Avery Partners Inc

The agency's emergency's preparedness policy and procedures failed to include procedures to comply with all applicable Federal, State and local emergency preparedness requirements.

The agency's emergency's plan failed to ensure an up to date all hazards risk assessment had been completed for the agency.

The agency's emergency's plan failed to address the types of services the agency has the ability to provide in an emergency.

The agency failed to develop and implement emergency preparedness policies and procedures in regards to their process for ensuring cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to ensure an integrated response during a…

The agency failed to develop and implement emergency preparedness policies and procedures related to identified hazards within the facility's risk assessment and the facility's overall emergency preparedness program.

The agency's emergency's preparedness policy and procedures failed to include procedures to inform State and local emergency preparedness officials about home health patients in need of evacuation from their residences.

The agency's emergency's preparedness policy and procedures failed to include the procedures to follow up with on-duty staff and patients.

The agency's emergency's preparedness policy and procedures failed to include a policy for medical documents.

The agency's emergency's preparedness policy and procedures failed to include a policy and procedure for the use of volunteers in an emergency or for emergency staffing needs.

The agency failed to ensure they had an emergency communication plan that was updated at least annually.

The agency's emergency's preparedness communication plan failed to include the names and contact information for all entities providing services under arrangement.

The agency's emergency's preparedness communication plan failed to include an emergency preparedness plan that had been updated annually and included contact information for federal, state and local emergency preparedness staff.

The agency's emergency's preparedness policy failed to include methods for sharing medical documentation for patients with other health providers to maintain continuity of care.

The agency's emergency's preparedness policy failed to include a comprehensive communication plan.

The agency failed to implement a training and testing program Findings The agency's emergency preparedness plan, policies, and procedures were reviewed in the agency on 03/28/2018. The agency failed to include the development and maintain an emergency preparedness training and testing program.

The agency failed to provide initial training in emergency preparedness policies and procedures that are consistent with their roles in an emergency to all new and existing staff, individuals providing services under arrangement, and volunteers.

The agency failed to implement or document the annual tabletop and full-scale exercises.

Agency staff failed to provide the patient and/or caregiver with a copy of written instructions within 5 days of completion of the comprehensive assessment outlining the following: (1) Visit schedule, including frequency of visits by the agency's personnel acting on behalf of the agency, (2)…

Staff interview it was determined the agency's CLIA (Clinical Laboratory Improvement Amendments) waiver expired in 2016. Findings: The agency's CLIA Waiver was reviewed in the agency on 03/27/2018. The CLIA Waiver expired in 2016. An interview was conducted in the agency on 03/27/2018 with the…

Agency failed to ensure patients were provided the agency's transfer and discharge policies.

Agency staff failed to ensure patients were provided the contact information for the home health administrator, including the administrator's name, business address and business phone number in order to receive complaints.

Agency staff failed to document the disciplines that would furnish care, the frequency of the proposed visits and expected outcomes for seven (7) of thirteen (13) clinical records reviewed in the survey sample (Clinical records: 1, 3, 4, 7,8, 10 and 12).

Agency staff failed to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and…

The agency failed to ensure the patient's medication profiles contained a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions…

The agency failed to ensure the patient's individualized plan of care included measurable outcomes and goals identified by the agency and/or failed to contain dose/frequency and route of patient medications for nine (9) of nine (9) clinical records reviewed in the survey sample of patient's…

The agency failed to ensure drugs, services, and treatments were administered only as ordered by a physician for four (4) of thirteen (13) clinical records reviewed in the survey sample.

Agency staff failed to ensure patients were advised of the name and contact information of the Home Health Agency's clinical manager for two (2) of three (3) patients admitted on or after 01/13/2018. (Patients #10 & 13) Findings: Five (5) home visits were conducted on 03/27/2018 between the hours…

The agency failed to ensure the Registered Nurse addressed all required elements for each home health aide supervisory visit conducted on or after 01/13/2018 for four (4) of four (4) clinical records reviewed in the survey sample with home health aide supervisory visits conducted on or after…

The Administrator failed to ensure the agency employs qualified personnel and ensures adequate staff education, such as, competencies and skills check lists for eight (8) of ten (10) personnel files reviewed in the survey sample.