Loretta's Home Health Care, Inc

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure its infection control program was included in QAPI program activities for all patients and staff.

The agency failed to ensure governing body oversite of: 1. A patient centered QAPI program for calendar year 2021 and 01/01/22 through 07/28/22; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2021 and 01/01/22 through 10/19/22; and 3.…

The agency failed to develop and implement an agency emergency preparedness program for all patients and employees.

The agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) that identified the agency and included a date the assessment was developed, implemented and/or reviewed and in place for all patients and employees.

The agency failed to ensure development, implementation and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees.

The agency failed to ensure administrative policies and procedures related to an Emergency Preparedness Plan were in place for all patients and employees.

The agency failed to ensure development of an Emergency Preparedness Communication Plan which included required information related to all patients, employees and resources of the agency affecting all patients and employees.

The agency failed to ensure an Emergency Preparedness Communication Plan included required contact information for Federal, State, Tribal, Regional and Local emergency management agencies for the agency, all patients and employees.

The agency failed to ensure: 1. An emergency preparedness testing and training program was developed, implemented and reviewed/updated for all patients and employees and; 2. An after-action report was documented after each drill, exercise or plan activation event for all patients and employees.

The agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar years 2020, 2021 and for 01/01/22 to 10/19/22 for all patients and employees.

The agency failed to ensure completion of a transfer/discharge summary for two (Patients #6 and #7) of seven patients.

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of a patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure its infection control program was included in QAPI program activities for all patients and staff.

The agency failed to ensure infection control education was: 1. Included in QAPI activities; 2. Showed interventions to reduce future infections; and 3. Provided and/or maintained for all patients and employees.

The agency failed to ensure governing body oversite of: 1. A patient centered QAPI program for calendar year 2021 and 01/01/22 through 07/28/22; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2021 and 01/01/22 through 10/19/22; and 3.…

The agency failed to ensure governing body appointment of the alternate clinical manager and/or alternate supervising RN for the agency affecting all patients and staff.

The agency failed to ensure patients received a statement of rights at the time of admission to the agency for care and services for seven patients (Patients #1-7).

The agency failed to ensure patients received informed consent at the time of admission to the agency for care and services for seven of seven patients (Patients #1-7).

The agency failed to ensure patients received a statement of billing and complaint processes at the time of admission to the agency for care and services for seven patients.

The agency failed to ensure patients received a statement of the grievance processes and OSDH complaint hotline information at the time of admission to the agency for care and services for seven patients.

The agency failed to ensure a medication profile was reviewed and updated with changes in medications for two (Patients #3 and #5) of seven patients.

The agency failed to ensure: 1. Physician orders for physical therapy visits for one (Patient #3) of seven patients; 2. Physician ordered wound care for one (Patient #5) of seven patients; 3. Physician orders for SN to administer insulin medications for one (Patient #5) of seven patients and; 4.…

The agency failed to ensure services were provided as ordered on the POC’s for: 1. SN to conduct assessment of patient blood pressure every visit and notify the physician of levels outside of reporting parameters for one (Patient #1) of seven patients; 2. SN to conduct assessment of patient weight…

The agency failed to ensure governing body appointment of the clinical manager and/or supervising RN for the agency affecting all patients and staff.

The agency failed to ensure a completed discharge summary was provided for two (Patients #6 and #7) of seven patients.