintain a Quality Assurance/Performance Improvement (QAPI) program which measured, analyzed, and tracked quality indicators demonstrating improvement in outcomes and quality of care during 2018. Findings include: The agency could not produce evidence it tracked any data for a…

The agency failed to establish and implement Quality Assurance Performance Improvement (QAPI) activities.

The agency failed to initiate and document performance improvement project(s) that would reflect the scope and complexity of services and demonstrate progress toward identified measurable goals.

The agency's Governing Body did not ensure an ongoing Quality Assurance/Performance Improvement Program (QAPI) was implemented, evaluate its effectiveness, or assure priorities were identified to improve patient care and safety.

The home health agency failed to ensure infection control standards of practice were implemented by staff during a home visit and while providing care for 1 of 4 patients (Patient (P)10).

The home health agency failed to provide infection control education to staff after hire and prior to providing direct care or an annual basis.

The agency failed to ensure there was a designated Clinical Manager available and accessible to the patients, staff and to supervise the home health services to patients.

The home health agency was not in compliance with rules regarding safeguarding personal health information creating a risk of loss and unauthorized use of resident information.

The home health agency failed to ensure patients and/or caregivers were provided with a written schedule identifying the frequency of discipline visits outlined in the Plan of Care (POC) for four of four patients (Patient (P)7, P8, P9, and P10) reviewed for home visits.

The agency failed to provide 3 of 4 patients (Patient (P)7, P8, and P9) reviewed during home visits with a current medication list and instructions that were understandable to the patient.

The agency failed to ensure skilled professional supervisory visits for two of 10 sample patients (P)7 and P10, who received Home Health Aide (HHA) services.

The home health agency failed to ensure the electronic home health computer program included clinical notes and visits for 4 of 10 Patients (P)5, P6, P7 and P8 when completed with up to a delay of 14 days.