Everest Healthcare Solutions

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-0009) include a process for cooperation and collaboration with local, tribal, regional, State…

This facility failed to ensure the following: (G-0642) that a Quality assessment and performance improvement program (QAPI) was established, developed, implemented, maintained, and evaluated, and reflected implementation of process improvement measures to improve quality of patient care requiring…

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 agency failed to update the plan with 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 require that their Quality assessment and performance improvement program (QAPI) was established, developed, implemented, maintained, and evaluated, and reflected implementation of process improvement measures to improve quality of patient care requiring action plans to…

This facility failed to ensure their QAPI program utilized Quality indicator data including measures derived from Oasis to monitor their facility's effectiveness and safety of services and quality of care, and ensure the governing body approved the frequency and detail of the data collection done.

The facility failed to ensure that addressed improved quality of care and patient safety, and that all improvement actions are evaluated for effeto ensure that the HHA's governing body ensured that an ongoing program for quality improvement and patient safety was defined, implemented, and…

The facility failed to ensure an adequate infection control program, as evidenced by a lack of a written plan or policy and procedures for infection control, which poses the potential risk for a negative patient outcome, if infections and or communicable disease are not identified, monitored…

The facility failed to ensure that education was provided to staff, patients, and caregivers, as evidenced by lack of written infection prevention policies and procedures available for review, which poses the potential risk that staff, patients and caregivers are not informed on current standards…

The facility failed to ensure that the contact information for the HHA administrator, including the administrator's name, was provided to any of the patient's, as evidenced by the name of the administrator is not on any of the forms provided to the patient, which poses the potential risk for a…

The facility failed to ensure that an accurate notice of charges the Agency may bill, as evidenced by multiple fees schedules present to the surveyors, which had the potential for misunderstandings with the patient and caregivers of fees that may be charged, causing unwanted outcomes.

The facility failed to ensure the patient be informed of the state toll free home health telephone hotline, as evidenced by the phone number provided in the "Skilled Service Agreement and Admission Booklet" is a wrong phone number, which poses the potential risk for a patient not being able to file…

The facility failed to ensure that an RN supervises an LPN, as evidenced by lack of any documentation of the RN supervising the care to patients provided by the LPN staff, which poses the potential risk for negative patient outcomes.

The facility failed to ensure that a pre-designated person was authorized by the governing body, to assume the same responsibilities and obligations as the administrator as evidenced by the contact person had to check with the adminsitrator, who was located in the Chicago, IL area, to retrieve each…