Palm Valley Health Care Inc

E-0004; Development of Emergency Plan, Review and Update Annually Based on record review and interviews, the agency failed to review its written emergency preparedness and response plan at least once a year and after an actual emergency response to decide if the plan worked and to update it if…

G-434; Participate in Care Based on clinical record review and interview, the Agency failed to respect the patient's rights to have an established individualized Plan of Care (POC [ 485] ) for 1 of 2 (#1) active Agency Licensed and Certified patients and 1 of 5 (#6) discharged Licensed and…

G-572; Plan of Care Based on clinical record review and interview, the Supervising Nurse failed to ensure the patients plan of care was executed as written for 5 of 7 ( #1, #2, #3, #4 and #7) patients whose records were reviewed.

G-642; Program Scope Based on record review and interview, the agency failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations.

G-944; Administrator; The Administrator must... Based on record review and interview, the Agency failed to organize and direct the agency's ongoing functions as follows: 1. The Administrator failed to implement a policy that required the Agency to measure, analyze and track quality indicators to…

The agency failed to review its written emergency preparedness and response plan at least once a year and after an actual emergency response to decide if the plan worked and to update it if needed for 2020 and currently in 2021. This failure placed the agency's 2 active patients at risk for harm by…

The Agency's written emergency preparedness and response plan failed to include a continuity of operation business plan that addressed emergency financial needs, essential functions for patient services, critical personnel, and how to return to normal operations as quickly as possible for 2020 and…

Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. Based on record reviews and interviews, the agency failed to include or use in its emergency preparedness and response plan, procedures…

The agency's Emergency Preparedness and Response Plan failed to include a communication plan that complied with 42 Code of Federal Regulation (CFR) 484.22(c), for 2019, 2020 and currently in 2021. This failure could place the agency's 2 active Licensed and Certified patients and any future clients…

The Agency's written emergency preparedness and response plan failed to include procedures to release patient information in the event of a disaster for 2020 and currently in 2021. This failure could place the agency's 2 active Licensed and Certified patients at risk of harm in the event of an…

The Supervising Nurse failed to ensure the patients plan of care was executed as written for 5 of 7 ( #1, #2, #3, #4 and #7) patients whose records were reviewed.

The HHA must: Based on record review and interview, the agency failed to enforce its written policy to ensure the integration of patient services among all agency personnel providing care and services for 2 of 7 Patients (#1 and #2) whose records were reviewed.

The agency failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations.

The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed and immediately corrected identified problems that directly or could potentially threaten the patient care and safety, in that the Agency did not have or complete a Performance improvement…

The agency's Governing Body failed to ensure that the Quality Assessment Performance Improvement (QAPI) Committee met at least twice a year in 2020 and currently in 2021 to make sure that an ongoing program for quality improvement and patient safety was defined implemented and maintained.

The Administrator failed to organize and direct the agency's ongoing functions as follows: 1. The Administrator failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations.

The Agency failed to respect the patient's rights to have an established individualized Plan of Care (POC [ 485] ) for 1 of 2 (#1) active Agency Licensed and Certified patients and 1 of 5 (#6) discharged Licensed and Certified patients whose clinical records were reviewed.

The Administrator failed to manage the daily operations of the agency in that: 1. The Administrator failed to respect the patient's rights to have an established individualized Plan of Care (POC [ 485]) for 1 of 2 (#1) active Agency Licensed and Certified patients and 1 of 5 (#6) discharged…