Blue Ridge Home Health Care

The agency's professional staff failed to promptly alert the patient's physician to any changes that suggest a need to alter the patient's plan of care for one (1) of (17) clinical records in the survey sample (Clinical record #7).

The agency failed to send the patient's discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit for one (1) of two (2) closed clinical records that was applicable for a discharge summary reviewed in the survey sample.

The agency failed to develop and document strategies for addressing emergency events identified by their community and facility based assessments.

The agency failed to include a description of their patient population including but not limited to the types of services the agency would be able to provide during an emergency situation and delegations of authority in order to maintain continuity of operations . Findings: The agency's emergency…

The agency failed to include in their emergency preparedness plan a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials in an effort to maintain an integrated response during a disaster or emergency situation.

The agency failed to ensure individual emergency preparedness plans for each patient were developed and completely filled out for seventeen (17) of seventeen (17) medical records reviewed in the survey sample.

The Policy and Procedure section of their emergency preparedness plan failed to include the procedures to inform State/Local officials regarding patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition…

The Policy and Procedure section of their emergency preparedness plan failed to include the procedures to follow up with on-duty staff and patients to determine services that are needed, in the event there is an interruption in services during or due to an emergency and inform State and local…

The Policy and Procedure section of their emergency preparedness plan failed to include a description of their of medical documentation system that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

The Policy and Procedure section of their emergency preparedness plan failed to include a description of the use of volunteers in an emergency/disaster and other staffing strategies to address surge needs during an emergency.

The Communication Plan section of their emergency preparedness plan failed to include contact information for Federal, State, regional, or local emergency preparedness staff.

The agency failed to ensure the communication plan section of their emergency preparedness plan contained the following elements: (1) A method for sharing information and medical documentation for patients under the agency's care, with other health providers to maintain continuity of care.

The Communication Plan section of their emergency preparedness plan failed to include a means of providing information about the agency's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

The agency's emergency preparedness plan failed to contain documentation regarding initial and annual training in the agency's emergency preparedness plan (EPP) to all new and existing staff.

The agency failed to ensure the patent and/or caregiver was provided with a written copy of the HHA's transfer and discharge policies for (1) of (1) agency admission handbook reviewed in the agency.

The agency failed to ensure informed consents completed at the time of admission contained documentation regarding the frequency and/or duration of visits for seventeen (17) of (17) seventeen informed consents in patient records that were reviewed in the survey sample.

The agency failed to document informing patients at the time of admission regarding: (1) The extent to which payment for HHA (home health agency) services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (2) The charges for services…

The agency failed to document the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (1) Agency on Aging (2) Center for Independent Living (3) Protection and Advocacy Agency,(4) Aging and Disability…

The agency failed to document the patient's strengths including information that may be used to evaluate the patient's progress toward achievement of their goals for seventeen (17) of seventeen (17) medical records reviewed in the survey sample.

The agency failed to document all necessary interventions to address the underlying patient risks for emergency department visits and hospital re-admissions, measurable outcomes and goals identified by the home health agency (HHA) and the patient, and information related to any advance directives…

The agency failed to ensure completed discharge summaries were sent to the patient's primary care practitioner within five (5) business days of the patient's discharge for three (3) of five (5) medical records reviewed in the survey sample.