Alfred Healthcare Services, Inc.

The agency failed to comply with all applicable Federal, State, and local emergency preparedness requirements.

The agency failed to maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for two of two years reviewed (2020 and 2021).

The agency failed to provide written information in three (Patients # 1, # 2 and # 3) of three patients who received a home visit.

The agency failed to conduct and document PIP(s) for three of three years reviewed (2019, 2020 and 2021) that reflected the scope, complexity and past performance of the agency's services and operations.

The agency failed to maintain a coordinated agency‐wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's QAPI program.

The agency failed to ensure that each hha competency evaluation was performed by a registered nurse, in three of (hha # 1, # 2, and # 4) three home health aide's personnel records reviewed for competency evaluation.

The agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 7) of two inactive patient records reviewed.

The agency failed to ensure that a registered nurse conducted an initial assessment visit within 48 hours of referral in two (Clinical Records # 2 and # 3) of two patients with a diagnosis of hypertensive heart disease whose clinical records were reviewed.