Good Samaritan Society - Legacy Home Care

The home health agency failed to ensure an emergency preparedness plan specific to the agency's needs and include emerging infectious diseases in the plan.

The agency failed to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program.

The agency failed to maintain compliance with State Law posing the risk that patient care, needs, and services cannot be fully reviewed and compliance determination cannot be evaluated posing the risk of poor care and negative outcomes.

The facility failed to develop and maintain a completed Emergency Preparedness Plan.

The Home Health Agency(HHA) failed to have a process to engage in collaborative planning for an integrated emergency response and include this integrated response process in its emergency plan.

The HHA failed to ensure to keep a copy of the patient's individualized emergency plan in the patient's file as well as provide a copy to the patient and or their caregiver.

The facility has failed to ensure policy creation for the provision of volunteers or other emergency staffing strategies to address surge staffing needs during an emergency.

The HHA failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws that included names and contact information of current staff, entities providing services under arrangement, and patients' physicians.

The HHA failed to maintain or produce agency-specific performance improvement projects/activities.

The facility failed to provide evidence of a performance improvement plan that addresses issues specific to the population served with the goal of improving healthcare processes and outcomes by strategizing ways to improve care for the individuals receiving services.

The HHA failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program.

A review of the personnel list provided did not list the employee mentioned in the admission packet.

The HHA failed to advise patients of the names, addresses, and telephone numbers of the required Federally-funded and state-funded entities that serve the area where the patient resides.

The facility failed to conduct an initial assessment within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date or 2 (two) out of 14(fourteen) patients.

The facility failed to obtain physician orders prior to services being rendered.