Home Health Systems, Inc/Familycare in Home Medical Srvcs

The agency's EPP failed to maintain staff documentation of training and demonstrate staff knowledge regarding the EPP.

The agency failed to ensure that patients were informed about and consented to the frequency of proposed visits in advance of starting care in seven (7) of seven (7) clinical records reviewed in the survey sample.

The agency failed to ensure an up to date facility-based, community based, risk assessment had been completed using an all hazards approach.

The agency failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation…

The agency's emergency's preparedness policy and procedures failed to include the procedures to notify local officials of any on-duty staff and patients they are unable to contact during an emergency.

The agency failed to document the specific policies and/or procedures to implement regarding a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records in order to support continuity of…

The agency's emergency's preparedness policy and procedures failed to include a policy and procedure for the use of volunteers in an emergency or for emergency staffing needs.

The agency failed to include the names and contact information for the following in the Communication Plan section of their Emergency Preparedness Plan: Staff, Entities providing services under arrangement/contract, patient's physicians, volunteers if applicable, and/or other agencies.

Based policy and procedure review it was determined the agency failed to document contact information for Federal emergency preparedness officials and other sources of assistance.

The agency failed to have a procedure regarding providing information about the agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, and/or designee.

The agency failed to provide initial training in emergency preparedness policies and procedures that are consistent with their roles in an emergency to all new and existing staff, individuals providing services under arrangement, and volunteers.

The agency failed to document conducting emergency preparedness exercises to test their emergency plan at least annually which consisted of: 1. Participated in a full-scale exercise that was community-based or when a community-based exercise was not accessible, an individual, agency-based.

The agency failed to maintain documentation of the agency informing patients in writing within four business days of the initial evaluation visit of the agency's transfer policy for seven (7) of seven (7) medical records reviewed in the survey sample and were admitted/recertified on or after…

The agency failed to ensure each patient was advised in advance of providing care the extent to which payment for HHA (home health agency) services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, the charges for services that may not…

The agency failed to ensure the patient's medication profiles contained a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions…

The agency failed to ensure the patient's individualized plan of care included a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors and evidence the patient participated in goal setting…

The agency failed to ensure drugs, services, and treatments were administered only as ordered by a physician for one (1) of seven (7) medical records reviewed in the survey sample (medical record # 3).