Bjc Home Care Services

The home health provider failed to promptly alert the physician of changes in the patient’s condition that suggested the plan of care may need to be altered in, one of three patients sampled (Record/Patient #1).

The home health provider failed to ensure the individualized plan of care was reviewed and revised to reflect significant and recurring catheter-related changes in condition in, one of three sampled patients (Record/Patient #1).

The home health provider failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, in but not limited to, one of five full records reviewed (Record/Patient #2).

The home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status including relevant past medical history in one of five full records reviewed (Record/Patient #1).

The home health provider failed to ensure the comprehensive assessment included the names of other agencies and persons involved in the past and present care of the patient in one of five full records reviewed (Record/Patient #4).

The home health provider failed to ensure staff performed a complete medication review in three of five full records reviewed (Records/Patients #1, #2, and #3).

The home health provider failed to ensure the individualized plan of care (POC) included all pertinent interventions and treatment orders, in two of five full records reviewed (Record/Patient #1 and #2).

The home health provider failed to ensure the physician was promptly notified of changes in the patient’s condition or needs that suggest that the plan of care should be altered in one of five full records reviewed (Record/Patient #3).

The home health provider failed to assure coordination of care to meet the needs of the patient when the provider failed to verify discrepancies and/or orders in the referral record in, one of five full records reviewed (Record/Patient #1).

The agency failed to ensure that the patients received the home health services that were written on the individualized POC (plan of care) when the patients did not receive visits according to the visit frequency ordered on the POC in one (Record/Patient #5) of five full record reviews completed.

The agency failed to provide written notice of patient rights regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit.

The agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week) in the admission booklet.

The agency failed to update the written notice of patient rights to include that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge.

The agency failed to ensure an accurate medication review and/or update of patient medications was completed in, one (Record/Patient #5) of five full records reviewed.

The agency failed to ensure services and treatments were administered only as ordered by a physician in, one (Record/Patient #5) of five full records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in two (Records/Patients #1 and #5) of five full records reviewed.

The agency failed to provide the name and contact information for the clinical manager, in one (Record/Patient #2) of three home visits conducted.

The agency failed to provide a registered nurse skilled in providing the necessary care and services which resulted in a complaint investigation with an immediate jeopardy level finding which included: - Providing services that are ordered by the physician in the plan of care (G710); and -…

The agency failed to ensure that accepted standards of practice to prevent transmission of infection was used during wound care in one (Record/Patient #7) out of five home visit observed.

The agency failed to maintain professional standards according to their policies when: - Pain assessments were incomplete; and - The staff failed to address increased pain findings, in, but not limited to, two (Record/Patient #2 and #12) of 14 records reviewed.

The agency failed to ensure that the home health aide completed a competency evaluation program in, one (Employee/Aide A) of two home health aide employee files reviewed.

The agency failed to ensure that the home health skilled professional staff completed/maintained an accurate patient-specific home health aide assignment sheet in one (Record/Patient #14) of one record reviewed for home health aide services.

The agency failed to ensure an accurate medication review and/or update of the patient medication profile when there were new/changed medications in, but not limited to, two (Records/Patients #4 and #6) of 14 records reviewed.

The agency failed to provide an individualized plan of care that included; - All types of services, supplies, and equipment required for care; - Nutritional requirements; and - All medications and treatments In, but not limited to, three (Records/Patients #4, #6, and #8) of 14 records reviewed.

The agency failed to ensure conformance with the patient's plan of care in, but not limited to, three (Records/Patients #4, #7, and #8) of 14 records reviewed.

The agency failed to ensure the registered nurse (RN) provided services necessary for the care of the patient and as ordered by the physician, in two (Record/Patient #2 and #11) of 14 records reviewed.

The agency failed to ensure that the skilled professionals assumed responsibility for patient and caregiver education in, but not limited to, one record (Record/Patient #6) out of 14 records reviewed.

The agency failed to ensure the registered nurse (RN) communicated with all physicians related to the current plan of care, in one (Record/Patient #2) of three records reviewed during the complaint portion of the survey.

The agency failed to ensure a completed discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the agency within five business days of the patient's discharge in one (Record/Patient…

The agency failed to ensure staff adequately assessed and documented the provisions the caregiver made for care of the patient when the caregiver was not in the home for one patient (Record/Patient #1) and failed to provide a social work assessment as ordered by the physician and ensure social work…

The agency failed to develop a complete plan of care (POC) in, but not limited to, one (Record/Patient #2) of three records reviewed.

The agency failed to provide services as ordered by the physician in, but not limited to, one (Record/Patient #2) of three records reviewed.

The agency staff failed to ensure the patient's plan of care was followed consistent with the patient's assessed needs, in one (Record/Patient #1) of four patient records reviewed.