Maxicare Home Health, Inc.

The agency failed to: (E-0004) maintain, review and update the emergency preparedness plan annually; (E-0006) develop a community-based risk assessment prior to developing the agency's emergency plan; (E-0009) include a process for cooperation and collaboration with local, tribal, regional, State…

This facility failed to ensure the following: (G-0642) a Quality assessment and performance improvement program (QAPI) was established, developed, implemented, maintained, and evaluated, and reflected implementation of process improvement measures to improve quality of patient care requiring action…

The agency failed to maintain, review and update the emergency preparedness plan annually.

The facility failed to develop a community-based risk assessment prior to developing the facility's emergency plan.

The agency failed to update the plan with a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

The agency failed to have an individual EP plan for each patient identified in the comprehensive assessment.

The agency failed to update and annually review the EP plan and policies, to inform State and Local emergency preparedness officials about patients in need to be evacuated from their residence.

The agency failed to develop and implement a policy and procedure for the use of volunteers in an emergency.

The facility failed to develop and implement an emergency preparedness Communication Plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually.

The agency failed to have a primary and alternate means of communication during an emergency.

The facility failed to develop and implement a method for sharing information and medical documentation for patients under the HHA'S care, as necessary, with other health care providers to maintain the continuity of care.

The agency failed to develop a means to sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction.

The facility failed to develop a facility based emergency planning, training and testing program.

The agency failed to have the existing staff review the emergency preparedness policies and procedures training, at least annually.

The facility failed to conduct exercises to test the emergency plan at least annually.

The facility failed to analyze and track quality indicators, including adverse patient events, to assess processes of care, services and operations.

The facility failed to analyze and track quality indicators, including adverse patient events, to assess processes of care, services and operations, which poses a potential risk that issues related to delivery of care will not be addressed and or corrected to ensure patient needs are met.

The facility failed to ensure a process that addressed improved quality of care and patient safety, and that all improvement actions were evaluated to ensure that the HHA's governing body ensured that an ongoing program for quality improvement and patient safety was defined, implemented, and…

The agency failed to ensure the Plan of Care and physicians orders were signed and dated in the 30 day time-frame dictated by the policy, which poses the potential risk that the needs of the patients will not be met.