Sheme Home Healthcare Agency, Inc

The Home Health Agency (HHA) failed to develop and maintain an Emergency Preparedness (EP) plan that is reviewed every two year; failed to include assessment of natural disasters, man-made disasters, and facility-based disasters, which could include care related emergencies, equipment and utility…

The Home Health Agency (HHA) failed to develop and maintain in Emergency Preparedness (EP) plan that was reviewed and updated at least every two years and includes assessment of the potential risks of natural disasters, man-made disasters and HHA based disasters.

The Home Health Agency (HHA) failed to include in the facility's Emergency Preparedness (EP) plan a facility-based and community-based risk assessment, utilizing an all-hazards approach which includes strategies for addressing emergency events identified by the risk assessment.

The Home Health Agency's (HHA) emergency preparedness (EP) plan failed to included cooperations and collaboration with local, regional, State, and Federal emergency officials.

The Home Health Agency (HHA) failed to include in the Emergency Preparedness (EP) plan that the HHA would inform State and local EP officials about the HHA’s patients in need of evacuation during an emergency.

The Home Health Agency (HHA) failed to develop and implement policies and procedures to address a system for medical documentation that preserves the patients’ information, confidentiality of the patients’ information and secures and maintains the availability of the patients’ records.

The Home Health Agency (HHA) failed to develop procedures for the use of volunteers during an emergency, and emergency staffing strategies or a procedure to use State or Federally designated health care professions to address surge needs during an emergency in the HHA’s Emergency Preparedness (EP)…

The Home Health Agency (HHA) failed to develop and maintain an emergency preparedness (EP) communication program demonstrating collaboration between federal, state, and local officials.

The Home Health Agency (HHA) failed to maintain a communication plan that contained a list of names and contact information of staff, contractors, facilities, and volunteers.

The Home Health Agency (HHA) failed to include a communication plan that includes contact information for Federal, State, regional, and local Emergency Preparedness (EP) staff and other sources of assistance.

The Home Health Agency (HHA) failed to include an alternate means of communication with staff, Federal, State, regional, regional, and local emergency management agencies in the HHA’s Emergency Preparedness (EP) plan.

The Home Health Agency (HHA) failed to have a method for sharing patient and medical information with other health care providers needed for the continuity of care and a way to provide information about patient’s condition and location who are receiving care from the HHA.

The Home Health Agency (HHA) Emergency Preparedness (EP) plan failed to develop and implement policies and procedures to communicate HHA’s occupancy, needs, and the HHA’s ability to provide assistance to the authorities having jurisdiction during an emergency.

The Home Health agency (HHA) failed to train staff on HHA’s Emergency Preparedness (EP) plan and test the EP plan.

The Home Health Agency (HHA) failed to train staff on HHA’s Emergency Preparedness (EP) plan including initial training for all new and existing staff, contractors, and volunteers.

The Home Health Agency (HHA) failed to conduct an exercise to test the HHA’s Emergency Preparedness (EP) plan by participating in a community-based full-scale exercise annually or a facility-based exercise every two years.

The Home Health Agency (HHA) failed to assure a Registered Nurse (RN) supervised the Home Health Aide in-service training for one (HHA1) of one home health aide employed by the HHA.

The Home Health Agency (HHA) nursing staff failed to assure all physician orders on the plan of care were implemented as ordered for one (Patient (P)8) of eight patients' records reviewed.

The agency failed to review the emergency preparedness plan (EPP) at least every two years.

The agency failed to develop an emergency preparedness plan based on a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach to include strategies for addressing emergency events identified by the risk assessments.

The agency's emergency preparedness policies and procedures failed to contain a current communication plan that included contact information for federal, state, tribal, regional and local emergency preparedness (EP) staff.

The agency failed to provide initial and ongoing training to staff, provide training at least annually, demonstrate staff knowledge and maintain documentation of all emergency preparedness training.

The agency's Emergency Preparedness Plan (EPP) failed to contain documentation of the agency participating in a facility- based or community-based exercise to test the agency's EPP.

The agency failed to mitigate the risk for COVID-19 transmission.

The agency failed to provide a Home Health Change of Care Notice (HHCCN) to Medicare patients in advanced of reducing/discontinuing services for one (1) of one (1) clinical records in the survey sample for which a HHCCN was applicable (clinical record: #7).

The agency failed to provide to it's patients the names, addresses, and telephone numbers of the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center; and the Quality Improvement Organization where the patient resides.

The agency failed to ensure the patient's individualized plan of care contained the correct treatment orders for one (1) of seven (7) records reviewed in the survey sample (clinical record #3).

The agency failed to develop and maintain an emergency preparedness plan (EPP) that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency…

The agency's emergency's preparedness plan (EPP) failed to include the procedures to follow up with on-duty staff and patients.

The agency's emergency preparedness policies (EPP) and procedures failed to include a policy and procedure for the use of volunteers in an emergency or other professionals for emergency staffing needs.

The agency's emergency's preparedness policy (EPP) failed to include methods for sharing medical documentation for patients with other health providers to maintain continuity of care.

The agency's emergency's preparedness (EP) policy failed to include a means for providing information about the agency's needs, and its ability to provide assistance to the authority having jurisdiction, the incident command center, or designee.

The agency failed to provide initial training in the emergency preparedness plan (EPP) that is consistent with their roles in an emergency to all new and existing staff, individuals providing services under arrangement, and volunteers.

The agency failed to provide initial and ongoing training to staff, provide training at least annually, demonstrate staff knowledge and maintain documentation of all emergency preparedness training.

The agency's Emergency Preparedness Plan (EPP) failed to contain documentation of the agency participating in a facility- based or community-based exercise to test the agency's EPP.

Agency failed to ensure patients were provided the agency's transfer and discharge policies for five (5) of five (5) patients in the survey sample admitted to the agency on or after 01/13/18 (patient #1, 3, 5, 6, and 7).

The agency's admission packet failed to contain the contact information for the HHA (home health agency) Administrator, specifically the Administrator's name and address in order to receive complaints for five (5) of five (5) patients whose records were reviewed in the survey sample and were…

The agency failed to ensure patients were informed at the time of admission or prior to services being provided of the frequency of visits for the disciplines providing care for seven (7) of seven (7) patient medical records reviewed in the survey sample (medical records #1-7).

The agency failed to provide the names, addresses, and telephone numbers of the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center; and the Quality Improvement Organization where the patient resides.

The agency failed to ensure the patient's individualized plan of care included a description of the patient's risk for emergency department (ED) visits and hospital re-admissions.