Best Care Health Services, Inc.

The agency failed to: (E-0004) maintain, review and update the emergency preparedness plan annually; (E-0006) develop a community-based risk assessment prior to developing the agency's emergency plan; (E-0007) address patient/client population, including, but not limited to, persons at risk…

The facility failed to: (G 0642) ensure a Quality Management (QM) program was documented and implemented, as evidenced by there was no available documented QM information to review, which poses the potential risk to the health and safety of patients if services provided to patients are not…

The agency failed to maintain, review and update the emergency preparedness plan annually.

The facility failed to develop a community-based risk assessment prior to developing the facility's emergency plan.

The facility failed to address patient population, persons at-risk, services the HHA can provide in an emergency, delegation of authority, and succession plans.

The facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

The agency failed to have an individual EP plan for each patient identified in the comprehensive assessment.

The agency failed to update and annually review the EP plan and policies, to inform State and Local emergency preparedness officials about patients in need to be evacuated from their residence.

The agency failed to develop and implement a policy and procedure for the use of volunteers in an emergency.

The facility failed to develop and implement an emergency preparedness Communication Plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually.

The agency failed to have a primary and alternate means of communication during an emergency.

The facility failed to develop and implement a method for sharing information and medical documentation for patients under the HHA'S care, as necessary, with other health care providers to maintain the continuity of care.

The agency failed to develop a means to sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction.

The facility failed to develop a facility based emergency planning, training and testing program.

The agency failed to have the existing staff review the emergency preparedness policies and procedures training, at least annually.

The facility failed to conduct exercises to test the emergency plan at least annually.

The facility failed to ensure care plans were developed for each patient, as evidenced by 6 of 6 patient records failed to demonstrate that a care plan was included, which poses the potential risk to the health and safety of patients by not documenting indentified patient-specific measurable…

The facility failed to ensure a Quality Management (QM) program was documented and implemented, as evidenced by there was no available documented QM information to review, which poses the potential risk to the health and safety of patients if services provided to patients are not monitored…

The facility failed to ensure that an initial assessment visit was performed by a RN, as evidenced by review of 6 of 6 medical records which did not have documentation of an initial visit conducted by a RN, which increases the patient's risk for a potentially avoidable event.