Adoration Home Health and Hospice Care East Tn

This Condition is not met as evidenced by: Based on policy review, observation, medical record review and interview, it was determined that the home health agency (HHA) failed to complete an initial comprehensive assessment within 48 hours (G514).

This Condition is not met as evidenced by: Based on medical record review and interview, it was determined that the home health agency (HHA) failed to include patient preference goals (G574).

The facility failed to analyze the response to a disaster exercise drill dated 12/29/21. The findings include: Review of the Emergency Operations Plan (not dated) revealed "...An after action review (AAR) will be held within 2 weeks after the disaster or exercise...A written report will be…

The agency failed to provide physical therapy as ordered by the physician for 1 patient (#1); failed to provide an occupational therapy evaluation as ordered on the referral for 1 patient (#2); and failed to assess blood sugar levels for 1 patient (#7) of 17 patients reviewed.

The agency failed to maintain infection control for 1 patient (#2) of 7 patients reviewed.

The agency failed to have 100% staff vaccinations to include medical and non-medical exemptions and failed to have a process to accurately track staff vaccination status for medical and non-medical exemption status.

The agency failed to admit 1 patient (#2) within the 48 hours of the referral date out of 17 patients reviewed.

The agency failed to include a pain goal for 1 patient (#10) of 17 patients reviewed.

The agency failed to reconcile medications for 1 patient (#1) of 7 patients observed and reviewed.

The agency failed to add measurable goals pertaining to pain for 1 patient (#10) of 17 patients reviewed.

The agency failed to alert the physician regarding the delay of a physical therapy evaluation for 1 patient (#1); failed to clarify orders on the referral with the physician for 1 patient (#2); and failed to notify the physician of increased pain for 1 patient (#10).

The agency failed to inform the physician in a timely manner of a discharge for 1 patient (#2) of 6 patients who were discharged.

The agency failed to provide instructions on pain management for 1 patient (#10) of 17 patients reviewed.

The agency failed to document the site of an intramuscular injection for 1 patient (#1) of 1 patient reviewed for injections.

The agency failed to alert the physician of changes in the condition of 1 patient (#1) of 4 patients reviewed.