Aspire Home Healthcare of Arizona, Inc.

The facility has failed to update the emergency preparedness plan at least every 2 years.

The facility has failed to develop and maintain an emergency preparedness plan based on the all-hazards facility and community-based risk assessments including strategies for addressing high risk emergency events identified by the risk assessments.

The facility failed to develop a policy regarding the use of volunteers during an emergency.

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

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 has failed to consider and accommodate any patient requests within the parameters of the assessment and plan of care, and the patient must be treated by the HHA as an active partner in the delivery of care.

The facility failed to document both the existence of the complaints and the resolution of the complaints.

The facility has failed to produce documentation for each complaint received that confirms that an investigation was conducted and records the investigation findings as well as the ultimate resolution of the complaint.

The facility failed to develop written policies and procedures that address influenza and pneumococcal vaccine administration, vaccination screening for safety exclusions, assessing contraindications prior to administration and managing adverse reactions.

The facility failed to ensure verbal orders are authenticated and dated by the physician or allowed practitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies.

The agency failed to develop a community-based risk assessment prior to developing the agency's emergency plan.

The agency failed to update the plan with a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

The agency failed to have an individual EP plan for each patient identified in the comprehensive assessment.

The agency failed to develop and implement a policy and procedure for the use of volunteers in an emergency.

The agency failed to have the existing staff review the emergency preparedness policies and procedures training.

The personnel records failed to contain documentation that personnel had participated in EP plan testing exercises.

The agency failed to ensure the Physical Therapist (PT) provided services to patient #'s 2 and 4 according to their plan of care, which poses a potential risk for the patient if not provided PT services to reach their discharge goal.

The clinical staff (Registered Nurse (RN) #3) failed to comply with the Home Health Agency's "Hand Hygiene" policy (HH7- 1A.01-C.01).

The agency failed to: 1. require RN #3 maintain a respectful attitude and approach to Patient #2, while providing care at all times; and 2. require RN #3 to follow and maintain acceptable and respectful boundaries of Patient #2's personal property, per established facility patient rights.