Homunity Health Services

E-0001 COP This condition was not met as evidenced by document review and interview which revealed the agency failed to review and update the emergency plan every two years E-0004; Failed to update the facility/community based risk assessment utilizing the all hazards approach and to include…

The agency’s QAPI (Quality Assurance Performance Improvement) failed to ensure to implement and maintain a coordinated agency-wide program for the surveillance investigation, identification, prevention control and investigation of infectious and communicable diseases (G642); failed to ensure…

The agency's Emergency Preparedness Plan (EPP) failed to review and update the EPP every 2 years.

The agency's Emergency Preparedness Plan failed to review and update the community risk assessment with strategies identified and the all-hazards approach to include cyber-attacks.

The agency failed to have evidence that the policies and procedures for the risk assessments and communication plan were reviewed and updated at least every 2 years.

The agency failed to have evidence of policies and procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact within a specific timeframe or an outline of surrounding facilities to ensure patient care is continued.

The agency failed to review and update all contact information every 2 years.

The agency failed to maintain documentation of a training and testing program based on the agency's risk assessment required for staff.

The agency failed to maintain documentation of evidence of the staff’s ability to demonstrate knowledge of agency’s emergency preparedness plan.

The plan failed to contain evidence of conducting annual testing including unannounced staff drills using the emergency procedures and/or participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based.

The agency failed to ensure that each patient received the home health services according to a written plan of care.

The agency's QAPI (Quality Assurance Performance Improvement) program failed to maintain a coordinated agency-wide program for the surveillance investigation, identification, prevention control and investigation of infectious and communicable diseases including TB (Tuberculosis) testing for the…

The agency failed to ensure its performance improvement activities that must focus on high risk, high volume, or problem-prone areas.

The agency failed to ensure its performance improvement activities tracked adverse patient events, analyze their causes, and implement preventative actions.

The agency's QAPI (Quality Assurance and Performance Improvement) plan failed to conduct Performance Improvement Projects (PIPs) each year.

The facility failed to ensure the agency's quality improvement program was ongoing, defined, implemented, and maintained.

The agency failed to test its employees for TB (tuberculosis) according to the CDC (Centers for Disease Control and Prevention) healthcare employee recommendations for four (4) of eight (8) employee files reviewed in the survey sample (Employee records for Employee #s 3, 5, 7, and 8).

The agency failed to ensure accurate and complete medication lists were documented in four (4) of (10) clinical records reviewed in the survey sample (clinical records for Patient #'s 1, 5, 7 and 10).

The agency failed to provide each patient written information regarding the patient’s medication regimen based on the medication review conducted by the Home Health Agency for (10) of (10) clinical records reviewed in the survey sample (clinical records for Patient #s 1, 2, 3, 4, 5, 6, 7, 8, 9 and…

The agency failed to ensure its Quality Assessment Performance Improvement Plan (QAPI) ensured sustained improvements.