Bmo Home Health Care Inc

The home health aide failed to prepare clinical notes to include the clinician’s title in 1of 2 clinical records reviewed receiving home health aide services.

The administrator failed to be responsible for the day-to-day operations of the agency.

The clinical manger failed to provide oversight of coordinating referrals.

The agency failed to ensure the patient’s medication was reviewed to identify any potential adverse effects and drug reactions in 2 of 2 clinical records reviewed.

The agency failed to ensure all orders were recorded in the plan of care in 1 of 1 clinical record reviewed with wounds.

The agency failed to electronically report and transmit an OASIS (Outcome and Assessment Information Set) assessment in 1 of 1 clinical record reviewed receiving skilled nursing services.

The registered nurse failed to include in the comprehensive assessment the size and description of the sacral wound.

Patient received wound care from a wound clinic, and the agency failed to incorporate wound care orders from the wound clinic into the patient’s plan of care.

The agency failed to develop and implement individualized emergency preparedness plans for the patients which provided appropriate instructions, in the event of an emergency in 2 of 2 home visits.

The agency failed to develop and maintain an emergency preparedness communication plan which included contact information for Federal and State emergency preparedness staff.

The agency failed to conduct exercises to test the emergency preparedness plan at least annually.

The agency failed to ensure the comprehensive assessment was updated and revised with changes in the patient’s physical and mental status in 2 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure home health aide services were provided to the patient per the ordered frequency as directed in the plan of care in 1 of 1 clinical record reviewed with skilled nursing services.

The home health agency failed to document a performance improvement project.

The home health agency failed to ensure all employees practiced standard/universal precautions to prevent the transmission of infections and failed to follow agency infection control policies and procedures in 2 of 2 home visits.

The home health agency failed to ensure the home health aides had complete, patient-specific written patient care instructions to be performed by the home health aides in 2 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure the comprehensive assessment reflected the patient’s current physical and mental status in 2 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure the patient’s goals and measurable outcomes were included in the comprehensive assessment in 1 of 1 clinical record reviewed with skilled nursing services.

The agency failed to ensure the plan of care was individualized to include all diagnoses, medications, medical equipment and supplies, services, treatments, safety precautions, and patient-specific interventions in 3 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure treatments and services were provided only as ordered by a physician in 1 of 1 clinical record reviewed with skilled nursing services.

The agency failed to ensure the plan of care was reviewed by the physician responsible for the plan of care no less than every 60 days in 2 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure the physician was notified of changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or the plan of care should be altered in 1 of 1 clinical record reviewed with wounds.

The agency failed to integrate all orders into the plan of care in 1 of 1 clinical record reviewed with wounds.

The agency failed to coordinate care with the wound clinic providing care in 1 of 1 clinical record reviewed with wounds.

The agency failed to provide the patient and caregiver in writing with the name and contact information of the clinical manager in 2 of 2 home visits conducted.

The agency failed to ensure the performance improvement activities focused on high risk areas.

The registered nurse failed to report to the physician vital signs outside of the ordered parameters as directed in the plan of care, in 1 of 1 clinical record reviewed with skilled nursing services.

The skilled nurse failed to prepare clinical notes accurately and completely in 2 of 3 active clinical records reviewed receiving home health aide services.

The home health agency failed to ensure the home health aides provided care as directed in the home health aide care plan in 2 of 3 active clinical records reviewed with home health aide services.

The home health aide failed to report changes in the patient’s condition to a registered nurse or other appropriate skilled professional in 2 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure the home health aide (HHA) was supervised to ensure the aides furnished care that followed the patient’s plan of care in 2 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure the skilled nurses assessed patients and documented those assessments for wound care, catheter care, and/or blood glucose levels per the plan of care (See G706); failed to ensure services were not provided absent of a physician's order and skilled nursing failed to…

The agency failed to ensure the home health aide care plan contained specific frequencies, per patient needs, to the tasks assigned for 1 of 9 records reviewed.

The agency failed to ensure clinical records were filed or available for reviewing in 1 of 5 discharge records requested.

The agency failed to ensure the plan of care (POC) contained the frequency and duration of all visits to be made in 2 of 9 records reviewed.

The agency failed to ensure that the patient's care was coordinated with another agency that provided skilled nursing in 1 of 1 patient receiving skilled care from a different agency in a sample of 9 records reviewed.

The agency failed to ensure the skilled nurses assessed patients and documented those assessments for wound care, catheter care, and/or blood glucose levels per the plan of care for 2 of 3 patients with wounds in a sample of 9 records reviewed.

The skilled nurse failed to ensure services were not provided absent of a physician's order for 1 of 9 (#2) records reviewed and skilled nursing failed to followed the physician's orders per the plan of care (POC) for wound care in 1 of 3 patients (#6) with wounds in a sample of 9 records reviewed.

The skilled nurse failed to inform the physician of elevated blood sugars as ordered in the plan of care for 2 of 2 patients with diabetes in a sample of 9 records reviewed.

The home health aide failed to provide the visit frequencies and/ or durations as ordered on the plan of care in 1 of 9 patients records reviewed.

The agency failed to ensure that the skilled nurse completed a supervisory visit every 14 days for 3 of 9 patients receiving home health aide (HHA) services in a sample of 9 records reviewed.

The agency failed to ensure clinical records were complete and contained a signed plan of care within a timely manner and 4 of 9 patients reviewed.

The agency failed to evidence that a discharge summary was completed for 2 of 5 discharge patients in a sample of 9 records reviewed.