Building Blocks Pediatric Home Health Services

The agency failed to ensure the emergency preparedness plan included the strategies for addressing the emergency events identified by the risk assessment.

The agency failed to ensure the emergency preparedness plan included the type of services to be provided in an emergency and continuity of operations, including delegations of authority and succession plans.

The agency failed to ensure the emergency preparedness plan included a process for cooperation and collaboration with the local, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during an emergency.

The agency failed to ensure the emergency preparedness P&P was developed and implemented based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section.

The agency failed to ensure the emergency preparedness P&P addressed the requirements for each patient's individual plan during a natural or man made disasters to be included as part of the comprehensive patient assessments, creating the increased risk of not addressing the care needs for the…

The agency failed to ensure the emergency preparedness P&P addressed the procedures to follow up with the on-duty staff and patients to determine if the interruption of services occurred and inform the State and local officials of any on-duty staff or patients that they were unable to contact…

The agency failed to ensure the emergency preparedness P&P included a system of medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained the availability of records in the event of an emergency.

The agency failed to ensure the emergency preparedness P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

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

The agency failed to develop and maintain the emergency communication plan that includes contact information for the Federal, State, and local emergency preparedness staff.

The agency's communication plan failed to address the method for sharing information and medical documentation for patients under the agency's care as necessary with other health providers to maintain the continuity of care.

The agency failed to ensure the communication plan included a means of providing information about the HHA's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the incident command center or designee.

The agency failed to develop and maintain the emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the…

The agency failed to ensure the initial training in emergency preparedness P&P was provided to all of the staff including the contracted staff and volunteers, consistent with their expected role.

The agency failed to ensure the participation in a community-based full scale exercise drill and one table top drill exercise drill.

The agency failed to ensure care and services were provided as per the POC for one of seven sampled patients (Patient 1), creating the risk of not providing appropriate, consistent, and quality care to this patient.

The agency failed to ensure the clinical records were accurate and complete for three of seven sampled patients (Patients 1, 4, and 5), creating the risk of substandard care provided to these patients as their clinical information was not complete.

The agency failed to ensure the initial comprehensive assessments were complete in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for two of seven sampled patients (Patients 1 and 3), creating the risk of not identifying and…

The agency failed to ensure the comprehensive assessment was completed at discharge for one of seven sampled patients (Patient 1), creating the risk of not updating the patient's status for this patient.

The agency failed to ensure the physician's verbal orders were dated by the SN who received the orders and signed by the physician by the physician within 30 working days as per the agency's P&P for five of seven sampled patients (Patients 1, 2, 3, 4, and 7), creating the risk of not providing…

The agency failed to coordinate care to meet the patient's care needs for one of seven sampled patients (Patient 1), creating the risk of not providing the necessary care and services to this patient.

The agency failed to ensure their P&P addressing the TB screening was conformed with the regulatory requirements as per CCR, Title 22. In addition, the agency failed to ensure one employee (RN 1) had the annual TB screening as per CCR, Title 22, creating the risk for spreading the infections.