Holy Name Home Care, Inc

The Agency failed to develop an Emergency Preparedness plan that must be reviewed and updated, including guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel (See E 0004); failed to develop an Emergency Preparedness plan that must be reviewed and updated at least…

The Agency failed to develop a Quality Assurance and Performance Improvement (QAPI) program that measured, tracked, and analyzed its quality indicators in order to quantitatively assess outcomes concerning care and services furnished by the Agency (See G 642); failed to provide data collected which…

The Agency failed to ensure effective infection prevention and control measures were utilized (G-682); failed to maintain an Agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that was incorporated into the…

The Home Health Agency failed to ensure the Governing Body consisted of more than one person which assumed full legal authority and responsibility in hiring a qualified Administrator to provide appropriate oversight concerning the Agency's overall management and operation, and its quality…

The Agency failed to ensure the current Administrator possessed the necessary training and experience required to be qualified to work as an Administrator of a home health agency, which has the potential to affect all patients serviced by the agency (See G 1052).

The Agency failed to develop an emergency preparedness plan that must be reviewed and updated to include strategies to address the Covid-19 global pandemic, resulting in no directions for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to develop an Emergency Preparedness Plan that was based on both a facility-based and community-based all-hazards risk assessment, resulting in the potential for being unprepared to respond effectively in the event of an emergency.

The Agency failed to develop and update Emergency Preparedness (EP) policies and procedures that were based on an EP plan, risk assessment, and communication plan, resulting in the Agency's inability to implement appropriate emergency actions which could negatively affect the health and safety of…

The Agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws, and must be reviewed and updated at least every 2 years, resulting in the Agency's inability to ensure the coordination of patient care in the event of an actual…

The Agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies/procedures, and communication plan, which must be reviewed and updated at least every two years.

The Agency failed to provide documentation that it had conducted exercises to test its emergency plan annually, by way of a tabletop and community based full-scale exercise required every two years, and failed to conduct an additional exercise at least every two years opposite the year of the…

The Agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all patients serviced by the Agency, resulting in a potential for poor patient outcomes due to the provision of substandard care.

The Agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement (QAPI) program, which had the potential to negatively affect all patients serviced by this…

The Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the annual performance improvement projects, and the reasons for conducting these projects with measurable progress achieved, resulting in the Agency's inability to show improvement in areas…

The Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect…

The Agency failed to develop and update an Infection Control Program which incorporated policies and procedures within accepted standards of practice to prevent the transmission of infections and communicable diseases, including Covid-19. This deficient practice resulted in the increased potential…

The Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; failed to develop a method to screen visitors and agency staff prior to providing clinical services, and failed to develop an infection control program that is…

The agency failed to provide evidence of infection control education concerning Covid-19 and other communicable disease was provided to any staff employed by the agency, resulting in the potential for the development and spread of the Covid-19 and other infectious agents to staff and all patients…

Agency failed to ensure the Governing Body consisted of more than one individual which assumed full legal authority in hiring a qualified Administrator to provide appropriate oversight concerning the Agency's overall management and operation and failed to review its quality assurance and…

The current Administrator did not have the training and experience required to be qualified to work as an Administrator of a home health agency, which has the potential to affect all patients serviced by the agency, resulting in the potential for patients to receive services that are unsafe or…

The Agency failed to include full contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The Agency failed to inform patients how to access auxiliary aids and language services, resulting in the potential for unmet patient care needs for all patients serviced by this Agency.

The Agency failed to ensure a qualified alternate administrator, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in a lack of organization and direction of the Agency's ongoing functions to assure the availability and…