Able Home Health, Inc.

The Condition of Participation ("CoP") for Emergency Preparedness was not met as evidenced by the agency's failure to develop an emergency preparedness program that included a detailed emergency plan, policies and procedures, a communication plan, training, and testing.

The agency failed to develop and maintain of an emergency preparedness program that was reviewed and updated at least every two (2) years.

The agency failed to ensure the emergency preparedness plan was based on and included a documented, agency-based and community-based risk assessment, utilizing an all-hazards approach, and that included strategies for addressing emergency events identified by the risk assessment.

The agency failed ensure the emergency preparedness plan addressed patient population, including, but not limited to, the type of services the agency had the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

The agency failed to ensure the emergency preparedness plan 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 situation.

The agency failed to develop and implement emergency preparedness policies and procedures, based on a risk assessment and the communication plan, and ensure these policies and procedures were updated at least every two (2) years.

The agency failed to ensure emergency preparedness policies and procedures that addressed a system of medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records.

The agency failed ensure the emergency preparedness policies and procedures addressed 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 professionals, to address surge needs…

The agency failed to ensure an emergency preparedness communication plan that complied with Federal, State and local laws was reviewed and updated at least every two (2) years.

The agency failed to ensure the emergency preparedness communication plan included the names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers.

The agency failed to ensure the emergency preparedness communication plan included contact information for Federal, State, regional and local emergency preparedness staff.

The agency failed ensure the agency's emergency preparedness communication plan included the primary and alternate means for communicating with the clinic staff and federal, state, tribal, regional, and local emergency management agencies.

The agency failed to ensure the emergency preparedness communication plan included a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care.

The agency failed to ensure the agency's emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

The agency failed to ensure the agency's emergency preparedness training and testing program was reviewed and updated at least every two (2) years.

The agency failed to provide emergency preparedness training at least every two (2) years.

The agency failed to conduct exercises to test the emergency plan annually.

The facility failed to ensure the implementation of developed policies and procedures for COVID-19 Coronavirus 2019 ("COVID-19").

The agency failed to ensure that protected health information in the patient's medical records were safeguarded from unauthorized access.

The agency failed to provide evidence that action was taken to prevent further potential violations, including retaliation, while a complaint was being investigated for three (3) of three (3) complaints reviewed.

The agency failed to ensure that a pre-designated person assumed the same responsibilities of the Administrator and obligations as the Administrator in the Administrator’s absence.