Sac County Phns

The agency failed to ensure agency staff developed a policy and procedures to inform State and local emergency officials about homebound patients in need of evacuation due to an emergency situation.

The agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency.

The agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 8 of 10 direct employees (Staff F and Staff G) and 11 out of 11 contracted staff.

The agency failed to ensure participation in emergency preparedness exercises in 2020 or 2021, including an after action report to analyze the agency's response to the exercise.

The agency failed to complete a drug regimen review within the required time frames with the comprehensive assessments for 3 of 7 sampled patients (Patient #1, #2 and #7).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 3 sampled patients with surveyor home visit observation(Patient #1, #2 and #3).

The agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 3 of 7 sampled patients with new verbal/interim orders.

The agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 3 of 7 sampled patients (Patients #2, #3 and #5).

The agency failed to have a written policy and procedure for the use of volunteers in an emergency, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The agency failed to follow a Plan of Care established and periodically reviewed by a doctor of medicine, osteopathy or podiatry or notify the physician of the need to vary from the physician ordered Plan for 4 of 7 sampled patients (Patients #1, #2, #3 and #5).

The agency failed to ensure authentication of hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature as directed by agency policy for 5 of 7 sampled patients (Patients #3, #4, #5, #6 and #7).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 5 of 7 sampled patients (Patients #1, #2, #3, #4 and #5).

The agency failed to update the Plan of Care with all new orders for 4 of 7 sampled patients (Patients #2, #3, #4 and #6).

The agency failed to complete and send a transfer summary to the physician or other health care professionals responsible for providing care to the patient after transfer to an inpatient facility within 2 business days of the patient's transfer for 2 of 2 sampled patients (Patients #3 and #6) that…