Touchette Regional Hospital Inc.

The Home Health Agency failed to develop and implement policies and procedures based on the emergency plan.

The Governing Body failed to implement, evaluate, and maintain an effective, ongoing, data-driven Quality Assessment and Performance Improvement program.

The Home Health Agency failed to maintain and document an infection control program, which has as its goal the prevention and control of infections and communicable diseases.

The Home Health Agency (HHA) failed to develop and implement emergency preparedness policies, as part of its comprehensive Emergency Preparedness (EP) Program, that would be reviewed and/or updated at least annually.

The Home Health Agency (HHA) failed to develop and implement emergency preparedness policies and procedures to address a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

The Home Health Agency (HHA) failed to develop and implement emergency preparedness policies and procedures to address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care…

For 1 of 9 (Pt #7) patients, hospitalized then resumed services, the Home Health Agency (HHA) failed to ensure a complete Comprehensive Assessment was conducted for resumption of care.

The Home Health Agency (HHA) failed to implement and establish quality indicators, benchmarks, data collection methods/frequency/numbers, tracking methods, analysis procedure, and an ongoing evaluation process to continuously improve and maintain quality of care/services.

The Home Health Agency (HHA) failed to develop a Governing Body approved Quality Assessment and Performance Improvement (QAPI) Program which identified, collected, and utilized relevant quality indicator data in order to monitor the effectiveness and safety of services and quality of care, and…

The Governing Body failed to implement, evaluate, and maintain an effective, ongoing, data-driven Quality Assessment and Performance Improvement (QAPI) program.

The Home Health Agency failed to ensure an infection control program was maintained and documented which addressed surveillance and control of infections.

For 1 of 9 (Pt #1) patients, the nurse failed to review and update the medication profile to include the non prescription medications and evaluate for possible drug interactions and side effects.

In 1 of 9 (Pt #4) clinical records reviewed, the Home Health Agency failed to ensure services are administered only as ordered by a physician.

In 1 of 9 (Pt #4) clinical records reviewed, the Home Health Agency (HHA) failed to ensure a change in condition communication with the physician, whom was involved with the plan of care.

The Home Health Agency (HHA) failed to ensure a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, to assume the same responsibilities and obligations as the Administrator in the Administrator's absence.