RN Home Health Care, PLLC

The agency failed to develop an Emergency Preparedness plan that included a communication plan, training, and testing.

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that measures, tracks and analyzes it's quality indicators in order to assess the processes of care and services provided by the agency, resulting in the inability to improve patient care with…

The agency failed to document any infection control meeting minutes.

The agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency's provision of home health services…

The agency failed to develop an emergency preparedness plan that must be reviewed and updated at least annually.

The agency failed to develop an Emergency Preparedness Plan using a facility-based and community-based risk assessment, and utilizing an all-hazards approach, resulting in the potential to negatively affect all patients seen by the clinic.

The agency failed to develop Emergency Preparedness policies and procedures that aligned with the emergency plan, risk assessment and communication plan.

The agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least annually.

The agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan.

The home health agency failed to conduct exercises to annually test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the agency's…

The agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all agency patients.

The agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the…

The agency failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs.

The agency failed to initiate, develop, or have completed any performance improvement projects within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs.

The Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for…

The agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement program, resulting in the potential spread of infections…

The Agency (HHA) failed to provide documented evidence that infection control education was provided to all staff employed by the agency and who were granted clinical privileges, resulting in the potential for the development and spread of infection.

The agency failed to have 1 of 1 home health aides complete yearly in-services, resulting in the potential for poor patient outcomes.

The home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans and…

The home health agency failed to advise the patients of the names, addresses and telephone numbers of Federally funded and State funded entities that serve the area where the patient resides, resulting in the potential for patient needs being unmet.

The agency failed to have the administrator be appointed by the governing body.