Lorian Health

The agency failed to ensure it reviewed and updated its emergency preparedness plan every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to identifying patients in need of home evacuation at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to identifying on duty staff or patients the agency was unable to contact at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to a system of medical documentation preserving patient information, protecting confidentiality of patient information, and securing/maintaining availability of records at least every 2…

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years.

The agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its emergency preparedness training and testing program at least every 2 years.

The agency's nurse failed to accurately assess a patient's medication administration ability and whether a patient used a walker for 1 of 17 sampled patients (Patient 15).

The agency failed to provide ordered treatment in relation to a physical therapy visit for 2 of 17 sampled patients (Patient 1 and 14).

The agency failed to ensure patients received written instructions outlining services provided to patients in the plan of care for 2 of 7 sampled patients visited (Patient 9 and 2).

The agency failed to follow its infection control practices when conducting home visits for 2 of 7 sampled patients visited (Patient 2 and 9).

The agency failed to update their staff vaccine policy and maintain a staff vaccination rate of 100%. Findings include: On 05/06/2022, in the afternoon, the Director of Patient Care Services (DPCS) confirmed the agency had no updated/revised staff vaccine policy which documented the following: -All…

The facility failed to confirm if their social workers were qualified for their positions for two of three Social Workers (Social Worker 1 and 2).

The agency failed to ensure treatments were administered only as ordered by a physician or allowed Nurse Practitioner for 1 of 17 sampled patients (Patient 8).

The agency failed to provide documented evidence of written visit schedules in the home for 1 of 7 sampled patients visited (Patient 9).

The agency failed to coordinate care in a manner which the plan of care clearly reflected wound care orders skilled nurses could readily implement for 1 of 17 sampled patients (Patient 8) and failed to ensure a patient's changes in weight would be monitored and reported for significant changes…

The facility failed to develop and implement an Emergency Preparedness Plan that addressed a procedure/process for follow-up with on-duty staff and patients, to determine the services that would be needed should there be interruption in services during or due to an emergency.

The facility failed to develop and implement an Emergency Preparedness Communication Plan that was reviewed and updated at least annually.

The facility failed to participate in a community-based, full-scale emergency exercise on an annual basis as a part of the facility's Emergency Preparedness Plan (EPP).

The agency failed to demonstrate the presence of a comprehensive Performance Improvement Project (PIP) that included projects undertaken, rationale for initiating the project(s) and evidence of measurable goals' progress towards established threshold/target.

The facility failed to ensure an initial assessment visit was completed within 48 hours of receiving a referral for 4 of 17 patients (Patient (P)1, P4, P5, and P11. Findings include: Review of the facility's policy titled, "Patient Admission Process" dated 01/11/19 indicated "Upon referral, each…

The home health agency (HHA) failed to ensure an HHA nurse reviewed the medication list for 1 of 2 patients, (Patient (P)8), who was admitted by a physical therapist (PT) for therapy-only services.

The agency failed to ensure there were skilled professional visits for four of six sampled patients (P)13, P15, P16 and P17 who received Home Health Aide (HHA) services.