Buena Vista County Public Health and Home Care

The agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits in 2 of 2 sampled patients with missed visits.

The agency failed to ensure a timely completion of the update to the comprehensive assessment by a Registered Nurse or in therapy only cases, a qualified therapist, who last visualized the patient or made a home visit at discharge for 1 of 2 sampled patients requiring a comprehensive assessment at…

The agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment, medications and orders that specify the frequency for each discipline for 2 of 7 sampled patients (Patients #3 and #5).

The agency failed to provide medications, treatments or services only as ordered by the physician for 3 of 7 sampled patients (Patients #1, #5 and #7).

The agency failed to ensure accurate and thorough completion of all pertinent components of each comprehensive assessment for 1 of 7 sampled patients (Patient #1).

The agency failed to send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 business days for 1 of 2 sampled patients discharged from the agency.

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 2 sampled patients receiving home health aide services (Patients #4).

Agency policy review the agency failed to provide an initial assessment visit within 48 hours of receipt of referral and/or return home, for 1 of 7 sampled patients (Patient #2)).

The agency failed to accurately complete a drug regimen review (DRR), including completion of all required components and identification of any findings within the required time frames as part of the comprehensive assessment for 4 of 7 sampled patients (Patients #1, #3, #5 and #7).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care for 1 of 7 sampled patients (Patients #4).

The agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 2 of 3 sampled patients with wounds (Patient #1 and #4).

The agency failed to ensure agency staff completed and send a transfer summary to the health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of the planned transfer for 2 of 2 sampled patients requiring transmission of a…

The home health agency failed to ensure the clinical record included a copy of an individualized emergency plan developed as part of the comprehensive assessment and/or failed to ensure each patient received a copy of the individualized emergency plan to keep in the home for 7 of 7 sampled patients…

The agency failed to ensure a registered nurse performed direct observation of home health aide performance of all required basic home health aide (HHA) skills on a home health patient to determine satisfactory competency prior to allowing the home health aide to provide care independently to…

The agency failed to include an individualized assessment relating to the patient's current health status when completing comprehensive assessments for 1 of 2 sampled patients with wounds (Patients #1).

The agency failed to update the Plan of Care with all new orders for 1 of 8 sampled patients.