Pampering Plus Inc

The agency failed to ensure the plan included policies and procedures for the use of volunteers and other staffing strategies.

The agency failed to establish and maintain an emergency preparedness communication plan that included contact information for local/regional/state/federal emergency preparedness staff and was reviewed and updated annually.

The agency failed to establish and maintain an emergency preparedness communication plan that included a method for sharing of information, location and medical documentation for patients under the facility's care to other health care providers to maintain continuity of care.

The agency failed to conduct exercises to test the emergency plan at least annually.

The agency failed to encode and electronically transmit each completed OASIS (outcome and assessment information set) to CMS within 30 days of completing the assessment for one (1) of three (3) clinical records reviewed (CR # 2).

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program.

The agency failed to develop a plan of care in accordance with agency policy and regulatory standards pertaining to the plan of care for two (2) of three (3) CR reviewed (CR #1 and 3).

The agency failed to follow state regulations and its policy ensuring that the Plan of Care and verbal orders were signed by the primary physician within seven (7) days for three (3) of three (3) clinical records reviewed.

The agency failed to follow agency policy and send the required 60 day summary to the patient's physician for two (2) of three (3) CR reviewed.

Agency failed to provide documentation that a discharge summary was sent to the primary care physician upon discharge for three (3) of three (3) CRs reviewed (CR# 1, 2, and 3).

Agency failed to provide documentation that a discharge summary was sent to the primary care physician within five (5) days of discharge for three (3) of three (3) CRs reviewed (CR# 1, 2, and 3).