Sc Home Health Nfp

The facility failed to ensure the administrator was appointed by the governing body.

The facility failed to ensure a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available, was provided in writing, as authorized by the administrator and governing body.

The Home Health Agency (HHA) failed to obtain an agreement/arrangement for aide training.

The Home Health Agency (HHA) failed to ensure a comprehensive Emergency Preparedness Program was established and maintained, which met regulatory requirements.

The agency failed to provide documentation of the development, implementation, evaluation, and maintenance of an effective, ongoing, HHA-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program.

The Home Health Agency failed to maintain and document an infection control program, which has as its goal the prevention and control of infections and communicable diseases.

The Agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and…

The Agency failed to ensure its Emergency Preparedness Plan was reviewed and updated at least annually.

The Home Health Agency (HHA) failed to develop and maintain an Emergency Preparedness training and testing program, that is based on the Emergency Plan which is based on the comprehensive Emergency Preparedness Program findings; and is reviewed/updated at least annually.

The Home Health Agency (HHA) failed to establish an Emergency Preparedness training program based on its comprehensive Emergency Preparedness Program; inclusive of policies and procedure, and initial and annual documented training of new and existing direct staff, contracted staff, and volunteer…

The Home Health Agency (HHA) failed to establish an annual testing plan for its Emergency Preparedness Program, inclusive of participation in an annual full-scale community-based or facility-based exercise or tabletop exercise, with analysis, documentation, and revision of the HHA's emergency plan…

The Agency failed to ensure complaints were reported and investigated.

For 1 of 7 (Pt #2) patients, the Agency failed to ensure visits were conducted in accordance with the physician ordered plan of care (PoC).

The Agency failed to ensure measurable indicators were developed, analyzed and tracked to identify trends in patient care.

The Agency failed to ensure quality indicators were utilized to measure the effectiveness of the safety of services, the quality of care provided and identified opportunities for improvement.

The Agency failed to ensure performance improvement focused on high risk safety indicators, identified opportunities for immediate improvement and monitored the success of the interventions implemented.

The Agency failed to ensure performance improvement projects were identified and implemented annually.

The Governing Board failed to ensure a quality improvement and patient safety program was implemented and maintained.

The Agency failed to ensure expired biologicals and medications were disposed of after single patient use or expiration.

The Agency failed to ensure a program for the surveillance, identification, prevention, control and investigation of infections and communicable diseases which was incorporated into the Agency's Quality Assurance Performance Improvement (QAPI).

For 11 of 11 licensed staff of Home Health Agency, the Agency failed to ensure staff were educated on infection control practices upon hire and annually per policy.

For 4 of 12 (E#5, E#6, E#7, E#8) staff members, the Home Health Agency (HHA) failed to ensure staff were vaccinated or had approved exemptions.

The Governing Body failed to ensure oversight of its overall program and services.

The Agency failed to ensure the Governing Body prepared an Annual Operating Budget and Capital Expenditure Plan.

The Agency failed to ensure nurses were licensed prior to employment.

The Home Health Agency (HHA) failed to provide Aide services to patients needing assistance with medical and/or nursing needs.

For 1 of 3 (Pt #2) patients, where home visits were conducted, the Home Health Agency (HHA) failed to ensure all medications, including over-the-counter medications were included on the patient's drug profile, thereby preventing potential adverse drug reactions, significant side effects…

For 11 of 11 (E#15, E#16, E#17, E#18, E#19, E#20, E#21, E#22, E#23 E#24, E#25) Patient Care Staff, the Agency failed to ensure employees were oriented, and trained.