Gateway Home Health Care

The agency failed to develop a patient centered QAPI Program for 15 current patients.

The agency failed to ensure the development of a facility-based risk assessment for all employees and all 15 patients.

The agency failed to document emergency drills for the 15 current patients and all employees.

The agency failed to ensure the utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement. for all 15 current patients.

The agency failed to ensure the utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement. for all 15 current patients.

The agency failed to develop performance improvement activities that focused on high-risk problem areas for all current 15 patients.

The agency failed to develop PIPS to track adverse patient events for all 15 current patients.

The agency failed to document performance improvement within the QAPI Program for all 15 current patients.

The agency failed to ensure an ongoing, comprehensive QAPI program was approved by the governing body all 15 current patients.

The agency failed to ensure CHHA completion of 12 hours of annual training for two (CHHA #1 and 2) of two CHHA.

The agency failed to ensure the governing body provided oversight of agency operations and programs for 15 current patients and all employees.

The agency failed to ensure SN frequencies were followed as ordered for one (Pt #3) of seven patients.

The agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 14 patients and all employees.

The agency failed to ensure utilization of OASIS data to improve program effectiveness, quality of patient care and overall program improvement for all 14 patients. ` A review of administrative records showed no OASIS data collection activities utilized in the agency's QAPI Program for calendar…

The agency failed to ensure:1) The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infection throughout the agency and;2) The Infection Control Program was included in QAPI activities for all agency staff and patients.

The agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees.