Nemaha County Home Health & Hospice
Inspection 2024-04-04
· Recertification · 14 deficiencies · CMS source report (PDF)The Home Health agency failed to maintain an up-to-date comprehensive emergency preparedness program plan (EPP).
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The Home Health agency failed to address the patient population, including persons at-risk, the type of services available during an emergency, and continuity of operations, including delegations of authority and succession plans, as required by the regulation.
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The Home Health 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, as required by the regulation.
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Policies and procedures review and interview the agency failed to develop and implement emergency preparedness policies and procedures aligned with the requirements outlined in the regulation.
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The Home Health agency failed to establish and execute individualized emergency preparedness plans for patients as part of their comprehensive patient assessment, as mandated by the regulation for 7 of 7 patients reviewed (Patient 1-7).
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The Home Health agency failed to develop and implement policies and procedures concerning the utilization of volunteers in emergencies or other emergency staffing strategies, including the integration of State and Federally designated healthcare professionals to address surge needs during such…
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The Home Health agency failed to ensure a documented training and testing program was in place as required by CFR Section 484.102(d).
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The Home Health agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, as required by CFR Section 484.102(d)(1).
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The Home Health agency (HHA) failed to contact the physician for specific orders when performing a Comprehensive Assessment and establishing an individualized Plan of Care (POC) for patients with general referrals for services for 2 of 7 sample patients (Patient 2 and 5).
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The Home Health agency (HHA) failed to follow acceptable standards of practice, including the use of standard precautions to prevent infections for 1 of 3 patient hoe visits (Patient 3).
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The Home Health agency (HHA) failed to ensure the patient's right to participate in, be informed about, and consent or refuse care in advance of and during treatment with respect to the disciplines that will furnish the care and the frequency of visits for 3 of 7 sample patients (Patients 3, 4, and…
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The Home Health agency (HHA) failed to ensure the patient's comprehensive assessment included patient input as to their specific goals and outcomes to be achieved from home health services for 7 of 7 sample patient reviewed (Patients 1 - 7).
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The home health agency failed to ensure the plan of care was individualized to include interventions, goals, and safety precautions to manage patients medical diagnosis for 6 of 7 sample patients (Patient 1 - 6).
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The Home Health agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient care services for 1 of 7 sample patients (Patient 6).
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