Salmon Valley Home Health LLC

The facility failed to ensure a comprehensive QAPI program was developed and maintained.

The agency failed to ensure a functional infection control program in the HHA . This resulted in the HHA 's failure to document and maintain infection control guidelines and practices.

The GB failed to ensure that the HHA operated in accordance with its own policies and failed to ensure proper oversight, including administrative and supervisory functions, were performed.

The agency failed to demonstrate a biennial review had been conducted on the EP plan.

The agency failed to test the emergency plan at least annually.

The HHA failed to ensure that quality indicators, including adverse patient events, and infections were being tracked, measured and analyzed.

The Home Health Agency failed to analyze quality indicator data to monitor the effectiveness and safety of services and the quality of care, and failed to identify opportunities for improvement.

The agency failed to track all adverse patient events for 1 of 2 patients (Patient #1) whose records were reviewed and were no longer on service.

The agency failed to ensure that distinct performance improvement projects which reflected the scope, complexity and past performance of the HHA were identified and analyzed.

The agency failed to maintain a sanitary environment for 1 of 3 patients (Patient #3) who had observation visits and received care at the Home Health agency.

The HHA failed to ensure a functional infection control program to track and ensure the provision of services in the agency.

The GB failed to ensure the HHA operated in accordance with its own policies.

The agency failed to demonstrate that a biennial review had been conducted on the EP plan.

The agency failed to conduct a Hazard and Vulnerability Analysis (HVA) every 2 years.

The agency failed to test the emergency plan at least annually.

The agency failed to ensure encoded OASIS data accurately reflected patient information at the time of discharge from the agency for 1 of 2 patients (Patient #6) whose closed records were reviewed.

The agency failed to ensure all home health aides had the required hours of documented inservice training.