Hunt Country Nursing Services, Inc

The agency failed to have an emergency preparedness plan.

The agency failed to implement, evaluate and maintain an effective, ongoing HHA (Home Health Agency)-wide, data driven QAPI (Quality Assurance Performance Improvement) program (refer to G 642); The agency failed to utilize quality indicator data, including measures derived from OASIS (Outcome and…

The agency failed to develop and implement an emergency preparedness plan (EPP) that contained all the required elements of the regulations and was reviewed annually.

The agency failed to ensure an up to date all hazards risk assessment had been completed for the agency.

The agency failed to have an emergency preparedness program and failed to address the types of services the agency has the ability to provide in an emergency.

The agency failed to develop and maintain an emergency preparedness plan (EPP) 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…

The agency's emergency's preparedness policy and procedures failed to include procedures to inform State and local emergency preparedness officials about home health patients in need of evacuation from their residences.

The agency's emergency's preparedness policy and procedures failed to include the procedures to follow up with on-duty staff and patients.

The agency's emergency's preparedness policy and procedures failed to include a policy for medical documents.

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

The agency failed to ensure they had an emergency communication plan that was updated at least annually.

The agency failed to include the names and contact information for the following in their Emergency Preparedness Plan (EPP): staff, entities providing services under arrangement/contract, patient's physicians, volunteers if applicable, and/or other agencies.

The agency's emergency preparedness policies and procedures failed to contain a current communication plan that included contact information for federal, state, tribal, regional and local emergency preparedness (EP) staff.

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

The agency's emergency's preparedness policy (EPP) failed to include methods for sharing medical documentation for patients with other health providers to maintain continuity of care.

The agency failed to provide initial training in the emergency preparedness plan (EPP) that is consistent with their roles in an emergency to all new and existing staff, individuals providing services under arrangement, and volunteers.

The agency failed to provide initial and ongoing training to staff, provide training at least annually, demonstrate staff knowledge and maintain documentation of all emergency preparedness training.

The agency's Emergency Preparedness Plan (EPP) failed to contain documentation of the agency participating in a facility- based or community-based exercise to test the agency's EPP.

The agency failed to maintain a quality assessment/process improvement program (QAPI) with identified quality indicators.

The agency's governing body failed to utilize quality indicator data, including measures derived from OASIS and other relevant data for the time period of 2015 through 2018. The findings were: An interview with the clinical manager on 2/13/19 at 11:45 when the QAPI manual was presented for review…

The agency failed to maintain a quality assessment/process improvement program (QAPI) with identified performance improvement activities.

The agency's governing body failed to track adverse patient events.

The agency failed to conduct a performance improvement project for the calendar years of 2015 through 2018. The findings were: An interview with the clinical manager on 2/13/19 at 11:45 when the QAPI manual was presented for review revealed, "We are really behind, I'm ashamed to say".

The agency's governing body failed to ensure an ongoing program for quality improvement and patient safety is defined, implemented and maintained.

The agency failed to ensure patients were provided with the agency's transfer and discharge policies for two (2) of two (2) patients in the survey sample admitted to the agency on or after 01/13/18 (patient #1 and 2).

The agency failed to provide the contact information for the HHA (home health agency) Administrator, specifically the Administrator's name and address in order to receive complaints two (2) of two (2) patients in the survey sample admitted to the agency on or after 01/13/18 (patients #1 and 2).

The agency failed to provide the names, addresses, and telephone numbers of the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center; and the Quality Improvement Organization where the patient resides for two (2) of two (2) patients in…

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-admissions.

The agency failed to take actions aimed at performance improvement, measure its success and track performance to ensure that improvements are sustained for the time period of 2015 through 2018. The findings were: An interview with the clinical manager on 2/13/19 at 11:45 when the QAPI manual was…

The agency failed to notify the state survey agency or Medicare of the addition of a branch location.