Angeles San Cristobal

The agency failed to provide to the surveyor evidence of the development, implementation, evaluation, and maintenance of an effective, ongoing, Home Health Agency (HHA)-wide, data-driven Quality Assessment Performance Improvement- QAPI program, to evaluate compliance with this Condition of…

The facility failed to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

The facility failed to address patient/client population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

The facility failed to include 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 Findings include: During the review of the facilities…

The facility failed to stablish written policies and procedures.

The facility failed to stablish individual plans for each patient must be included as part of the comprehensive patient assessment.

The facility failed to develop and implement procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment.

The facility failed to have written procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency.

The facility failed to stablish a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

The facility failed to stablish policies and procedures for the use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years.

The facility failed to include names and contact information for staff, entities providing services under arrangement, patients' physicians and volunteers.

The facility failed to have primary and alternate means of communicating with staff, Federal, State, tribal, regional, and local emergency management agencies.

The facility failed to have a method for sharing information and medical documentation for patients under facility's care, as necessary, with other health providers to maintain the continuity of care.

The facility failed to provide a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

The facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan.

The facility failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.

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

The facility failed to ensure that for the Outcome Assessment Information Set -OASIS (comprehensive assessment) data collection and report there are available detailed procedures developed and implemented by facility, who include provisions to be taken to encode and transmit OASIS data within 30…

The facility failed to ensure that service and treatments are provided only as ordered by physician 2 out of 17 records reviewed (RR-CR #13 and HV #4) Findings Include: CCR #13 is a 71-year-old female patient admitted on 08/19/2023 with Cerebrovascular accident.

The agency failed to disclose the change of address to state survey agency at the time of the Home Health Agency move to other address.

The agency failed to vaccine with Influenza vaccine accordance to Health Department Administrative Order #244, Criminal Record, Health Certificate, Cardiopulmonary Resuscitation (CPR), Law 300, and Hepatitis B for 9 out of 23. (MD#1, RN#5, RN# 7, RN#9, RN#10, RN# 12, PT#13, PT#14, PT#16, and PT#18)…

The agency failed to ensure that governing body assume full legal responsibility providing its quality assessment and performance improvement program.

The agency failed to ensure that medical records contain and reflect past and current information of patient's status for 4 out of 17 records reviewed (R.R-H.V #1, #3, R.R #11, and #12).

The agency failed to ensure that patient medical record be available to the patient free of charge upon request at next home visit or within 4 business days.

The agency failed to ensure provide to all patients written notice of the right and responsibilities related to discharge and transfer.

It was determinate that the facility failed to promote patients right to receive contact information for the Home Health Agency (HHA) Administrator (employee# 2), including the name, business address and phone number to receive complaints.

The facility failed to promote patient rights by not receiving privacy education sheets for patients for whom Outcome Assessment Information Set-OASIS data collected.

The agency failed to ensure that personnel be train related to 45 CFR parts 160 and 164 pertain to requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

The facility failed to ensure to document the correct telephone numbers for the State Licensing (Law 101) and the Medicare State Agency established for the purpose of receiving any complaints.

The agency failed to ensure that transfer or discharge is necessary for the patient’s welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity for 4 out of 17 records…

The agency failed to ensure that the Initial Assessment was performed withing 48 hour of receiving the patient referred for 11 out of 17 Records Reviewed (R.R-H.V #1, #2, #3, R.R. #8, #9, #10, #11, #12, Closed R.R #14, #16, and #17).

The agency failed to ensure that the comprehensive assessment must be updated the last 5 days of every 60 days beginning the stat of Care date for 4 out of 17 records reviewed (H.V. #1, #5, R.R #11, and #12).

The agency failed to ensure patient physician be promptly alert that agency lack of Physical Therapist- PT from 09/29/2023 through 10/11/2023 for 4 out of 17 records reviewed (R.R-H.V #3, R.R. #8, #9 and #10).

It was determinate that the facility failed to promote patients right to receive contact information for the Home Health Agency (HHA) Clinical Manager (employee #3), including the name, business address and phone number to receive complaints.

The agency failed demonstrate that skilled professional services participate in the implementation of the HHA’s Quality Assessment and Performance Improvement (QAPI) program.

The agency failed to include education for physical therapy and speech therapy personnel.

The facility failed to ensure that all Home Health Agency (HHA) services must be provided in accordance with current clinical practice guidelines for infection control accepted hand washing professional standards of practice and urinary catheter insertion standard practice for 2 out of 7 home…

The facility failed to develop and maintain an emergency preparedness plan with specific approach to the location of the facility and surroundings including emerging infectious disease.

The facility failed to develop and maintain an emergency preparedness plan that include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences during emerging infectious disease, COVID-19 and includes all hazard approaches that…

The facility failed to develop and maintain an emergency preparedness plan that address patient population, types of services the facility has the ability to provide, continuity of operations and delegation of authority.

The facility failed to develop and maintain an emergency preparedness plan that include a process for cooperation and collaboration to maintain a respond during a disaster or emergency situation.

The facility failed to develop policies and procedures based on the emergency and communication plan.

The facility failed to develop policies and procedures based on patient individual emergency plan.

The facility failed to provide evidence of policies and procedures to inform State and local emergency preparedness officials about patients in needs Findings include: The facility did not provide evidence of the policies and procedures to inform State and local emergency preparedness officials…

The facility failed to provide evidence of policies and procedures to contact local authorities in the case the facility cannot establish communications with on duty staff or patients Findings include: The facility did not provide evidence of the policies and procedures to contact local authorities…

The facility failed to develop policies and procedures for medical documentation that preserves patient information, protects confidentiality of patient information and secures and maintains availability of records.

The facility failed to ensure that the emergency plan policies and procedures are develop to facilitate the support of volunteers and other healthcare professionals in an emergency.

The facility failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State and local laws.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated every two years.

The facility failed to provide evidence of an emergency preparedness training and testing.

The facility failed to develop and maintain an emergency preparedness training program.

The facility failed to conduct exercises to test the emergency plan.

The facility failed to ensure that the Home Health Agency (HHA) provide infection control education to all staff.

The agency failed to ensure Home health aide are assigned by a registered nurse or other appropriate skilled professional, with written patient care instructions for 1 out of 10 cases reviewed ( CRR # 1).

The facility failed to ensure that the clinical records contain correct clinical past and current findings for each home health patient related to complete documentation of implementation of plan of care for 2 out of 10 records reviewed (H.V. #3, and Closed RR #2) Findings include: 1. H.

The facility failed to promote patient's right to receive information about phone numbers and entities whom to contact to file a grievance.

The agency failed to supervise personnel for reviewing in every home visit the medications that the patients are taking for 2 out of 10 drug regimen records reviewed (HV#2, and HV#4).

The facility failed to develop and maintain an emergency preparedness plan that include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the…

The facility failed to develop and maintain an emergency preparedness plan that address patient population, types of services the facility has the ability to provide, continuity of operations and delegation of authority.

The facility failed to develop and maintain an emergency preparedness plan that include a process for cooperation and collaboration to maintain a respond during a disaster or emergency situation.

The facility failed to develop policies and procedures based on the emergency and communication plan.

The facility failed to provide evidence of policies and procedures to inform State and local emergency preparedness officials about patients in needs Findings include: The facility did not provide evidence of the policies and procedures to inform State and local emergency preparedness officials…

The facility failed to provide evidence of policies and procedures to contact local authorities in the case the facility cannot establish communications with on duty staff or patients Findings include: The facility did not provide evidence of the policies and procedures to contact local authorities…

The facility failed to develop policies and procedures for medical documentation that preserves patient information, protects confidentiality of patient information and secures and maintains availability of records.

The facility failed to ensure that the emergency plan policies and procedures are develop to facilitate the support of volunteers and other healthcare professionals in an emergency.

The facility failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State and local laws.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

The facility failed to include in its communication plan, a process to communicate the required information to the local and federal agencies in charge in an emergency situation.

The facility did not provide evidence of an emergency preparedness training and testing.

The facility failed to develop and maintain an emergency preparedness training program.

The facility failed to conduct exercises to test the emergency plan.

Facility failed to ensure that clinical record contain pertinent information related with patient care and treatment.