Hope Healthcare, LLC

The agency failed to: (E-0004) maintain, review and update the emergency preparedness plan annually; (E-0006) develop a community-based risk assessment prior to developing the agency's emergency plan; (E-0009) include a process for cooperation and collaboration with local, tribal, regional, State…

This facility failed to ensure the following: (G-0642) that a Quality assessment and performance improvement program (QAPI) was established, developed, implemented, maintained, and evaluated, and reflected implementation of process improvement measures to improve quality of patient care requiring…

The agency failed to maintain, review and update the emergency preparedness plan annually.

The facility failed to develop a community-based risk assessment prior to developing the facility's emergency plan.

The agency failed to update the plan with a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

The agency failed to have an individual EP plan for each patient identified in the comprehensive assessment.

The agency failed to update and annually review the EP plan and policies.

The agency failed to develop and implement a policy and procedure for the use of volunteers in an emergency.

The facility failed to develop and implement an emergency preparedness Communication Plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually.

The agency failed to have a primary and alternate means of communication during an emergency.

The facility failed to develop and implement a method for sharing information and medical documentation for patients under the HHA'S care, as necessary, with other health care providers to maintain the continuity of care.

The agency failed to develop a means to sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction.

The facility failed to develop a facility based emergency planning, training and testing program.

The agency failed to have the existing staff review the emergency preparedness policies and procedures training.

The facility failed to conduct exercises to test the emergency plan at least annually.

The facility failed to require that their Quality assessment and performance improvement program (QAPI) was established, developed, implemented, maintained, and evaluated, and reflected implementation of process improvement measures to improve quality of patient care requiring action plans to…

This facility failed to ensure their QAPI program utilized Quality indicator data including measures derived from Oasis to monitor their facility's effectiveness and safety of services and quality of care, and ensure the governing body approved the frequency and detail of the data collection done.

The facility failed to ensure a method to evaluate the data collected for infection control, which had the potential for not determining whether the actions taken improved the provision of services of responding to infections and patient complaints.

The agency failed to provide skilled nursing services directly.

The facility failed to ensure the staff completed a medication assessment at every visit, document the assessment on the visit note, and document medications the client may take on the medication profile, which poses a potential risk for medication error, adverse drug effects and reactions…

The facility failed to ensure that 2 of 3 home health aides (HHA) received at least 12 hours of in-service training, as evidenced by a lack of any documentation in the personnel files of verification reviewed, which poses the potential risk for negative patient care outcomes.