Bethany Holding LLC

The agency failed to ensure the psychosocial assessment was implemented in the plan of care for 10 of 10 patient records reviewed (Clinical record #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10).

The Governing Body of King's Daughters' Health failed to ensure policies that were adopted by the agency contained only information of the home health agency and not that of entity 2; and failed to adopt Bylaws specific to home health and not that of entity 3; failed to have governing body meeting…

The agency failed to provide medication instruction written in plain language to patients and caregivers for 5 of 8 active records reviewed (Patient 5, 6, 7, 9, 11); and for 1 of 3 closed records reviewed.

The agency failed to ensure staff were following acceptable standards of practice by actively screening visitors for Covid 19 (virus) prior to entering the agency for 1 of 1 home health agency.

The Governing Body of King's Daughters' Health failed to ensure policies that were adopted by the agency contained only information of the home health agency and not that of entity 2; and failed to adopt Bylaws specific to home health and not that of entity 3; failed to have governing body meeting…

The administrator failed to demonstrate distinct boundaries of the Medicare-certified program in relation to any other programs the larger organization had to offer in 1 of 1 home health agencies.

The agency failed to ensure patient confidential records and employee personal health information were safeguarded against loss and unauthorized access in an office setting for 1 of 1 home health agency.

The agency failed to ensure patient rights were adhered to by failing to protect the privacy and security of patient confidential records and patient electronic records in an office setting for 1 of 1 home health agency.

The agency failed to show that communication and coordination of care between nurses and physicians occurred for 1 of 4 patients with wounds.

The agency failed to appropriately measure depth on a pressure injury for 1 of 2 patient observations with pressure injuries.

The agency failed to ensure the caregiver followed agency education regarding a wound dressing for 1 of 2 patient observations with wounds.

The agency failed to provide documentation of a qualified home health aide in good standing on the state nurse aide registry for 1 of 1 Home Health Aide records reviewed.

The agency failed to separate the home health agency QAPI (quality assessment and program improvement) data from entity 2's QAPI program; and failed to ensure the home health agency emergency preparedness program listed patients for the home health agency and not that of entity 2 for 1 of 1…

The agency failed to ensure personnel were qualified based on the requirements for employment at a home health agency in 4 of 6 personnel files reviewed (Employees I, BB, F, A), and failed to assure the agency developed personnel qualifications and policies specific to the agency in 1 of 1 entity's…

The agency failed to ensure a pre-designated person authorized in writing by the Governing Body was available to fulfil the role of administrator in the absence of the administrator for 1 of 1 agencies reviewed.

The clinical manager failed to ensure clinicians continually provided medication instructions written in plain language to patients and caregivers for 5 of 8 active records reviewed (Patient 5, 6, 7, 9, 11); and for 1 of 3 closed records reviewed (Patient 2); and failed to ensure agency staff…

The agency failed to ensure a written agreement with the individual of another entity furnishing services for 1 of 1 home health agencies.

The agency failed to ensure accepted standards of practice regarding measurement of a pressure injury were maintained for 1 of 2 patient observations with pressure injuries.