Esperanza Home Health Care/Hospice

The facility failed to establish a comprehensive emergency preparedness program.

The facility failed to establish an ongoing Quality Assessment and Performance Improvement (QAPI) program by: 1. Failing to ensure that issues were addressed by the facility such as falls 2. Failing to conduct Quarterly QAPI meetings This failed practice is likely to lead to poor recognition of…

The facility failed to ensure the governing body members are included and are fully informed regarding the operation of the agency and it's services and performance improvement.

The facility failed to ensure that items utilized for direct patient care are furnished appropriately by using items passed expiration dates and not identified as being under an extended use authorization by the United Stated Food and Drug Administration.

The facility failed to update the Plan of Care after patient fell twice at home and suffered injuries.

The facility failed to conduct interdisciplinary meetings (meetings that contain all levels and types of staff, such as social workers/doctors/nurses) beyond 9/22/2020. This deficient practice is likely to affect all residents in the facility if the facility is not aware of patients' current…

The entity failed to meet the Condition of Participation for Quality Assessment and Performance Improvement.

The entity failed to meet the Condition of Participation for Infection Control.

The agency failed to completely fill out the authorization for release of health information under the Health Insurance Portability and Accountability Act (HIPPA) portion of the admission packet indicating which health information may be used and/or disclosed in 8 of 8 patient charts (P#1 - P#8).

The entity failed to coordinate the execution of the plan of care by the team members, Nursing, Therapy, Medicine, and Aides for 7 of 7 (P#1-P#7) sampled patients.

The entity failed to track performance improvement activities in any of its service areas.

The entity failed to track any adverse events including medication errors, falls, incidents of patient harm, or turn them into Performance Improvement activities in any of its service areas.

The Governing Body failed to ensure the entity had current policies and procedures for Infection Control, Coordination of Care and an active Quality Assurance Process Improvement Program.

The entity failed to develop and maintain an entity-wide Infection Control plan and failed to include this plan in their Quality Assurance Process Improvement (QAPI) program.

The entity failed to develop and provide professionally accepted Infection Control training for staff.

The Governing Body failed to ensure the entity had current policies and procedures for Infection Control, Coordination of Care and an active Quality Assurance Process Improvement program.

The entity failed to review medications for possible interactions and side effects for 7 of 7 patients (P#1-P#7).

The entity failed to track performance improvement activities in any of its service lines that were potential of high risk, high volume or problem-prone areas.