Patient Care Advocates, LLC

The facility failed to: (E-0004) develop and maintain an EP plan that must be reviewed, and updated at least annually.

The facility failed to ensure: (0684) an Infection Control program was maintained, documented, available and implemented to ensure the health and safety of its patients that the facility cares for.

The agency failed to maintain, review and update the Emergency Preparedness (EP) Plan annually.

The facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan.

The facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations.

The facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

The facility failed to develop, implement and update emergency preparedness policies and procedures and communication plan.

The home health agency failed to develop individual plans for patients based on the comprehensive assessment.

The facility failed to develop and maintain an emergency preparedness(EP) communication plan annually.

Bases on review of the 2017 Emergency Plan and staff interview, it was determined the facility failed to develop and maintain an emergency preparedness communication plan that includes the names and contact information for staff, entities providing services under arrangement, patient's physicians…

The facility failed to have a primary and alternate means of communication during an emergency.

The facility failed to develop a facility based emergency planning, training and testing program.

The facility failed to have the new and existing staff review the emergency preparedness policies and procedures.

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

The facility failed to ensure that an Infection Control program was maintained, documented, available and implemented to ensure the health and safety of its patients that the facility cares for.

The governing body failed to maintain oversight, and direction for the agency's quality assurance and performance improvement since 2017. The failure by the governing body to manage and provide oversight of the agency's performance increases risk for poor compliance and adverse patient outcomes.

The HHA (Home Health Agency) failed to include an individual disaster plan as a part of the comprehensive assessment for Patient #'s 1-11. This poses an increased risk to the health and safety of patients and staff in the event of an emergency, if the patient is not aware of what to do in the event…

The facility administrator failed to ensure that policies were implemented to protect the health and safety of patients, as evidenced by the failure to follow agency policy on orientation, education, competency and ongoing training / education for 10 out of 10 clinical employees.