Hampstead Home Health Care, Inc

The facility failed to complete a comprehensive plan to coordinate with other healthcare facilities and the community during a disaster or emergency.

The agency failed to develop, implement, evaluate and maintain an effective, ongoing, Home Health Agency wide, data-driven QAPI (Quality Assurance Performance Improvement).

The facility failed to complete an Emergency Preparedness Plan (E.P.P.) annual review and annual update.

The facility failed to include a"community-based risk assessment using an all-hazards approach in the development of the Emergency Preparedness Plan (E.P.P.).

The facility failed to include a process for cooperation and collaboration with emergency preparedness officials.

The facility failed to develop a policy and procedure based on the community risk assessment, communication plan and an all hazards approach for the Emergency Preparedness Plan (E.P.P.).

The facility failed to ensure that the Emergency Preparedness Plan (E.P.P.) training and testing program for facility Staff was reviewed and updated on an annual basis.

The facility failed to ensure that annual Emergency Preparedness Plan (E.P.P.) training and testing documentation was available for review.

The facility failed to conduct and document the facility based and a community based disaster drill's in the last 3 years.

The facility failed to submit OASIS (Outcome and Assessment Information Set) comprehensive assessments for any of it's skilled clientele for a minimum of 6 months prior to this survey.

The agency failed to comply with physician's orders for a survey sample of 3 out of 7 client records reviewed.

The Agency failed to be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care and failed to measure, analyze, and track quality indicators, including adverse patient…

The Agency failed to follow regulatory standards as follows: (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program.

The Agency failed to ensure that performance improvement activities had been developed and implemented.

The Agency failed to track adverse patient events, analyze their causes, and implement preventive actions.

The Agency failed to meet the following: Standard: Performance improvement projects.

The Agency failed to have a governing body that oversees the following: Standard: Executive responsibilities.

The agency failed to provide the annual 12 hours of home health aide in-service training for 4 home health aide personnel records reviewed.

The home health agency failed to ensure that the governing body developed a QAPI (Quality Assessment and Performance Improvement) program.

The agency failed to provide proper written notice in advance of services being non-covered.

The Agency failed to focus on high risk, high volume, or problem-prone areas in their QAPI (Quality Assurance Performance Improvement) Program.

The Agency failed to consider incidence, prevalence, and severity of problems in problem prone areas.

The Agency failed to regularly perform activities that would lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.

The Agency failed to take actions aimed at performance improvement, and, after implementing those actions, the Home Health Agency must measure its success and track performance to ensure that improvements are sustained.

The home health agency failed to ensure that, when the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator.