Bay at Woodlands Home Health LLC

This agency failed to ensure there is a comprehensive Emergency Preparedness Program, in 1 of 1 Emergency Programs reviewed.

This agency failed to document the Emergency Plan risk assessment is reviewed and updated every two years in 1 of 1 Emergency Preparedness Programs reviewed.

This agency failed to ensure Emergency Preparedness Policy and Procedures were reviewed and updated every two years in 1 of 1 Emergency Preparedness Plan reviewed.

This agency failed to ensure the Emergency Preparedness communication plan is reviewed and updated every two years in 1 of 1 Emergency Preparedness Plan reviewed.

This agency failed to ensure the Emergency Preparedness training and testing is reviewed and documented every two years in 1 of 1 Emergency Preparedness Plan reviewed.

This agency failed to conduct one full-scale community-based exercise every two years in 1 of 1 Emergency Preparedness Plan reviewed.

Agency staff failed to develop Plans of Care (POC) that were individualized to meet the specific needs of the patients and/or develop goals that were measurable within a specified timeframe and/or individualized in 8 of 8 patients (Patients #1, #2, #3, #4, #5, #6, #7, and #8) records reviewed.

The agency failed to ensure there is a policy on securing and making medical records available in an emergency, in 1 of 1 Emergency Preparedness Programs reviewed.

The agency failed to ensure there is a policy on a process for sharing patient medical records in an emergency, in 1 of 1 Emergency Preparedness Programs reviewed.

The agency failed to document each patient's risk for emergency department visits and hospital re-admission within the plan of care (POC) in 4 of 7 (#1, 2, 3, and 7) clients.