Homestead Health LLC

The agency was not in substantial compliance with the Conditions of Participation for Emergency Preparedness. - The agency failed to develop and implement an emergency preparedness plan and update the plan every two years.

Findings include: - The agency failed to develop and analyze measurable improvement in indicators for which there was evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The agency was not in substantial compliance with§484.70 of the Conditions of Participation for Infection Control.

The agency was not in substantial compliance with §484.105 of the Conditions of Participation for Organization and administration of services.

The agency failed to develop and implement an emergency preparedness plan and update the plan every two years.

The agency failed to implement an all-hazard risk assessment to address emergency events.

The agency failed to implement an emergency plan based on the agency's patient population.

The agency failed to implement an emergency preparedness plan to include a process for collaboration and communication with local, tribal, regional, State and Federal emergency officials to ensure an integrated response process.

The agency failed to ensure policies were developed, implemented and reviewed every two years.

The agency failed to develop and implement a procedure for notification of on-duty staff and patients to determine what services were needed if there was an interruption in services due to an emergency.

The agency failed to implement policies and procedures for using 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 during an emergency.

The agency failed to develop a communication plan and failed to review and update policies and procedures related to the communication plan every two years.

The agency failed to develop and implement a communication plan to include staff, volunteers, patients' physician, and contracted services.

The agency failed to develop a communication plan for emergency preparedness to include Federal, State, tribal, regional and local emergency preparedness staff, and any other resources for assistance.

The agency failed to develop and implement a communication plan to include a primary and secondary means for contacting staff and emergency officials during an emergency.

The agency failed to develop and implement a communication plan to include a method for sharing information and medical documentation with other healthcare providers to ensure continuity of care.

The agency failed to develop and implement a training and testing emergency preparedness program.

The agency failed to develop, implement and evaluate an emergency preparedness training program, failed to show the training program was based off of the agency risk assessment, and failed to review and update the program.

The agency failed to develop and implement a testing program for its emergency preparedness program and conduct exercises annually.

The agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system for start of care assessments within 30 days after admission for 96 of 212 assessments during the last fiscal year.

The agency failed to develop and analyze measurable improvement in indicators for which there was evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.

The agency failed to monitor the effectiveness and safety of services, quality of care provided, and identify opportunities for improvement.

The agency failed to identify performance improvement activities focusing on high risk, high volume, and problem prone areas.

The agency failed to track adverse patient events, analyze their causes, and implement corrective and preventive actions.

The agency failed to develop and implement any performance improvement projects.

The agency's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained; failed to ensure quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that…

The agency failed to ensure staff sanitized or washed hands in between glove changes for 1 (#5), and failed to ensure equipment was cleaned prior to putting the equipment back in the supply bag for 2 (#s 5 and 6) of 7 sampled patients.

The agency failed to develop and implement an infection control program which identified infections, communicable diseases, and failed to implement a plan to control and improve disease results.

The agency's governing body failed to assume responsibility for the agency's overall management and operation, including QAPI, Infection Control, Emergency Preparedness programs, implementation of a fiscal budget/Capital Expenditures, and adoption of policies and procedures.

The agency and governing body failed to prepare a budget that includes an annual operating budget and capital expenditure plan.

The agency failed to complete the initial assessment visit within 48 hours of a referral or return to their home for 4 (#s 3, 5, 6, and 7) of 7 sampled patients.

The agency failed to implement, measure and track performance improvement activities to ensure improvements were sustained.

The agency failed to appoint a qualified person to assume the responsibilities and obligations of the administrator, if the administrator of record was not available.

The agency failed to ensure an individualized plan of care was developed for 2 (#s 3 and 5) of 7 sampled patients.

The agency failed to establish policy and procedures to ensure standard precautions were implemented to prevent the transmission of infections for environmental cleaning and disinfection, injection and medication safety, and reprocessing of reusable medical equipment between each patient and when…

The agency failed to ensure a Clinical Manager was available to provide oversight of all patient care services and personnel.

The agency failed to ensure the completion of the comprehensive assessment to assist in developing the patient's plan of care for 2 (#s 3 and 5) of 7 sampled patients.

The agency failed to ensure the employed home health aide had successfully completed the home health aide training and competency evaluation prior to performing duties as assigned.