Maranatha Home Health, Inc

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 information sharing were in place for all patients and employees.

The agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff.

The agency failed to ensure: 1. An emergency preparedness testing and training program was developed, implemented and reviewed/updated at least annually for all 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 05/12/23 to 11/14/24 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 that included self-monitoring efforts and opportunities to identify problems to improve care, services and operations for all patients and employees.

The agency failed to ensure the selection, review and reporting of ongoing PIP data through the QAPI program for 01/01/24 to 11/14/24 for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program for calendar year 2023, and 01/01/24 to 11/14/24 for all patients and employees.

The agency failed to ensure the Infection Control Program surveillance data was included in QAPI program activities for all patients and employees.

The agency failed to ensure governing body oversite of the agency’s program evaluation for calendar year 2023, and 01/01/24 to 11/14/24 for all patients and employees.

The agency failed to ensure patient consent for the provision of agency care and services were obtained for two (Patients #8 and #9) of 10 patients reviewed.

The agency failed to ensure start of care within 48 hours of referral for five (Patients #1, 3, 6, 7 and #8) of 10 patients.

The agency failed to ensure individualized patient POC included: 1. Primary diagnosis related to the provision of care for home health services for three (Patients #3, 4 and #9) of 10 patients; 2. SN interventions related to medication administration for one (Patient #9) of 10 patients; 3. SN…

The agency failed to ensure physician orders were documented for SN services during and after an in-patient admission for one (Patient #3) of 10 patients.

The agency failed to ensure physician orders for SN visits and SN interventions for medication administration and blood sugar monitoring were obtained for two (Patients #3 and #9) of 10 patients.

The agency failed to ensure care was coordinated between the agency and physician for four (Patients #1, 2, 3 and #4) of 10 patients.

The agency failed to ensure SN services (visits) were provided as ordered on the POC for one (Patient #4) of 10 patients.

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure clinical visit note documentation was completed for five (Patients #1, 2, 5, 6 and #9) of 10 patients.

The agency failed to ensure a completed transfer/discharge summary was provided to the receiving service provider for two (Patients #3 and #8) of 10 patients.

The agency failed to ensure update of the comprehensive nurse assessments to reflect the current status of wounds for one (Patient #6) of seven patients.

The agency failed to ensure plan of care development included diagnosis appropriate interventions for two (Patients #1 and 7) of 7 patients.

The agency failed to ensure development of a facility-based community-based risk assessment.

The agency failed to document emergency drills at least annually for 47 current patients and all employees.

The agency failed to document PIPs conducted through their QAPI Program for all employees and 47 current patients.

The agency failed to ensure the governing body provided oversight of agency operations and programs for 46 current patients and all employees.

The agency failed to ensure physician notification of vital signs outside of ordered parameters for one (Pt #1) of seven patients.