Nightingale Home Health Service

It was identified that the agency failed to maintain an emergency preparedness plan that was reviewed and updated every two years.

The agency's emergency preparedness plan failed to review and update the all-hazard approach to include emerging infectious disease threats.

The agency failed to have evidence that the policies and procedures included a risk assessment and a communication plan.

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.

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 have written evidence of furnishing the patient's rights in a language and manner the individual understands during the initial evaluation visit in advance of care in order to protect promote the exercise of these rights for two (2) of two (2) patients in the survey sample with…

The agency failed to have written evidence of furnishing the Patient's Rights and Responsibilities and the agencies transfer and discharge policies since the start of care (SOC) for two (2) of two (2) patients in the survey sample with closed records (Clinical record #s 1 and 2).

The agency staff failed to have written evidence to include visit frequencies on the “Service Agreement” for two (2) of two (2) patients in the survey sample closed records (Clinical record #s 1 and 2).

The agency failed to have written evidence of advising on the extent of payment by Medicare, Medicaid or any other federally funded or federal aid program known to the agency for services that maybe expected or may not be covered for two (2) of two (2) patients in the survey sample with closed…

The agency's staff failed to document patient measurable outcomes based on their strengths, goals, and care preferences, including information that may be used to determine the patient's progress toward achievement of identified goals for seven (7) of seven (7) patients in the survey sample (Client…

The agency failed to document 75 hours of classroom and supervised practical training for their home health aides for four (4) out of four (4) in the survey sample.

The agency failed to document classroom training as part of the home health aides curriculum for four (4) out of four (4) in the survey sample.

The agency failed to ensure each patient receiving home health aide services received a supervisory visit by the registered nurse or other skilled professional no less frequently than every 14 days for one (1) of one (1) clinical records a home health aide was applicable in the survey sample.

It was identified that the agency failed to maintain an emergency preparedness plan that was reviewed and updated at least annually.

The agency's emergency preparedness plan failed to have evidence of being reviewed and updated annually that included a process to address cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response…

The agency failed to have evidence that the policies and procedures included a risk assessment and a communication plan.

The agency failed to have evidence of policies and procedures to inform State and local emergency preparedness officials about HHA (Home Health Agency) patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric…

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.

The agency failed to have policies and procedures for the agency's use of volunteers in an emergency or other emergency staffing strategies, including the process and role for the integration of State and Federally designated health care professionals to address surge needs during an emergency.

The agency's emergency preparedness (EP) program it was detrmined the agency failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.

The agency's emergency preparedness (EP) program the agency failed to have a complete communication plan to include all the following (1) Names and contact information for the following: (i) Staff; (ii) Entities providing services under arrangement; (iii) Patients' physicians and (iv) Volunteers…

The agency's emergency preparedness (EP) program failed to include contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff and (ii) Other sources of assistance.

The plan failed to contain evidence of conducting annual testing including unannounced staff drills using the emergency procedures and annually 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 conformed to physician orders (patient records #'s 4, 5, 6 & 7).

The agency's nurse failed to comply with accepted professional standards and principles that apply to professionals furnishing services in regards to infection prevention for two (2) of three (3) home visits in the survey sample (Patients #1 and #3).

The agency failed to have evidence of providing the correct contact information for the HHA (Home Health Agency) administrator, including the administrator's name and business address in order to receive complaints for three (3) of three (3) home visits in the survey sample (Patients #1-#3).

Three (3) of three (3) home visits in the survey sample failed to have a copy of the notice of rights and responsibilities in the home (Patient #1-#3).

Staff #2 (Home Health Aide-HHA) informed the RN of a possible developing wound during the home visit and the nurse failed to assess that possible wound during that home visit.

The agency failed to have evidence of providing information to the HHA (Home Health Agency) patients and designees on how to make complaints regarding treatment and care that is (or fails to be) furnished, for the three (3) home visit's (Home Visits) in the survey sample (Patient #1-#3).

Three (3) of three (3) patients who had home visits made from the survey sample failed to receive all services outlined in their individualized POC (Plan of Care) or received services that were not ordered in their POC, (Patients #1-#3).

Three (3) of seven (7) patients in the survey sample failed to have an individualized POC (Plan of Care) that included all services, treatments and medications provided, (Patients #1-#3).

Six (6) of seven (7) patients in the survey sample failed to have evidence of the HHA (Home Health Agency) promptly alerting the physician to any changes in the patient's condition, needs that suggest that outcomes are not being achieved and/or that the POC (Plan of Care) should be altered…