Pacific Home Health and Hospice

The agency failed to demonstrate that its emergency preparedness plan was reviewed and updated at least every 2 years.

The agency failed to conduct and/or maintain documentation demonstrating completion of the required annual emergency preparedness exercise for 1 of the 2 most recent annual testing periods reviewed.

The agency failed to demonstrate an ongoing process to measure, analyze, and track quality indicators to assess agency processes, services, and operations.

The agency failed to maintain Hepatitis B employee-health documentation for 3 of 5 personnel records reviewed (Staff #1, Staff #2, and Staff #4).

The agency failed to provide documentation of required annual infection prevention and control education for 3 of 5 personnel records reviewed Staff #1, Staff #2, and Staff #4. Findings:Review of the agency policy titled “Oregon Administrative Policy & Procedure Manual,” Section: Infection Control…

The agency failed to provide documentation demonstrating that 1 of 1 home health aide reviewed (Staff #4) completed at least 12 hours of in-service training during each applicable 12-month period after hire.

The agency failed to ensure the services ordered by the physician were provided for 1 of 7 patient records reviewed (Patient #4).

The agency failed to electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the beneficiary for 19 of 353 assessments processed.

The agency failed to ensure the registered nurse performed an initial assessment visit within 48 hours of referral for 5 of 7 patient records reviewed (Patients #1, #4-7).