Ascension at Home

The HHA failed to send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care in 6…

The agency failed to ensure personal care services and therapists were provided according to the written plan of care for 2 of 12 complete records reviewed.

The RNs (Registered Nurses) failed to ensure they practiced proper hand hygiene while providing wound care to a patient for 2 of 3 patient's observed receiving wound care services by the agency.

The registered nurse or the physical therapist failed to conduct an initial assessment within 48 hours of the patient’s return home in 1 of 6 records reviewed patients within their first certification period.

The agency failed to ensure the medication list included all medications taken by patients including PRN (as needed) medications and reviewed by an RN (registered nurse) in therapy only cases in 7 out of 12 active records reviewed.

The registered nurse or the physical therapist failed to conduct an resumption of care assessment within 48 hours of the patient’s return home in 1 of 1 resumption of care records reviewed.

The agency failed to ensure the individualized plan of care was supported by the comprehensive assessment and included all interventions and measurable goals identified by the agency and patient, all durable medical equipment (DME) and supplies, advance directives, medications, allergies, all…

The agency failed to ensure coordination of care with outside providers was documented to effectively coordinate care to support the care planning objectives of the patient for 3 of 12 patients with outside service providers.

The RN (Registered Nurse) failed to assess and provide patient care according to professional standards for 2 of 3 skilled nurse observations.

The agency failed to ensure a discharge summary was written and sent to the primary care physician who is responsible for the patient's care after discharge within 5 business days of the patients discharge for 4 of 8 record review.

The agency failed to ensure the agency provided all the services ordered by the physician (See G572); failed to ensure the plan of care contained all the durable medical equipment in the patient's home; failed to ensure a complete oxygen therapy order was documented; failed to include care planning…

The skilled professionals failed to ensure they implemented agency policy to photograph wounds every 2 weeks and to upload the photographs into the clinical records (See G704); failed to ensure the clinicians continually assessed a patient's integumentary status and implemented wound care orders…

The Administrator failed to ensure the management of contracted services were not delegated to another agency or entity and failed to ensure it established and provided oversight for a coding contract, addendum to a coding contract, and a business associate agreement, with the potential to affect…

The facility failed to develop a method for sharing information and medical documentation for patients under the agency's care during disaster relief purposes for 4 of 4 agency emergency preparedness plan.

The agency failed to ensure the agency provided all the services ordered by the physician for 1 (Patient #11) of 18 patients.

The agency failed to monitor and evaluate its discharge procedures/processes in their quality assurance and performance improvement (QAPI) program for 1 of 1 home health agency.

The skilled professionals failed to ensure they implemented agency policy to photograph wounds every 2 weeks and to upload the photographs into the clinical records for 3 of 7 records reviewed (Patients #6, 8, 18) of patients with wounds in a sample of 18. The findings included: 1. Review of a…

The agency failed to ensure home health aide visits were furnished as ordered on the home health aide plan of care for 1 of 6 patients with home health aide services ordered, of a total of 18 patients whose clinical record was reviewed.

The agency failed to ensure the clinical record contained orders which had been signed by the physician for 1 (Patient #11) of 18 patients and failed to ensure physician orders were complete and authenticated in a timely manner for 3 of 18 records reviewed (#8 and #18).

The agency failed to ensure patient rights were accorded to include the provision of all services ordered by the physician for 1 (Patient #11) of 18 patients.

The agency failed to ensure patients' right to a confidential clinical record was maintained in relation to delegation of medical diagnosis coding to an outside entity, with the potential to affect the agency's current 1068 home health agency patients.

The registered nurse (RN) failed to document accurately the patient's diagnosis of peripheral artery disease in M 1028; failed to score 1 point for the presence of 3 or more diagnoses in the fall risk assessment; failed to identify the mode of delivery for supplemental oxygen therapy of 3…

The agency failed to ensure duplicative medications were clarified with the physician in 2 out of 18 records reviewed.

The agency failed to ensure the plan of care contained all the durable medical equipment in the patient's home for 1 (Patient #11) of 18 patients; failed to ensure a complete oxygen therapy order was documented for 1 of 2 patients with oxygen therapy (Patient #11); failed to include care planning…

The agency failed to ensure wound care orders were recorded into the plan of care for 1 (Patient #11) of 3 patients whose clinical record contained wound care orders of a total sample of 18. The findings included: Review of the clinical record of patient #11, start of care date of 5-11-17…

The agency failed to ensure treatments were provided as ordered for 4 (#7, 9, 11, 16) out of 7 patient records reviewed with wounds, failed to ensure services were furnished only after obtaining and documenting a verbal order at the start of care for 7 (Patients #3, 5, 6, 8, 11, 12, and 18) of 18…

The agency failed to ensure verbal orders were put into writing and signed/ dated by the ordering physician for 1 of 18 records reviewed.

The agency failed to ensure clinicians complied with agency policy and communicated with the physician at the time of the patient's discharge for 4 of 7 (Patient #9, 10, 14, and 15) discharged patients of a total sample of 18. The findings included: 1. Review of a policy, "Patient Transfer and…

The agency failed to ensure wound care orders were integrated into the plan of care for 1 (Patient #11) of 8 patients whose clinical record contained wound care orders of a total sample of 18. The findings included: Review of the clinical record of patient #11, start of care date of 5-11-17…

The agency failed to ensure coordination of care activities occurred and were documented for 2 (Patients #9 and 11) of 2 patients who received in-center hemodialysis.

The agency failed to ensure patients received education and training necessary to reach an established plan of care goal for 1 (Patient #12) of 11 active patients.

The skilled nurses failed to ensure the clinicians continually assessed a patient's integumentary status and implemented wound care orders, failed to identify the location of an peripherally inserted central catheter (PICC) for 1 (#8) of 1 patient record reviewed with an IV site, failed to assess…

The Registered Nurse failed to ensure the plan of care contained all the durable medical equipment in the patient's home for 1 (Patient #11) of 18 patients; failed to ensure a complete oxygen therapy order was documented for 1 of 2 patients with oxygen therapy (Patient #11); failed to include…

The skilled nurse failed to ensure the agency provided all the services ordered by the physician for 1 (Patient #11) of 18 patients.

The agency failed to ensure patients received education and training necessary to reach an established plan of care goal for 1 (Patient #12) of 11 active patients, and failed to ensure the physical therapist documented the content of medication education provided for 1 (Patient #17) of 1 patient…

Skilled nursing failed to ensure documentation of a diabetic patient's/ or caregiver's ability to demonstrate skin/ foot care to meet an established plan of care goal for 1 (Patient #12) of 11 active patients, of a total sample of 18 patients.

The administrator failed to report to the Governing Body in relation to 2 policies which required revision for 2 of 12 policies reviewed.

The Administrator failed to ensure governing body developed personnel policies related to the establishment of competency of personnel in relation to medication education of patient/caregiver for 1 (employee HH) of 1 physical therapist assigned to a patient (Patient #17) with physical therapy…

The Clinical Manager failed to ensure coordination of care activities occurred and were documented for 2 (Patient #9, 11) of 2 patients who received in-center hemodialysis of a total sample of 18 patients.

The Clinical Manager failed to ensure the clinicians continually assessed a patient's integumentary status and implemented wound care orders, failed to identify the location of an peripherally inserted central catheter (PICC) for 1 (#8) of 1 patient record reviewed with an IV site, failed to assess…

The Clinical Manager failed to ensure wound care orders were integrated into a revised plan of care and wound care had been provided as ordered for 1 (Patient #11) of 2 patients whose clinical record contained wound care orders, of a total sample of 18. The findings included: Review of the clinical…

The Administrator failed to ensure contracts were renewed after expiration and failed to ensure the contracts contained the legal name of the surveyed agency and not that of the corporation for 1 of 1 agency, with the potential to affect 1068 active agency patients.

The clinical record failed to contain a written verbal physician order that was obtained by a Licensed Practical Nurse for 1 of 18 patients records reviewed.