Upland Hills Home Health

The agency failed to conduct and/or participate in an emergency exercise to test the agency's response to an emergency in coordination with the hospital health system's emergency preparedness plan annually in 1 of 1 Emergency Preparedness Programs reviewed.

Failed to develop an emergency preparedness program that demonstrated the agency's involvement and coordination related to the unique circumstances and services offered in the event of a system-wide emergency in 1 of 1 Emergency Preparedness programs reviewed.

The agency nurse failed to assess the patient Peripherally inserted central catheter (PICC) Line per physician ordered plan of care (Patient #5) and failed to assess the patient weights per physician orders (Patient #7) in 2 of 7 patient records reviewed (Patient #5 and #7).

This agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program utilized program quality indicator data in monitoring effectiveness, identifying improvement opportunities, and outlining detail and frequency of data collection in 1 of 1 QAPI programs reviewed.

The agency failed to incorporate infection control data into the agency QAPI (Quality Assessment Performance Improvement) program in 1 of 1 infection programs reviewed.

Agency nursing staff failed to develop POC (Plans of Care) that were individualized to meet the patient needs based on diagnoses, including patient specific interventions and/or measurable goals in 7 out of 7 (Patients #1 - Patient # 7) patient records reviewed.

This agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program focused on high risk, high volume, or problem-prone areas based on agency risk assessment in 1 of 1 QAPI programs reviewed.