Regional Home Health Care, Inc.

The home health agency (HHA) failed to develop and implement a comprehensive emergency preparedness program when the agency failed to: - Develop an emergency preparedness plan based on an all hazards risk assessment (E-0004); - Develop an emergency preparedness plan based on and including a…

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information based on the new home health regulations effective 01/13/18. The agency failed to provide in writing, in advance of furnishing care, the…

The agency failed to: - Develop, implement and maintain an effective, ongoing, home health data-driven quality assessment and performance improvement program including adverse patient events, home health agency HHA services, and measurable improvement in indicators (G642); - The HHA program failed…

The agency failed to maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases.

Inc. failed to: - Ensure the governing body assumed full legal authority and responsibility for the agency's overall management and operation including a Quality Assessment and Performance Improvement (QAPI) program (G942); - Ensure the administrator organizes and directs the agency's ongoing…

The agency failed to develop a comprehensive emergency preparedness program.

The agency failed to develop an emergency preparedness plan based on and to include a documented facility based and community based risk assessment utilizing an all hazards approach.

The agency failed to develop a plan to include how the agency would continue operations during an emergency and delegate authority and successon plans.

The agency failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation…

The agency failed to develop an emergency preparedness plan based on and to include a documented facility based and community based risk assessment utilizing an all hazards approach.

The agency failed to document an individualized emergency plan as part of the patient's comprehensive assessment in, but not limited to five of five clinical records (RECORDS/PATIENTS #1, #2, #3, #4, and #5).

The agency failed to document a process to review and update policies/procedures at least annually to include the procedure for informing the State and local emergency preparedness officials regarding evacuation of homebound patients from their residence due to an emergency situation.

The agency failed to develop a procedure to follow-up with on-duty staff, patients, or notify state/local authorities when there was an interruption in services due to an emergency.

The agency failed to develop an emergency preparedness plan that included a system of medical documentation that preserves and protects patient information, and secures and maintains the availability of records in the event of a disaster.

The agency failed to develop an emergency preparedness plan that included use of volunteers or other staffing strategies during an emergency.

The agency failed to develop an emergency preparedness plan that included an alternate method of communication to alert local state and emergency officials of a disaster.

The agency failed to develop an emergency preparedness plan that included a communication plan with name and contact information for staff, patients' physicians, other facilities and volunteers.

The agency failed to develop an emergency preparedness plan that included a communication plan with contact information for federal, state, or local emergency preparedness staff.

The agency failed to develop an emergency preparedness plan that included a communication plan with a primary and alternate means for communicating with staff, federal, state, regional and local emergency management agencies.

The agency failed to develop an emergency preparedness plan that included a communication plan with a method for sharing information and medical documentation for patients as necessary, with other health providers to maintain continuity of care, and a means of providing information about the…

The agency failed to develop an emergency preparedness plan that included a communication plan with a means of providing information about the occupancy needs, and its ability to provide assistance to the authority having jurisdiction, the incident command center, or designee.

Employee file review and interview the agency failed to develop an emergency preparedness plan that included training and testing of all employees.

Employee file review and interview the agency failed to develop an emergency preparedness plan training program that included initial training in emergency preparedness policies and procedures to all new and existing staff (Employee E-1, E-2, E-3, E-4), and failed to maintain documentation of all…

The agency failed to develop an emergency preparedness plan training and testing program that included conducting two exercises to test the emergency plan at least annually.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the notice that if the state court has not been adjudged a patient to lack legal capacity to make health care decisions as defined by…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities…

The agency's 2018 QAPI plan failed to: - Be capable of showing measurable improvements in indicators; and - Show how quality indicators are measured, analyzed and tracked.

The agency's 2018 QAPI plan failed to: - Utilize quality indicator data, including measures derived from OASIS (Outcome and Assessment Information Set) and other relevant data; - Use the data collected to monitor services and quality of care and identify opportunities for improvement; and This…

The agency's 2018 QAPI plan failed to develop any program activities.

The agency's 2018 QAPI plan failed to develop any program activities that tracked adverse patient events, analyze their causes, and implement preventive actions.

The agency's 2018 QAPI activities failed to show the agency conducted at least one performance improvement project to reflect the scope, complexity, and past performance of the agency's services/operations with measurable progress achieved.

The agency failed to show the governing body was responsible for ensuring a quality improvement program that included evaluation for effectiveness, clear expectations for patient safety established, and findings of fraud or waste are appropriately addressed.

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is a part of the agency's quality assessment and performance improvement (QAPI) program.

The agency failed to ensure staff completed infection control education before staff was allowed to perform their duties initially upon hire and annually in four applicable cases (Employee E-1, E-2, E-3, E-4).

The agency failed to ensure the home health aide received at least 12 hours of in-service training during a 12 month period in one applicable case (Employee E-3).

The agency failed to ensure effective management and oversight of the provision of all home health services and the performance improvement program.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include: - Transfer and discharge policies; - Rights and responsibilities that are understandable to persons who have limited English…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the administrator's name and contact information in order to receive patient complaints.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include verbal notice of the patient's rights and responsibilities in the individual's language, free of charge, no later than the completion of…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the written notice to the patient about their right to have a copy of the patient's rights and responsibilities provided to a…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be free from verbal, mental, sexual and physical abuse, including injuries of unknown source, neglect and…

The agency failed to update/provide the written notice of patient rights that included the patient's right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to completion of assessments, care to be furnished, plan of…

The agency failed to update/provide the written notice of patient rights that included the patient's right to receive all services outlined in the plan of care.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of financial liability changes as soon as possible, in advance of the next home health visit and…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of the requirement or non-covered care and comply with the patient notice requirements at 42 CFR…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 be advised of the names, addresses, telephone numbers of the Federally-funded and state-funded entities that serve the area where the patient…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 be free from disrimination or reprisal for exercising his/her rights to voice a grievance to the HHA or an outside entity.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be informed of the right to access auxiliary aids and language services and how to access these services.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency policy for discharge for cause: - Determines that the patient's (or other persons in the home), behavior is disruptive…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for discharge for cause, the agency must make efforts to resolve the problem.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must investigate the treatment or care that is (or fails to be) furnished or inappropriately.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must investigate mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must take action to prevent further potential violations, including retaliation while a complaint is being investigated.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that any agency staff in the normal course of providing services to patients, who identifies, notices, or recognizes incidences of…

The agency failed to ensure the comprehensive assessment for the start of care accurately reflected the patient's status and included the patient's current health in one but not limited to five cases (Record/Patient #2).

The agency failed to ensure an accurate review and update of all medications the patient was currently using in one (Record/Patient #2) of five cases.

The agency failed to ensure the plan of care (POC) contained complete and accurate information for services and interventions in, but not limited to two (Record/Patient #2, #3) of five records reviewed.

The agency failed to provide the patient a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel in two of two records reviewed (Record/Patient #2, #3).

The agency failed to provide the patient a copy of written instructions outlining the patient's medication schedule/instructions, to include the names, dosages, frequency, and which medications would be administered by agency personnel in but not limited to two (Record/Patient #2, #3) of three home…

The agency failed to provide the patient a copy of written instructions regarding treatments to be administered by the home health personnel and personnel acting on behalf of the home health agency in but not limited to two of three home visits (Record/Patient #2, #3).

The agency's 2018 QAPI plan failed to develop any program activities that focused on high risk, high volume, or problem-prone areas.

The agency's 2018 QAPI plan failed to develop any program activities that considers incidence, prevalence, and severity of problems in those areas.. This deficient practice has the potential to affect the quality of care for all agency patients.

The agency's 2018 QAPI plan failed to develop improvement activity that would lead to an immediate correction of any identified problem that directly or potentially threatens the health and safety of patients.

The agency's 2018 QAPI plan failed to aim at performance improvement, implement actions, and measure its success to ensure improvements were sustained.

The agency failed to ensure contracted physical therapy (PT) staff completed agency in service training/education in one applicable case (Employee E-4).

The contract failed to contain information regarding credentials of the agency, organization, or individual providing services under arrangement in one of one therapy contract.

Staff interview the agency failed to maintain compliance with regulations by failing to ensure they requested Family Care Safety Registry (FCSR) prior to hire in one applicable case (Employee-E2), The agency failed to offer Hepatitis B vaccine for one applicable case (Employee-E2), The agency…