Zuni Home Health Care Agency, Inc.

E0001- CONDITION Based on emergency preparedness (EP) plan review and interviews, the home health agency (HHA) failed to develop and maintain a comprehensive EP plan that would address the health, safety, and security needs of the agency staff and patients in the event of a community natural…

G570- CONDITION Based on record reviews, policy reviews, observation, and interviews, the home health agency (HHA) (1) failed ensure physician orders were obtained and implemented and (2) failed to ensure the registered nurse (RN) documented telephone orders in accordance with agency policy.

G640-CONDITION Based on policy review and interviews, the home health agency (HHA) failed to maintain and evaluate an effective, ongoing, HHA-wide, data-driven quality assessment and performance improvement (QAPI) program.

G680 - CONDITION Based on policy review, medical record review, observation, and interviews, the home health agency (HHA) failed to (1) screen patients for COVID-19 and complete hand hygiene, glove use, and disinfect patient care equipment per standard precautions, (2) document an infection control…

E0004 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the EP was reviewed and updated at least every two years.

E0006 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure a facility-based and community-based risk assessment, utilizing an all-hazards approach, was conducted, and strategies for addressing emergency events were developed based on the risk…

E0007 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the EP addressed the patient population and the type of services the HHA had the ability to provide in an emergency.

E0009 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the EP included the process for cooperating and collaborating with local, tribal, regional, State, and federal emergency preparedness officials.

E0013 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to develop, and update at least every two years, policies and procedures based on a facility and community-based risk assessment.

E0029 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to maintain an EP communication plan that complied with Federal, State, and local laws and was reviewed and updated at least every two years.

E0033 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the communication plan included a method for sharing information with other health providers for continuity of care and a means of providing information about the general condition…

E0034 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the communication plan included a means of providing information about the agency’s needs, and its ability to assist the authority having jurisdiction.

E0036 Based on emergency preparedness plan review and interview, the home health agency (HHA) failed to ensure its emergency preparedness plan (EP) included the requirement that the training and testing of the program be reviewed and updated at least every two years.

E0037 Based on emergency preparedness plan review and interview, the home health agency (HHA) failed to ensure the HHA staff received training on the agency’s emergency preparedness plan (EP) every two years.

E0039 Based on emergency preparedness plan review and interview, the home health agency (HHA) failed to ensure the HHA conducted emergency preparedness exercises annually to test the emergency preparedness plan (EP).

G0642 Based on policy review and interview, the home health agency (HHA) failed to identify, analyze, and track quality indicators, including adverse events, that enables the HHA to assess processes of care, HHA services, and operations.

G654 Based on review of quality assessment and performance improvement (QAPI) documentation, policy review, and interview, the home health agency (HHA) failed to track adverse patient events, analyze their causes, and implement preventive actions.

G682 Based on record reviews, policy review, observation, and interview, the home health agency (HHA) (1) failed to ensure the Registered Nurse followed infection prevention standard precautions when providing care to one of one patients (Patient (P)1) observed during a home visit and (2) failed to…

G684 Based on policy review, document review, and interview, the home health agency (HHA) failed to maintain ongoing documentation of surveillance, identification, and investigation of infectious and communicable diseases and include data from an infection control surveillance program as a part of…

G687 Based on policy review and interviews, the home health agency (HHA) failed to develop a policy for COVID-19 vaccination of staff that included all required components of the regulation.

G580 Based on policy review, record reviews, and interviews, the home health agency (HHA) failed to ensure physician orders were obtained and implemented for referrals to home health, wound care, lab draws, and/or extra nursing visits for six of seven patient (Patient (P) 1, P3, P4, P5, P6, P7)…

G584 Based on chart review, policy review, and interview, the home health agency (HHA) failed to ensure the registered nurse documented telephone orders in accordance with agency policy for two (Patient (P) 4, P7) of seven patient records reviewed for telephone orders.

G616 Based on record reviews, policy review, observation, and interviews, the home health agency (HHA) failed to ensure the patient's current list of medications (medication profile) was in the patient's home for one (Patient (P) 3) of one home visit made on 06/02/22 and the medication profile in…

G718 Based on record review, policy review, and interview, the home health agency (HHA) failed to ensure the registered nurse (RN) notified the physician when a nursing visit was missed in accordance with agency policy for one (Patient (P) 2) of seven patient records reviewed for missed visits.

" the facility failed to meet the Conditions for Coverage (CfC) for the Emergency Preparedness Program (EPP) as evidenced by the facility's failure to: 1) develop and maintain an emergency preparedness program that identified the hazards that were identified in the facility's risk assessment, and…

The facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually.

The facility failed to ensure the EPP was based on and included a documented, facility-based and community-based risk assessment.

The facility failed to have documentation of how the facility will address providing services to their patient population during an emergency.

The facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials, and did not include documentation of the facility's efforts to contact such officials.

The facility failed to develop and implement emergency preparedness policies and procedures based on the facility and community-based risk assessments that was reviewed and updated annually.

The facility failed to develop and implement emergency preparedness policies and procedures which addressed individual plans for each patient to be included as part of the comprehensive patient assessment.

The facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually.

The facility failed to ensure current and updated policies and procedures were in place to follow-up with staff and patients and to inform state and local authorities when unable to contact staff or patients.

The facility failed to have updated policies and procedures in place to protect the confidentiality of patient information, and secure and maintain patient medical records.

The facility failed to have a written communication plan in place.

The facility failed to have a written communication in place to include names and contact information for staff and for entities providing services under arrangement.

The facility failed to have a communication plan in place that included updated contact information for Federal, State, and Regional, emergency preparedness staff.

The facility failed to define the primary and secondary means of communication used in the facility's Emergency Preparedness Plan (EPP) that defined how the facility would communicate with staff members, and emergency preparedness agencies during an emergency.

The facility failed to participate in exercises to test the emergency plan.

The facility failed to ensure acceptable standards of practice to prevent the transmission of infection(s) during home visits for three (3) of four (4) patients home visits, Patient (P)2, P3, and P4. Observation of a licensed nurse during scheduled home visits revealed he/she did not follow the…

Staff interview the facility failed to document communication with the physician of a delay in care from receiving the initial referral to home health services to when the start of care (SOC) began for two of eight sampled patients (Patients (P) 6 and 8).