Hunt Country Health Services

This Condition was not met as evidenced by: Based on staff interview and document review it was determined the agency failed to fully develop and implement an emergency preparedness program (refer to E001), the Emergency Plan section failed to contain documentation regarding when the plan was…

This CONDITION was not met as evidenced by: Based on staff interview and review of patient medical records, agency admission packet, complaint log, and selected policies and procedures it was determined the agency failed to ensure and document that patients were informed verbally and in writing…

This CONDITION was not met as evidenced by: Based on staff interview, review of personnel files, and selected policies and procedures it was determined the Governing Body and/or Administrator failed to ensure the overall management and organization of resources in order to attain and provide the…

The agency failed to develop and implement a comprehensive Emergency Preparedness Plan which must be reviewed and updated at least annually.

The agency failed to develop and implement a comprehensive Emergency Preparedness Plan which included and was based on a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and contained strategies for addressing emergency events identified by the risk…

The agency failed to develop and implement a comprehensive Emergency Preparedness Plan which included and was based on a documented description of the agency's patient population, including, the type of services the agency has the ability to provide in an emergency; and continuity of operations…

The agency failed to include 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, including documentation of the agency's efforts to contact…

The agency failed to document the development and implementation of emergency preparedness policies and procedures, based on the emergency plan and communication plan sections and the risk assessment findings.

The agency failed to document the specific procedures to inform State and local emergency preparedness officials about homebound home health patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and…

The agency failed to document the specific policies and/or procedures to implement regarding communication with on-duty staff and patients to determine what services are needed, in the event that there is an interruption in services during or due to 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 failed to document policies and/or procedures regarding 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 during an emergency.

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.

The agency failed to include in the Communication Plan section of their Emergency Preparedness Plan their primary and alternate means for communicating with their staff and Federal, State, tribal, regional, and local emergency management agencies.

The agency failed to include in the Communication Plan section of their Emergency Preparedness Plan a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care and a means of providing…

The agency failed to include in the Communication Plan section of their Emergency Preparedness Plan 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…

The agency failed to develop and maintain an emergency preparedness training and testing program that was based on their emergency and communication plan sections, their risk assessment, and their policies and procedures.

The agency failed to document providing emergency preparedness training at least annually, maintain documentation of this annual training, and document the agency's staffs ability to demonstrate their knowledge of emergency procedures.

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 ensure written individualized plans of care contain patient-specific measurable outcomes and goals for one (1) of one (1) skilled care plan reviewed in the survey sample.

The Administrator failed to be responsible for the day to day operations of the agency and failed to ensure that care was being provided to a patient under the Medicaid personal care benefit by a qualified personal care aide (PCA) for one of one patient.

The Governing Body failed to inform Medicare (CMS) and the State Survey Agency that their current branch location is not operational.

The agency failed to develop a policy and procedure regarding where patient records will be housed in the event the agency closes and that the Office of Licensure and Certification will be notified of this location.

The agency failed to safeguard clinical record contents against unauthorized use for ten (10) of fourteen (14) medical records reviewed in the survey sample.

Five (5) of five (5) agency admissions completed on or after 01/13/18 failed to contain documentation of the agency providing patients with a copy of the agency's transfer and discharge policies.

The agency failed to ensure the contact information for the Home Health Agency Administrator to include name and business address in order to receive complaints was included in the information given to the patient at the time of admission and prior to services being provided for fourteen (14) of…

The agency failed to ensure patients were informed at the time of admission of the frequency of visits for the disciplines providing care for fourteen (14) of fourteen (14) patient medical records reviewed in the survey sample.

The Administrator failed to ensure patients received all services according to their care plan for ten (10) of fourteen (14) medical records reviewed in the survey sample.

The agency failed to maintain confidentiality of patient medical information for ten (10) of fourteen (14) medical records reviewed in the survey sample.

The agency failed to document informing the patient verbally and in writing at the time of admission and prior to services being provided regarding: The extent to which payment for HHA (home health aide) services may be expected from Medicaid, or any other federally-funded or federal aid program…

The agency failed to inform their patients both verbally and in writing at the time of admission and prior to services being provided 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…

Five (5) of five (5) agency admissions completed on or after 01/13/18 failed to contain documentation of the agency informing patients verbally and in writing at the time of admission and prior to services being provided of the names, addresses, and telephone numbers of the following…

The agency failed to document both the existence and the resolution of the complaint according to the agency's complaint policy and procedure.

The Governing Body failed to ensure the personnel file of the Administrator contain documentation of the Administrator being appointed by the Governing Body and reports to the Governing Body.

The Administrator failed to ensure the agency employed qualified personnel according to federal guidelines and the agency's policies and procedures.

The agency failed to maintain a complete, current, and accurate medical record for ten (10) of fourteen (14) medical records reviewed in the survey sample.