Always Independent Inc.

The agency failed to base the emergency preparedness plan on and to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

The agency failed to conduct an exercise to test the emergency plan at least annually.

The agency lacked documentation in their meeting minutes for the fiscal affairs of the agency in regard to approving an annual operating budget and reviewing the annual program evaluation.

The registered Nurse did not follow best practice guidelines concerning wound management for one (1) of one (1) clinical records reviewed (CR# 1) Findings include: The agency's policy concerning wound management was requested on 1/5/23 at approximately 12:30 PM and Director of Nursing/Administrator…

The agency failed to obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for one (1) of one (1) clinical record reviewed: CR#1 Review of the agency policy/documentation took place on 1/5/23 at…

The agency failed to ensure all patient care orders, including verbal orders were recorded in the plan of care for one (1) out of one (1) clinical record reviewed (CR#1) Findings include: Agency policy titled "Acceptance of Patients, Plan of Care, and Medical Supervision " was reviewed on January…

The agency failed to ensure Home Health Certification and Plan of Care/Treatment was created and signed by a physician for one (1) out of one (1) clinical record reviewed (CR#1) Findings include: Agency policy titled "Acceptance of Patients, Plan of Care, and Medical Supervision " was reviewed on…

The administrator failed to follow the agency's personnel requirements of annual performance evaluations for one (1) of one (1) personnel file (PF) reviewed (PF#1) Review of agency policy was conducted on 1/5/23 at approximately 12:15 PM and revealed the following: Policy titled, "Annual review"…

When asked who the alternate administrator/alternate director of nursing was the DON responded there was not an alternate for either the Administrator or Director of Nursing roles.

Agency failed to provide documentation that a discharge summary was sent to the physician within five (5) days of discharge for one (1) of one (1) discharge records reviewed (CR #1).