Comprehensive Quality Care, Inc Foundation

Based of review of Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Plan was established based on a risk assessment using an all hazards approach.

The Agency failed to conduct staff training related to Agency’s Emergency Preparedness Plan.

The Agency failed to conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Plan as required.

In 38 of 60 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning.

The Agency failed to provide the Pt./patient's representative information regarding the Administrator.

In 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies.

In 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to ensure the Pt./representative was informed in writing of the the frequency of visits provided by each discipline.

In 3 of 7 (Pts. #1, 5, and 4) clinical records reviewed, the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services.

In 2 of 2 (Pts. #6 and 7) discharged records reviewed, the Agency failed to ensure that a comprehensive assessment was updated at discharge.

In 6 of 7 (Pts. #1, 5, 7, 3, 4, and 6) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and/or Influenza vaccines, as required by the Agency.

The Agency failed to provide information regarding the Director of Patient Services and their contact information.

In 5 of 7 (Pts. # 4, 6, 1, 5 and 7) clinical records reviewed, the Agency failed to provide services as ordered by the Physician.

In 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the discharge summary.

The Agency failed to review and update its Emergency Preparedness plan, ensure the plan was established based on a risk assessment, review and update its communication plan and conduct staff training and testing relative to the Agency's Emergency Plan.

The Agency failed to ensure the Emergency plan was based on a risk assessment.

The Agency failed to develop a communication plan.

The Agency failed to conduct staff training and testing relative to the Agency's Emergency Preparedness Plan.

The Agency failed to ensure that patient medication profile include prescribed medications.

The Agency failed to ensure the comprehensive assessment was updated at discharge.

Based clinical record review, patient interview and staff interview, it was determined that the Agency failed to ensure patients received services as ordered by the physician in the Plan of Care.