West Virginia Home Health LLC

The agency failed to prevent the transmission of infections and communicable diseases by failing to follow standard infection control policies and procedures, in one (1) out of one (1) home visit (patient #5) conducted with a Registered Nurse (RN).

The agency failed to provide training for all agency staff on the Agency's Emergency Preparedness Plan policies and procedures.

The agency failed to conduct exercises to test the Emergency Preparedness Plan annually.

The facility failed to completely document an annual competency evaluation addressing a Home Health Aide's (HHA) job performance of specific tasks and subject areas.

The facility failed to completely document an annual competency evaluation addressing a Home Health Aide's (HHA) job performance of specific tasks and subject areas.

The facility failed to develop, implement, and maintain an effective agency-wide data-driven Quality Improvement/Performance Improvement (QA/PI) program.

The agency failed to have policies, procedures, and a communication plan as part of the four (4) required elements of an emergency preparedness plan.

The agency failed to have contact with local, state, and/or federal emergency preparedness officials as required for an emergency preparedness plan.

The agency failed to have a system of medical documentation that preserves patient information, protects confidentiality, and secures and maintains availability of patient records as required for an emergency preparedness plan.

The agency failed to have a teaching and training program for all staff for emergency preparedness.

The agency failed to ensure they participated in an annual tabletop or full-scale emergency exercise.

The agency failed to establish a Quality Assurance/Performance Improvement (QA/PI) plan/program, so there was no documentation of the program showing any measurable improvement in quality indicators.

The agency failed to collect quality indicator data as part of a Quality Assurance/Performance Improvement (QA/PI) plan/program, so there was no documentation the agency used data to monitor the safety and effectiveness of services and quality of its patient care.

The agency failed to document the existence of any performance improvement activities as part of a Quality Assurance/Performance Improvement (QA/PI) plan/program.

The agency failed to track adverse events, analyze their causes, and implement corrective action as part of a Quality Assurance/Performance Improvement (QA/PI) plan/program.

The agency failed to conduct performance improvement projects taking into consideration past performance, and the number, scope, and complexity of agency services as part of a Quality Assurance/Performance Improvement (QA/PI) plan/program.

The governing body of the agency failed to ensure that an ongoing program for quality improvement and patient safety was defined, implemented, and maintained by establishing clear expectations for patient safety.

The governing body failed to make a provision for an ongoing Quality Assurance/Performance Improvement (QA/PI) plan/program for the agency.

The agency failed to ensure all patients' plans of care included the required description of the patient's risk for emergency department (ED) visits, hospital re-admission, and, if applicable, patient specific interventions for six (6) of seven (7) records reviewed (patients #1, 2, 4, 5, 6 and 7).

The agency failed to ensure all services and treatments that are administered are done so only in accordance with physician orders in two (2) of two (2) records reviewed where services were provided without a physician's order (patients #1 and 2).

The agency failed to ensure all verbal orders were formatted legally with the name of the physician, the name of the clinician, and the date and time the clinician received the order in five (5) of five (5) records reviewed (patients # 1, 2, 4, 5 and 7).

The agency failed to collect quality indicator data that had a focus of high risk, high volume, and problem prone areas as part of a Quality Assurance/Performance Improvement (QA/PI) program, so there was no documentation the agency used data to monitor the safety and effectiveness of services and…

The agency failed to collect quality indicator data as part of a Quality Assurance/Performance Improvement (QA/PI) plan/program that considered incidence, prevalence, and severity of problems in high risk, high volume, and problem prone areas, so there was no documentation the agency used data to…

The agency failed to collect quality indicator data as part of a Quality Assurance/Performance Improvement (QA/PI) plan/program that considered incidence, prevalence, and severity of problems in high risk, high volume, and problem prone areas, so there was no documentation the agency used data to…

The agency failed to ensure the Registered Nurse (RN) supervised the Licensed Practical Nurse (LPN) in one (1) of seven (7) records reviewed that had nursing visits ordered (patient #3).

The agency failed to ensure the registered nurse made an on-site visit to the patient's home every fourteen (14) days for a home health aide supervisory visit for one (1) of two (2) patients reviewed who received aide services greater than (2) weeks (patient #5).