All Care Home Health

The Agency failed to maintain documentation direct care staff had receiving training on the agency's emergency preparedness plan for 10 of 10 employee files reviewed.

The Agency failed to evaluate the response to and maintain documentation of emergency drills to include the lessons learned following emergency drills and identify concerns to make improvements to their emergency plan; and conduct and maintain documentation of an annual tabletop exercise.

The agency failed to ensure the Outcome and Assessment Information Set (OASIS/a comprehensive patient assessment) was completed within the required time frame for 1 of 8 sampled patients (Patient 4).

The Agency failed to ensure the plan of care for 7 of 8 patients was signed and dated within thirty working days by the attending physician.

The agency failed to ensure confidentiality of a patient record for one unsampled patient.

The agency failed to identify oxygen as a medication on a medication profile for 1 of 8 patients (Patient #5).

The agency failed to ensure missed visits were communicated to physicians for 1 of 8 patients (Patient #5).

The agency failed to ensure it submitted a 60 day clinical summary to a physician for 1 of 8 patients (Patient #5).

The agency failed to ensure a medical social worker (MSW) was hired or contracted to provide the social services needs of the patients.

The agency failed to ensure a supervisory visit for a certified nursing assistant (CNA)/home health aide (HHA) was performed every 14 days for 1 of 8 sampled patients (Patient 4).

The facility failed to meet the Condition for Participation (COP) 484.102 for Emergency Preparedness when the facility failed to develop and implement emergency policies and procedures based on the emergency preparedness plan.

The Home Health Agency (HHA) failed to develop an emergency preparedness plan that included a community based risk assessment, utilizing an all-hazards approach.

The agency failed to document a process for cooperation and collaboration with emergency preparedness officials in developing an integrated response for emergency situations.

The agency failed to develop agency specific policies and procedures based on a developed emergency plan.

The agency failed to develop agency specific policies and procedures to inform State and local emergency preparedness officials of the need for patient evacuations.

The agency failed to develop agency specific procedures to follow up with on-duty staff and patients to determine services that were needed, in the event that there was an interruption in services during or due to an emergency.

The agency failed to develop a system of medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records during an emergency situation.

The agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness staff.

The agency failed to develop and maintain and emergency preparedness communication plan that included policies and procedures for an alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency management agencies.

The agency failed to develop and maintain an emergency preparedness communication plan that included a method for releasing and sharing information and medical documentation for patients under the agency's care, and as necessary with other health providers to maintain the continuity of care.

The agency failed to develop and maintain an emergency preparedness training and testing program.

The agency failed to maintain documentation of emergency preparedness training for all of its employees.

The agency failed to account for a physician ordered visit for 1 of 7 sampled patients (Patient #5).

The agency's skilled clinicians failed to employ bag technique for 1 of 7 sampled patients (Patient #3).

The agency failed to identify the plan of care contained ambiguous information for 1 of 7 sampled patients (Patient #6).

The agency's nurse(s) failed to accurately review and document all current patient medication for 2 of 7 sampled patients (Patient #6 and #7).

The agency provided wound care without an order and failed to obtain a physician order for a newly identified sacral wound; failed to obtain an order for catheter size used for a catheter change for 1 of 7 patients (Patient #6).

The agency failed to notify a physician of a newly opened pressure sore area for 1 of 7 sampled patients (Patient #6).

The agency failed to maintain documented evidence a Home Health Aide completed a competency evaluation.

The agency failed to maintain documented evidence Home Health Aides completed 12 units of continuing education credits on an annual basis.

The agency failed to complete a 60 day summary for 1 of 7 sampled patients (Patient #6).