Sullivan County Public Health Services Chha

The agency failed to ensure that care planning, coordination of services, and quality of care was performed on all patients to ensure the HHA can effectively and safely meet the Patient's needs.

The Governing Authority failed to develop, implement, evaluate, and maintain an effective, ongoing, agency-wide, data-driven QAPI program.

The Governing Authority failed to develop and implement policies to includes procedures for but not limited to addressing the identified risk within the agency's risk assessment.

The Governing Authority failed to ensure the development of a policy which includes procedures that complies with Federal and State laws during an emergency for following up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services…

The agency failed to ensure the development of a comprehensive written policy which includes procedures for for the Health Commerce System, that complies with Federal and State laws during an emergency.

The Governing Authority failed to ensure the development of a written policy which includes procedures for methods for sharing information, and medical documentation of patients that complies with Federal and State laws during an emergency.

Based the Agency's written Emergency Preparedness Plan dated 6/19, the agency failed to ensure the development and implementation of a policy which includes procedures for Emergency Preparedness training.

The agency failed to ensure that services are provided in accordance with the Plans of Care . This was evident for three (3) of seventeen (17) clinical records reviewed.

The Agency failed to ensure that the Plan of Care was updated and revised to reflect the patient's current medications and treatments.

The Governing Authority failed to ensure the development of measurable improvement indicators for clinical record reviews that are to be conducted by the Professional Advisory Committee (PAC).

The Governing Authority failed to ensure the utilization of quality indicators from OASIS and other relevant data collected by the Professional Advisory Committee (PAC).

The Governing Authority failed to conduct performance improvement activities and track adverse patient events, analyze their causes, and implement preventive actions.

The Governing Authority failed to document quality improvement projects are being performed, with the reasons for conducting these projects, and the measurable progress achieved on these projects.

The Governing Authority failed to ensure that the quality improvement and patient safety program is defined, implemented, and maintained.

The Governing Authority failed to ensure that the quality improvement and patient safety program included, implemented, and maintained an Infection Control Program.

The Governing Authority failed to develop a comprehensive written policy for COVID-19 to ensure that all staff are fully vaccinated.

The Governing Authority failed to ensure that Patients are informed of the services they are to receive, and the frequency for the services, and any related charges.

The agency failed to develop/revise a complete and comprehensive Plan of Care.

The agency failed to promptly notify the physician of changes in patients' status which may require alteration in Plans of Care.

The Governing Authority failed to ensure that audits are conducted to monitor the incidence, prevalence, and severity of problems areas.

The Governing Authority failed to ensure measurable improvement in indicators for the clinical record reviews that were being conducted by the Professional Advisory Committee (PAC).

The Governing Authority failed to ensure that the quality improvement and patient safety program included, implemented, and maintained an Infection Control Program.

The agency failed to ensure that services are provided in accordance with the Plans of Care (POC).

The agency failed to develop/revise complete and comprehensive Plans of Care.

The agency failed to promptly notify the physician of changes in patients' status which may require alteration in Plans of Care.