A Plus Home Health Care Incorporated

The agency failed to ensure each patient received the home health services as ordered and written in the individualized plan of care that identifies patient-specific measurable outcomes and goals in 2 of 5 active clinical records reviewed (Patient #1, 4) and 2 of 2 closed clinical records reviewed…

The agency failed to ensure accepted standards of practice to prevent the transmission of infections and diseases were followed in 1 of 3 active clinical records reviewed with home visits (Patient 1).

The agency failed to ensure all patient care orders were recorded in the POC in 3 of 3 active clinical records reviewed with PT services (Patients #1, 3, 5) and 1 of 1 closed clinical record with PT services (Patient #7).

The agency failed to ensure services and treatments were administered only as ordered by a physician in 3 of 3 active clinical records reviewed with PT services (Patient #1, 3, 5) and 1 of 1 closed clinical records reviewed with PT services (Patient #7).

The agency failed to ensure the contents of the clinical record included a completed transfer summary that was sent to the primary care provider within 2 business days if the patient was admitted into a health care facility in 1 of 1 active clinical record reviewed with a hospitalization in the…

The agency failed to ensure services were provided as ordered in the plan of care in 2 of 4 records reviewed not receiving therapy services (#3, #7).

The agency failed to conform with all physician orders in 2 of 3 records reviewed receiving physical therapy (#2, #5).

The agency failed to ensure the comprehensive assessment included the patient's current health status in 1 of 1 patient records reviewed with a feeding tube (#1).

The agency failed to ensure the individualized plan of care included all services, medications and treatments in 2 of 7 records reviewed (#1, #7).

The home health agency failed to update and revise the comprehensive assessment of the OASIS (Outcome and Assessment Information Set) as frequently as the patient's condition warrants due to a major decline in the patient's health status in 1 of 2 discharged records reviewed receiving wound care…

The home health agency failed to ensure the plan of care was followed and individualized in 3 of 3 records reviewed receiving home health aide services (#1, #2, #3).

The home health agency failed to ensure the home health aide followed accepted standards of practice to prevent the transmission of infections and communicable diseases in 1 of 1 home visits (#2) The findings include: Review of the agency policy, copyrighted in 2004, titled "Job Description-Title…

The agency failed to ensure the registered nurse provided a complete care plan for the home health aide [HHA] in 1 of 1 active clinical records reviewed for patient's receiving wound care (#1).

The home health agency failed to ensure all entries were appropriately authenticated in 2 of 7 clinical records reviewed.

The home health agency failed to meet the patient's needs , in 1 of 1 active records reviewed receiving wound care.

The agency failed to ensure the individualized plan of care included all services, safety measures, medications and treatments in 3 of 3 records receiving home health aide services (#1, #2, #3).

The home health agency failed to record the verbal orders in the plan of care in 1 of 2 discharged records reviewed receiving wound care (#4).

The home health agency failed to ensure the physician was alerted to patient's conditions indicating outcomes were not being achieved and the plan of care should be altered in 1 of 2 discharged records receiving wound care (#3).

The home health agency failed to provide the patient and caregiver with a copy of written instructions outlining the visit schedule, including frequency of visits by the agency personnel and personnel acting on behalf of the agency in 1 of 1 home visits (#2) The findings include: Review of the…

The home health agency failed to provide the patient and caregiver with the medication schedule/instructions, including: medication name, dosage, frequency and which medications will be administered by the home health agency in 1 of 1 home visits.

The home health agency failed to ensure the home health aide reported changes in the patient's condition to a registered nurse or other appropriate skilled professional in 1 of 1 clinical records reviewed of patient's with a home visit.

The home health agency failed to ensure a registered nurse or other appropriately skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions made an onsite visit to the patient's home no less frequently than every 14 days in 1 of 1…