Aloha Home Health, LLC

The Home Health Agency (HHA) failed to provide the prescribed physical therapy services for 1 of 17 sampled patients (Patient (P) 9 within 48 hours of the physical therapy (PT) referral.

The Home Health Agency was not in compliance with rules regarding safeguarding personal health information creating a risk of loss and unauthorized use of patient information.

The Home Health Agency failed to ensure Occupational Therapy (OT) visits or canceled visits were documented in the electronic medical record (EMR) for 2 of 17 sampled (Patients (P) P11 and P12. This deficient practice did not ensure current clinical assessments were available for the…

The agency failed to ensure a safe and appropriate transfer to a higher level of care was provided during a decline in status for 1 of 5 sampled patients (Patient #1).

The agency failed to ensure a patient was seen within 48 hours of the patient's return from the hospital for 1 of 5 sampled patients (Patient #1).

The agency failed to ensure a patient was seen within 48 hours of the patient's return from the hospital for 1 of 5 sampled patients (Patient #1).

The agency's Licensed Practical Nurse failed to notify a Physician regarding a change in status for 2 of 5 sampled patients (Patient #5 and #1).

The facility failed to meet the Conditions for Participation (COP) 484.22 for Emergency Preparedness when the facility failed to: 1. Have documented evidence of facility/community based risk assessment.

The agency failed to meet the Conditions of Participation (COP) 485.65 for Quality Assessment/Performance Improvement (QAPI) when the agency failed to: Findings include: 1. The agency failed to demonstrate the Quality Assessment/ Performance Improvement Program (QAPI) included goals of measurable…

The agency failed to meet the Conditions for Participation (COP) 484.105 for Organization and Administration of Services when the facility failed to: Findings include: 1. Agency failed to ensure oversight by a governing body resulting in inadequate management of the agency.

The facility failed to develop an emergency preparedness plan that included a community based plan.

The agency failed to develop an emergency preparedness plan that included notifying the State and local authorities of on-duty staff that the Home Health Agency (HHA) was not able to contactduring an emergency.

The agency failed to conduct drills to test the emergency preparedness plan and to include all staff employed or contracted by the Home Health Agency (HHA).

The facility failed to develop an emergency preparedness plan that included initial and annual training for staff.

The agency failed to develop an emergency preparedness plan that included a community-based all hazards exercise, and failed to document the inability to participate with the community.

The agency failed to ensure an overall evaluation of the agency's total program was conducted at least yearly by a committee of members including professional personnel, agency staff and consumers.

The agency failed to ensure there was a total program evaluation that consisted of a collection of pertinent data which should have included program appropriateness, adequacy, and program effectiveness and efficiency at least yearly.

The agency failed to provide evidence that the annual evaluation of all agency programs had been conducted.

The agency failed to ensure all Certified Nursing Assistants (NAs) maintained a minimum of 12 hours of in-services training per 12 months for 8 of 8 NA's employed by the facility.

The agency failed to ensure the governing body conducted a meeting at least yearly.

The agency failed to demonstrate the Administrator organized and directed the agency's ongoing functions and maintained an ongoing liaison between the governing body, the professional personnel (Medical Director) and the staff.

The agency failed to demonstrate the Administrator ensured adequate staff education.