Heaven's Touch Nursing Services LLC

The agency failed to ensure all services and treatments were administered only as ordered by a physician in one (1) of seven (7) clinical records reviewed in the survey sample (clinical record #7).

The agency failed to develop and implement an emergency preparedness plan (EPP) that contained all the required elements and was reviewed annually.

The agency failed to have an up to date all hazards risk assessment.

The agency's emergency's plan failed to address the types of services the agency has the ability to provide in an emergency.

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 preparedness (EPP) 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 for emergency staffing needs.

The agency's emergency preparedness policies and procedures failed to contain a current communication plan.

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's emergency preparedness policies and procedures failed to contain an alternate means of communication with agency staff, federal, state, tribal, regional and local emergency management staff.

The agency's emergency's preparedness policy failed to include methods for sharing medical documentation for patients with other health providers to maintain continuity of care.

The agency's emergency's preparedness (EP) policy failed to include a means for providing information about the agency's needs, and its ability to provide assistance to the authority having jurisdiction, the incident command center, or designee.

The agency failed to implement a training and testing program The findings were: An interview with the administrator on 3/13/18 at 11:17 am revealed the agency had a policy on emergency preparedness in the policy manual without any manual specific to emergency preparedness.

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 agency failed to ensure patients were admitted within 48 hours of the referral date or within 48 hours of the patient's return home for one (1) of (10) medical records in the sample survey (Medical record #2).

The agency's staff failed to update the comprehensive assessment when there was a significant decline in a patient's status for one (1) of ten (10) patients in the survey sample (patient #6).

The agency failed to document the patient's progress toward outcomes and goals specified in the plans of care for five (5) of five (5) medical records in the survey sample admitted/recertified on or after 01/13/2018. (Medical records: #1, #7, #8, #9, and #10).