Diamonds & Pearls Health Services LLC

The agency failed to develop and maintain a comprehensive emergency preparedness program.

The agency failed to ensure their plan was based on and included a documented, agency-based and community-based risk assessment, utilizing an all-hazards approach.

The agency failed to include a process for cooperation and collaboration with other EP officials.

The agency failed to ensure each patient had an individualized plan in the event of an emergency.

The agency failed to have a process for informing state and local officials of patients in need of evacuation in the event of an emergency.

The agency failed to ensure the plan included procedures for follow up with on-duty staff and patients and informing state and local officials of any on-duty staff or patients that they are unable to contact.

The agency failed to ensure have a policy or procedure that addressed the use of volunteers or other emergency staffing strategies in the event of an emergency.

The agency failed to have a communication plan that addressed and contained all of the required elements.

The agency failed to provide emergency preparedness training to all staff as required.

The facility failed to conduct exercises to test the emergency plan.

The agency failed to ensure the plan of care specified the frequency and duration with which visits were to made (Patients' #2, #3 and #5); failed to identify interventions to address underlying risk factors for hospitalization (Patients' #1-#5); failed to include patient and caregiver education…

The agency failed to clarify a physician's order for bowel routine, including the administration of a suppository for one of one patients with an ordered "bowel routine", Patient #1. A total of seven medical records were reviewed.