Quality Nursing LLC

The Home Health Agency (HHA) failed to ensure the emergency preparedness (EP) plan included a process for cooperating and collaborating with regional and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency.

The Home Health Agency (HHA) failed to ensure that an individualized emergency preparedness plan (EP) was developed during the comprehensive assessments performed by two of four (Registered Nurses (RNs)1, RN2) for seven of seven patients (P) 1, P2, P3, P4, P5, P6, P7) medical records reviewed for…

The Home Health Agency (HHA) failed to ensure that the emergency preparedness (EP) plan included a communication policy incorporating names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers; and failed to maintain a list of names…

The Home Health Agency (HHA) failed to ensure the emergency preparedness (EP) plan included a communication policy incorporating names and contact information for Federal, State, tribal, regional, and local emergency preparedness staff; and failed to maintain a list of names and contact information…

The Home Health Agency (HHA) failed to ensure that emergency preparedness (EP) training for seven of seven staff members (Administrator/Registered Nurse (RN) 1, Assistant Administrator/RN2, RN3, RN4, Licensed Practical Nurse (LPN), Physical Therapist (PT), and the Receptionist) had been performed…

The Home Health Agency (HHA) failed to ensure that testing of the emergency preparedness plan (EP) had been performed annually.

The Home Health Agency (HHA) failed to analyze and perform Project Performance Improvement Project (PIP) updates for the 2023 ACH PIP.

The Home Health Agency (HHA) failed to ensure that one of one Home Health Aide was competent to perform health aid tasks assigned by a Registered Nurse (RN) prior to caring for patients.

The Home Health Agency (HHA) failed to include the agency's policies for transfer and discharge found during one of three home visits patient (P) 6. This deficient practice had the potential to affect all patients receiving services from the HHA.

The Home Health Agency (HHA) failed to include contact information for the agency's administrator, including the administrator's name, business address, and business phone number in one of one "Notice of Patient Rights” document.

The Home Health Agency failed to 1) make referrals to the appropriate discipline (social services/social worker) for one of three patients (P5) reviewed during home visits and; 2) failed to coordinate care delivery services related to the time frame that telephone messages were shared with the…

The Home Health Agency (HHA) failed to ensure that one of one Licensed Practical Nurse (LPN) was competent to perform nursing skills routinely performed for patient's receiving care from the HHA.

The agency's staff failed to collaborate with local Office of Emergency Management (OEM) to maintain an integrated response during a disaster or emergency.

The agency's staff failed to develop, implement and maintain a process to inform state and local emergency preparedness officials about patients under the care of agency's staff who need evacuation from their residences at any time due to an emergency situation.

The agency's staff failed to maintain a current list of contact information that included federal, state, and local emergency preparedness staff and include agencies in their Emergency Preparedness Communication Plan.

The agency's staff failed to develop, implement, and maintain testing, training and programs related to emergency preparedness in the agency's Emergency Preparedness Plan (EPP).

The agency's staff failed to maintain a Quality Assurance Performance Improvement (QAPI) program which measured, analyzed, and tracked quality indicators showing improvement in outcomes and quality of care or to document actions aimed at performance improvement, measure actions taken for success…

The Home Health Agency's (HHA) staff failed to collect data and analyze data collection to implement preventative actions and make systemic improvement in the agency's operations.

The home health agency's (HHA) Governing body did not ensure an ongoing quality Assurance/Performance Improvement Program (QAPI) was implemented, evaluated its effectiveness, or assured that priorities were identified to improve patient care and safety.

The home health agency's (HHA) staff failed to maintain a program for identification, prevention, control, investigation, and analysis of infectious disease.

The home health agency failed to provide infection control education to staff on an annual basis.

The Home Health Agency's (HHA) staff failed to ensure that a Clinical Laboratory Improvement Amendment Certificate of Waiver (CLIA Waiver) was current and in good standing.

The Home Health Agency's (HHA) staff failed to ensure patients' medical records were appropriately authenticated for three of 10 patients (P) P2, P4, and P5. The agency's staff failed to ensure information from a visit was entered in a timely manner causing a potential for emergent care access to…

The Home Health Agency's (HHA) staff failed to develop a Quality Assessment and Performance Improvement (QAPI) program that used high risk, high volume, or problem prone areas as areas of importance in measuring agency activities.

The home health agency's (HHA) staff failed to develop a quality assessment and performance improvement (QAPI) program that considered incidence, prevalence, and severity of problems (ranking) in high risk, high volume areas.