Wesley Homes at Home, LLC

The agency failed to maintain and update an Emergency preparedness (EP) plan at least every two years.

The home health agency failed to maintain a quality improvement program designed to ensure patient safety and reduce adverse events.

The agency failed to develop and implement an infection control program which has as its goal the prevention and control of infections and communicable disease.

The agency failed to review and update at least every two years an emergency preparedness (EP) plan.

The agency failed to update and implement at least every two years an emergency preparedness (EP) policies and procedures (P&P).

The agency failed to establish patient-specific goals that are individualized to the patient’s medical diagnosis, physician’s orders, comprehensive assessment and patient input for 9 of 19 patients (Patients #101, #103, #105, #106, #109, #110, #111, #115 and #116).

The agency failed to identify and develop improvement projects for health indicators designed to address adverse outcomes, patient safety or improved quality of care.

The agency failed to use the data derived from OASIS to monitor the effectiveness and safety of services and develop and prioritize opportunities for quality improvement based on the collected data.

The agency failed to develop and implement an agency-wide program for infection control that included surveillance, identification, prevention, control and investigation of infectious and communicable disease as part of its overall quality assessment and performance improvement (QAPI) program.

The agency failed to develop and implement an agency-wide program to provide infection control education to patients and caregivers specific to the patient's plan of care caregivers that are specific to a patient’s plan of care, health, conditions, and individual learning needs (Item #1); and…

The agency failed to update its policies and procedures to remain compliant with state licensing requirements for 8 of 8 personnel files reviewed.

The agency failed to conduct the initial assessment visit within the 48 hours of completing the referral for 15 of 19 patients (Patients #101, #102, #103, #104, #105, #106, #108, #110, #111, #112, #114, #116, #117, #118, and #119).

The agency failed to provide Occupational Therapy (OT) services as ordered in the referral by the physician for 8 of 19 patients (Patient #101, #102, #103, #104, #107, #109, #111, and #119).

The agency failed to provide the patient’s discharge summary to the patient’s attending physician within 5 business days of the patient’s discharge for 4 of 6 discharged patients (Patient #115, #117, #118, and #119).