Friends Health Care Team, Inc

The agency failed to review and update the emergency preparedness plan at least every 2 years.

The agency failed to ensure the staff developed individualized emergency preparedness plans as part of the comprehensive assessment for seven (7) of seven (7) patients whose clinical records were reviewed in the survey sample (clinical records #1-7).

The agency staff failed to implement a training program for the emergency preparedness program.

The agency staff failed to implement a testing program for the emergency preparedness program.

The agency failed to develop an emergency preparedness plan based on a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach to include strategies for addressing emergency events identified by the risk assessments.

The agency failed to develop and maintain an emergency preparedness plan (EPP) that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency…

The agency's emergency's preparedness policy and procedures failed to include procedures to inform State and local emergency preparedness officials about home health patients in need of evacuation from their residences.

The agency's emergency's preparedness policy and procedures failed to include the procedures to follow up with on-duty staff and patients.

The agency's emergency's preparedness policy and procedures failed to include a policy for medical documents.

The agency's emergency preparedness policies and procedures failed to include a policy and procedure for the use of volunteers in an emergency or other professionals for emergency staffing needs.

The agency failed to include the names and contact information for the following in their emergency preparedness communication plan: (1) Staff.

The agency's emergency preparedness policies and procedures failed to contain a current communication plan that included contact information for federal, state, tribal, regional and local emergency preparedness (EP) staff.

The agency failed in their Emergency Preparedness Plan (EPP) their primary and alternate means for communicating with their staff and Federal, State, tribal, regional, and local emergency management agencies.

The agency failed to include in the Communication Plan section of their Emergency Preparedness Plan a procedure regarding providing information about the agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, and/or…

The agency failed to provide training in the emergency preparedness plan (EPP) that is consistent with their roles in an emergency to all new and existing staff, individuals providing services under arrangement, and volunteers.

The agency failed to provide initial and ongoing training to staff, provide training at least annually, demonstrate staff knowledge and maintain documentation of all emergency preparedness training.

The agency's Emergency Preparedness Plan (EPP) failed to contain documentation of the agency participating in a facility- based or community-based exercise to test the agency's EPP.

The agenc'sy staff failed to ensure home health services were provided according to the patient's individualized plan of care for two (2) out of seven (7) clinical records in the survey sample (Clinical records: #4 and #7).

The agency failed to ensure patients were informed at the time of admission of the disciplines that would provide care and the frequency of visits for one (1) of seven (7) patients in the survey sample (Clinical record: #5).

The agency failed to ensure the patient was informed at the time of admission regarding the charges the patient may have to pay for home health services before care is initiated for one (1) of seven (7) clinical records reviewed.

The agency failed to provide the names, addresses, and telephone numbers of the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center; and the Quality Improvement Organization where the patient resides.

The agency failed to ensure the patient's individualized plan of care included a description of the patient's risk for emergency department visits and hospital re-admissions.

The agency failed to ensure drugs, services and treatments provided to patients were documented as a complete order on the plan of care by the physician.

The agency failed to send the patient's discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit for seven (7) of seven (7) closed clinical records reviewed in the survey sample admitted or recertified on or after…

The agency failed to ensure home health aides received at least 12 hours of in-service training during each 12 month period in eleven (11) of eleven (11) applicable personnel files reviewed.

The agency failed to ensure the home health aide provided services according to the plan of care and consistent with the home health aide training in one (1) of eight (8) medical records reviewed in the survey sample.

The agency failed to ensure each patient receiving non-skilled care had an on-site supervisory visit no less frequency than every 60 days in order to assess each aide while he or she is performing care in eight (8) of eight (8) records reviewed in the survey sample.