Regal Home Health Services

The agency failed to document initial and ongoing training for the Emergency Preparedness Program per agency policy in 6 of 7 (A-F) employee files reviewed.

The agency failed to have the Governing Body review program annually in 1 of 1 Quality Assessment and Performance Improvement (QAPI) programs reviewed.

The agency staff failed to adhere to infection prevention practices related to handwashing, gloving, and bag practices in 3 of 3 home visit observations (Patient # 1, 2 and 3) for a total of 7 patient records reviewed.

The agency staff failed to provide services as ordered for 2 of 7 (#4 & #5) patient records reviewed.

Agency staff failed to maintain an accurate medication list on the plan of care as compared to what the patient is taking for 1 of 3 patients (Patient # 3) visits observed for a total of 7 patient records reviewed.

The agency failed to develop POC (Plans of Care) individualized to meet the patient specific needs in 2 of 3 home visits observed (Patient #2 and #3) in a total of 7 patient records reviewed.

Agency staff failed to include progress/clinical notes for 1 of 7 (#7) patient records reviewed.

The agency RN (Registered Nurse) failed to supervise the care provided by the LPN (Licensed Practical Nurse) in 1 of 7 patient (Patient #2) records reviewed.

The agency failed to ensure there is a comprehensive agency specific Emergency Preparedness Program in 1 of 1 Emergency plans reviewed.

The agency failed to ensure an agency specific Emergency Preparedness plan is developed and reviewed annually and to include an all-hazards risk assessment in 1 of 1 Emergency plans reviewed.

The agency failed to ensure agency specific Emergency Preparedness policies and procedures are developed based on the risk assessment in 1 of 1 Emergency plans reviewed.

The agency failed to ensure an agency specific Emergency Preparedness Communication Plan is developed and reviewed annually in 1 of 1 Emergency plans reviewed.

The agency failed to ensure that an emergency preparedness training and testing program was developed in 1 of 1 Emergency plans reviewed.

The agency nurses failed to adhere to infection prevention practices related to equipment disinfecting in 2 of 3 home visits (Patient #1 and #3).

The agency failed to provide RN (Registered Nurse) supervision to the LPN (Licensed Practical Nurse)/LVN (Licensed Vocational Nurse) in 2 of 3 patients (Patient #1 and #5) receiving LPN/LVN care in a total of 7 patient records reviewed.

The agency failed to provide RN (Registered Nurse) supervision no less than every 14 days to patients receiving Aide services in 1 of 2 patients (Patient #2) receiving Aide/Personal Care services in a total of 7 patient records reviewed.

The agency failed to document patient progression toward agency established goals in the patient plan of care and/or clinical record in 3 of 3 patients recertified for services (Patient #1, #2, #5) in a total of 7 records reviewed.