Bethesda Home Health

The agency failed to incorporate pertinent baseline information from the referral detailing the patient's current health at the time of admission in 5 (MR#'s 1, 2, 3, 4, 7) of 7 records reviewed (See G 528); failed to ensure the registered nurse reviewed patient medications for possible side…

The agency failed to ensure the Plan of Care (POC) included the diagnosis, pertinent interventions, education, and goals concerning non-compliant, uncontrolled diabetes, failed to have the POC include physician orders to provide wound care by skilled nursing, failed to have the POC acknowledge any…

The agency failed to ensure the Clinical Manager coordinated services that were ordered on the referral form in 3 (MR's# 3, 4, 5) of 7 records reviewed (See G 964); failed to ensure the Clinical Manager consistently monitored and assessed the patient's needs throughout the certification period in 2…

The agency failed to ensure the clinical record was complete and included all clinical notes and complete medical records for 4 (MR#’s 1, 2, 3, 4) of 7 records reviewed (See G 1012); and failed to ensure a discharge summary was forwarded to the physician within 5 days of discharge in 3 (MR#’s 1, 4…

The Agency failed to provide documentation that it had conducted exercises to test its emergency plan annually, by way of a tabletop and community based full-scale exercise required every two years, and failed to conduct an additional exercise at least every two years opposite the year of the…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission in 5 (MR#'s 1, 2, 3, 4, 7) of 7 records reviewed, resulting in incomplete clinical information in determining the needs of patients and a poor clinical outcome.

The agency failed to ensure the registered nurse reviewed patient medications for possible side effects and possible drug interactions for 3 of 3 (MR's 2, 6, 7) Physical Therapy records reviewed, failed to ensure the medication profile was accurate for 1 of 7 (MR#1) records reviewed, failed to…

The agency failed to ensure the patient was provided wound care for 1 of 1 record reviewed (MR #3) with wound care, for a potential of improper wound care and unmet care needs.

The Agency had failed to promptly notify the Physician concerning significant weight gain and severe lower leg edema for 1 (MR #7) of 1 patient with congestive heart failure, resulting in the potential for untreated health concerns and the potential for a poor clinical outcome.

The agency failed to ensure that 3 (MR's# 3, 4, 5) of 7 patients, out of a total sample of 7 records reviewed, were appropriately informed of their overall planning of care, including informing the patient/caregiver in advance of the specific disciplines providing care with associated visit…

The home health agency failed to ensure the patient needs were continually assessed during the certification period for 2 (MR#'s 4, 7) of 7 records reviewed, resulting in a poor clinical outcome and the potential of unmet care needs for all 16 patients serviced within the last 12 months.

The Clinical Director failed to ensure the plan of care was updated as needed for 1 of 7 (MR #3) records reviewed, resulting in a potential decline in physical functioning, and verification of the patient's well-being.

The agency failed to ensure the clinical record was complete and included all clinical notes and complete medical records for 4 (MR#’s 1, 2, 3, 4) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure a discharge summary was complete, provided the patient's health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 3 (MR#'s 1, 4, 6) of 4 discharged records; and failed to ensure a transfer summary was…