Waverly Assisted Living, LLC

The agency failed to: -Develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program; -Ensure governing body involvement in the development, approval and ongoing monitoring of the QAPI program; -Maintain documentary evidence of its QAPI program and be able to…

The agency failed to: -Maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases; -Include infection control as an integral part of its QAPI program; -Develop a method for identifying infectious and communicable…

The Governing Body failed to: -Assume responsibility for the agency's overall management, including its QAPI program; -Ensure a clinical manager was available during all operating hours; -Ensure a qualified administrator alternate was pre-designated in writing; -Ensure the duties of the clinical…

The agency failed to review and update the emergency preparedness plan at least every two years.

The agency failed to review and update a hazard vulnerability risk assessment every two years.

The agency failed to measure, analyze and track quality indicators as needed to maintain a QAPI program capable of showing measurable improvement.

The agency failed to utilize quality indicator data to monitor the effectiveness and safety of services, quality of care, and identify opportunities for improvement by using data collection methods approved by the governing body.

The agency failed to analyze adverse patient event causes and implement preventative actions.

The agency failed to maintain documentation of the measurable progress achieved on performance improvements projects.

The agency governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented and maintained; that the QAPI program efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program.

The governing body failed to assume responsibility for the agency's overall management and operation, review of operational plans, and its quality assessment and performance improvement program.

The agency failed to ensure that oversight of all patient care services and personnel was provided by the clinical manager and not delegated to another person on an on-going basis.

The agency failed to advise patients of the names, addresses, and telephone numbers of the Federally-funded and state-funded entities that serve the area where the patient resides as required.

The agency failed to provide clear information regarding access to auxiliary aids and language services and how to access these services.

The agency failed to conduct an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral for 2 of 7 active patient records reviewed (Patients #9 and #10).

The agency failed to provide written information to the patient regarding the name and contact information of the HHA clinical manager.

The agency failed to maintain documentation of performance improvement measure implementation, success and that improvements are sustained.

The agency failed to ensure that a clinical manager is available during all operating hours.

The agency failed to identify a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, to assume the same responsibilities and obligations as the administrator when the administrator is not available.

The agency failed to ensure that the clinical manager responsibilities of making patient and personnel assignments were completed by an employee who meets the qualifications of clinical manager.