Spectrum Home Healthcare LLC

The agency failed to: (E-0004) maintain, review and update the emergency preparedness plan annually; (E-0006) develop a community-based risk assessment prior to developing the agency's emergency plan; (E-0007) incorporate documentation in the EP plan to include the needs of the patient population…

The agency failed to maintain, review and update the emergency preparedness plan annually.

The agency failed to develop a community-based risk assessment prior to developing the agency's emergency plan.

The agency failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations.

The agency failed to update the plan with a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

The agency failed to have an individual EP plan for each patient identified in the comprehensive assessment.

The agency failed to update and annually review the EP plan and policies.

The agency failed to develop and implement a policy and procedure for the use of volunteers in an emergency.

The agency failed to develop an agency based emergency planning, training and testing program.

The agency failed to have the existing staff review the emergency preparedness policies and procedures training.

The personnel records failed to contain documentation that personnel had participated in EP plan testing exercises.

The quality assurance performance improvement program (QAPI) did not reflect implementation of process improvement measures to improve quality of patient care.

The governing body failed to maintain documentation of facility operations and oversight.

The facility failed to demonstrate 1 of 7 patients received a discharge summary, which is a potential risk to the patient (#4) not being provided care and services after being discharged.

The facility failed to demonstrate 1 of 7 patients received education and training as outlined in the plan of care, which is a potential risk to the patient not receiving the necessary treatment.