Acclaim Home Health Care, Inc

The agency failed to meet the §483.475 (Emergency Preparedness) requirements for Home Health Agencies and did not establish and maintain a comprehensive Emergency Preparedness (EP) program that met all of the standards specified within the Conditions of Participation for the EP program.

The agency failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements.

The agency failed to develop and maintain an emergency preparedness plan that included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

The agency failed to implement an emergency preparedness training program for new employee orientation and every 2 years thereafter as required.

The agency failed to ensure that annual exercises were conducted to test the emergency plan.

The agency failed to ensure Outcome and Assessment Information Set (OASIS) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS) within 30 days of completing the assessment of the beneficiary.

The agency failed to ensure the plan of care was followed for 1 Patient (#4), in a total sample of 7 patients.

The agency failed to ensure complete and appropriately authenticated, dated, and timed documentation.

The agency failed to ensure a registered nurse conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner ordered start of care date…

The agency failed to ensure staff made an update to the comprehensive assessment including a discharge summary and submission of a discharge Outcome and Assessment Information Set (OASIS) to Centers for Medicare and Medicaid Services (CMS) for one Patient (#2) out of total sample of 7 patients.

The agency failed to ensure a completed discharge summary was sent to the primary care practitioner after discharge from the Home Health Agency (HHA) within 5 business days of the patient's discharge, for one Patient (#2), out of a total sample of 7 patients.

Based of record review and interview the agency failed to ensure that seven Patients (#1, #2, #4, #5, #3, #6 and #7) out of a total sample of seven patients, had an individualized emergency plan as part of the clinical record.