Good Shepherd Homecare and Hospice, Inc.

The Home Health agency (HHA) failed to maintain an up-to-date comprehensive emergency preparedness program plan (EPP).

The Home Health Agency (HHA) failed to ensure patients and or their representatives were provided and informed of all patient rights.

The Home Health agency (HHA) failed to meet the condition of participation (CoP) requirements for care planning, coordination, and quality of care when the HHA failed to provide visit schedules, written medication instructions, and the clinical coordinators contact information.

The Home Health agency (HHA) failed to meet the condition of participation (CoP) requirements for clinical records when the HHA failed to ensure comprehensive assessments were performed and maintained, discharge summaries were completed and provided to the inpatient facilities for 5 of 7 patient…

The Home Health agency (HHA) failed to develop and maintain an EPP that is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment.

The Home Health agency (HHA) failed to develop and maintain an EPP that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan.

The Home Health agency (HHA) failed to include information addressing the process for cooperation and collaboration with local, regional, state and federal emergency preparedness officials in their EPP.

The Home Health agency (HHA) failed to review and update policies and procedures at least every 2 years and failed to develop EPP policies and procedures for all hazards identified within the facility's risk assessment.

The Home Health agency (HHA) failed to develop and implement individual EPP plans for each of the HHA's patients as a part of the comprehensive assessment for 7 of 7 sampled patients (Patients 1-7) reviewed.

The Home Health agency (HHA) failed to develop and implement EPP policies and procedures to inform State and local emergency preparedness officials about homebound patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and…

The Home Health agency (HHA) failed to provide procedures to follow up with on-duty staff and patients to determine services that are need, in the event that there is an interruption in services during or due to an emergency.

The Home Health agency (HHA) failed to develop and implement policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

The Home Health agency (HHA) failed to develop and implement policies and procedures for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs…

The Home Health agency (HHA) failed to develop and implement an EPP communication plan that included method of sharing information and medical documentation.

The Home Health agency (HHA) failed to develop and implement an EPP communication plan that includes a means of providing information about the HHA’s needs, and its ability to provide assistance to the authority having jurisdiction.

The Home Health agency (HHA) failed to develop and maintain an EPP training and testing program that is based on the emergency plan, its risk assessment and the communication plan.

The Home Health agency (HHA) failed to conduct or participate in exercises to test the EPP.

Staff interview the Home Health agency (HHA) failed to ensure the patient's right to be informed of the HHA's policies for transfer and discharge for 7 of 7 sample patients (Patients 1-7).

Staff interview the Home Health agency (HHA) failed to ensure the patient's right to receive the contact information for the HHA's administrator, including the administrator's name, business address, and business phone number in order to receive complaints for 7 of 7 sample patients (Patients 1-7).

Staff interview the Home Health Agency failed to ensure the patient's right to participate in, be informed about, and consent or refuse care in advance of and during treatment with respect to the disciplines that will furnish the care and the frequency of visits for 7 of 7 sample patients (Patients…

Staff interview the Home Health agency (HHA) failed to ensure the patient's right to receive the state toll-free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs for 7 of 7 sample patients…

The Home Health agency (HHA) failed to conduct an initial assessment visit within 48 hours after receiving a referral to provide services for 4 (Patients 2, 4, 5, 6) of 7 patients reviewed.

The Home Health agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining visit schedule including frequency of visits by HHA personnel for 7 of 7 Patients (Patients 1-7).

The Home Health agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining medication schedule/instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel for 7 of 7 Patients (Patients 1 - 7).

Staff interview the Home Health agency skilled staff failed to provide contact information of the HHA's clinical manager, including the telephone number and e-mail address to 7 of 7 sample patients (Patients 1-7).

Staff interview the Home Health agency (HHA) skilled staff failed to ensure that all Comprehensive Assessment including OASIS were performed and maintained in the clinical record for 5 of 7 sample patients (Patients 1 - 5).

The Home Health agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient health care services for 5 of 7 sample patients (Patients 1 - 5).