Angel's Hope Home Health, Inc.

The Home Health Agency (HHA) failed to develop and implement a QAPI program that included quality indicators for high risk and high volume indicators.

The facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA) waiver for laboratory testing performed by the Home Health Agency (HHA).

The Home Health Agency (HHA) failed to maintain an up-to-date medication profile for one of four (Patient (P)) 3 reviewed for home visits.

The agency's Emergency Preparedness (EP) Plan failed to include a communication plan which included the names and contact information of staff members, names of contracted services, contact information for patients' physicians, volunteers and of similar provider types . Findings include: The…

The agency's Emergency Preparedness (EP) Plan failed to establish an agreement with the local radio station to provide emergency communication with their patients and staff members or obtain the 2-way radios as documented in the EP communication plan Findings include: The agency's Emergency…

The agency failed to provide training on Emergency Preparedness (EP) policies and procedures to all new and existing staff members and individuals providing services under arrangement and failed to ensure staff could demonstrate knowledge of emergency procedures.

Based interview and document review, the agency failed failed to participate in drills, tabletop exercises, community or facility- based exercises on an annual basis as documented in the facility's Emergency Preparedness (EP) Plan.

The agency failed to comply with CMS (Centers for Medicare/Medicaid) time sensitive requirements for electronically submitting data.

The agency failed to ensure a patient had the correct ordered catheter size inserted for 1 of 7 patients (Patient #4).

The agency failed to ensure inspectors were screened regarding Covid-19 upon entry to the agency's office.

The clinical record lacked documented evidence of a physician order to conduct a second skilled nursing visit for the week.

The agency failed to integrate a patient's urologist's catheter change frequency order into the plan of care for 1 of 7 patients (Patient #4).