Divine Home Health Care, LLC

The home health agency failed to (E-0039) conduct exercises to test the emergency plan at least annually as evidenced by no table top exercises or community drills were provided to the Department for review for the year of 2020 and 2021. Finding Include: The agency policy contained "...1.Divine…

The agency failed to: (E-0004) maintain, review and update the emergency preparedness plan annually; (E-0006) develop a community-based risk assessment prior to developing the agency's emergency plan; (E-0007) address patient/client population, including, but not limited to, persons at risk…

The facility failed to: (G0642) Ensure that a Quality Management program was established and reflected an implementation of process improvement measures to improve quality of patient care.

The facility failed to ensure the following: (0682) an Infection Control program was maintained, documented, available and implemented to ensure the health and safety of its patients that the facility cares for.

The agency failed to maintain, review and update the emergency preparedness plan annually.

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

The facility failed to address patient population, persons at-risk, services the HHA can provide in an emergency, delegation 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.

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

The agency failed to update and annually review the EP plan and policies, to inform State and Local emergency preparedness officials about patients in need to be evacuated from their residence.

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

The facility failed to develop and implement 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 implement within the emergency preparedness Communication Plan, names and contact information for the following: staff, entities providing service under contract, patients' physicians, and volunteers.

The agency failed to have a primary and alternate means of communication during an emergency.

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

The agency failed to develop a means to sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction.

The facility failed to develop a facility based emergency planning, training and testing program.

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

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

The facility failed to ensure that a Quality Management program was established and reflected an implementation of process improvement measures to improve quality of patient care.

The facility failed to ensure that an Infection Control program was maintained, documented, available and implemented to ensure the health and safety of its patients that the facility cares for.