Adoration Home Health

The agency failed to ensure an infection control policy was implemented appropriately to prevent cross-contamination of equipment used and ensure safety of personnel and patients with proper hand hygiene for 5 of 5 home visits.

The agency failed to complete an initial assessment within 48 hours of a referral and failed to document the reason for the delayed start of care for 2 of 7 active record reviews.

The agency failed to obtain a signed POC or a detailed verbal POC order from the primary physician before providing services and treatments to patients for 3 of 7 active records reviewed with skilled nursing (Patient #9, #12, #14).

The agency failed to document all required components of a verbal order on 3 of 7 records reviewed with skilled nursing services (Patient #9, #12, #14 ).

The agency failed to ensure all patients received a visit schedule with frequency of visits and by what personnel for 5 of 5 home visits conducted (Patients #5, #6, #7, #9, and #11).

The agency failed to ensure staff reviewed patient medications during home visits for 1 of 1 observed PTA home visit (Patient #5) and 1 of 1 observed LPN home visit (Patient #7).

The agency failed to ensure a verified discharge summary was sent to the physician within 5 days for 2 of 4 closed records reviewed (Patients #1 and #3).

The agency failed to conduct an exercise opposite the full-scale or functional exercise with testing results, response, and analysis documented so the plan could be updated for 1 of 1 Emergency Preparedness Program review.

The agency failed to ensure all discharge summaries included all goals and outcomes related to the home health episodes of care, the patient's post-discharge goals, discharge instructions such as home exercise programs, follow-up appointments and referrals, and all pertinent medical information…

The agency failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries for 1 of 1 home health agency.

The agency failed to ensure the POC (Plan of Care) was complete, clear, and accurate for 2 of 2 records reviewed with IV (Intravenous) orders (Patient 13 & 16); and failed to accurately document the date and time of the Covid-19 screening assessment for 3 of 6 home visit observations.

The agency failed to ensure the comprehensive assessment reflected the patient's relevant medical history and current health problems; the patient's psychosocial status, such as ability to participate in care, ability to identify and meet one's needs, and support systems available; and education…

The agency failed to ensure all patients received a comprehensive assessment that included assessment of the patients' strengths for 4 of 13 active records reviewed (Patients 7, 8, 10, 11).

The agency failed to ensure all medications were listed on the Plan of Care (POC) for 1 of 2 patient’s receiving Intravenous (IV) medications (Patient 13); failed to ensure all physicians / allowed practitioners were specified in the POC for 2 of 13 active records reviewed (Patients 5 and 12); and…

The agency failed to ensure that current visit schedules, including visit type and frequency, were kept within the patients home for 3 of 6 patients observed (Patients 5, 15, and 17).

The agency failed to provide the patient with a current copy of written home exercise instructions and medication instructions for 2 of 3 therapy home visits.

The administrator failed to ensure contracts or written agreements that allowed overall responsibility to be maintained were in place for corporate employees who furnished services as direct employees for 1 of 1 agency.

The agency failed to ensure policies were specific to the agency and did not include other state requirements (See G942); the agency failed to ensure the administrator was appointed by the Governing Body (See G946); failed to identify specific members comprising the governing body to ensure proper…

The agency failed to ensure specific nutritional requirements for 2 of 2 patients with enteral (tube) feedings.

The agency failed to ensure measures derived from OASIS and other relevant data were included in the design of the home health agency's QAPI (quality assessment program improvement) program.

The agency failed to ensure the agency's policies, procedures, job descriptions, and bylaws were specific to the parent agency and not to include other out of state agencies.

The agency failed to ensure an overall plan and budget was created by a committee consisting of the administrative staff of the agency and a representative of the governing body and not delegated to an outside entity.

The agency failed to discharge a patient due to the caregiver's decision to decline wound care services at each visit to the extent that the agency can no longer meet the patient's needs and failed to educate the caregiver on the risks of refusing nursing services for 1 of 2 patient's with pressure…

The agency failed to ensure the patient's comprehensive assessment accurately reflected the patient's current health, functional, and cognitive status in 2 of 3 records reviewed of patient's with foley catheters.

The agency failed to update the physician to any changes in the patient's condition for 3 of 5 active records reviewed.

The home health agency failed to ensure coordination of care was provided for 2 of 3 patients with urinary catheters.

The agency failed to ensure that patients received written information regarding the patient's medication regimen for 1 of 5 home visit observations.

The agency failed to provide patients written documentation identifying the name and phone number of the clinical manager for 7 of 7 home visits.

The agency failed to provide services in the plan of care for 6 of 17 records reviewed (Patient 2, 3, 4, 12, 15, and 16).

The agency failed to ensure emergency preparedness education was provided to patients for 7 of 7 home visit observations.

The agency failed to ensure the administrator was appointed by the governing body and failed to ensure the administrator directly reported to the governing body without the use of intermediaries.

The agency failed to ensure the administrator/DOO (Director of Operations) was knowledgeable of the agencies processes and responsible for all of the day to day operations of the agency including maintaining human resource tasks within the agency, knowing the names and locations of all management…

The agency failed to ensure the alternate administrator was authorized in writing by the governing body.

The administrator failed to ensure coordination of patient care was provided for 1 of 1 shared patients.