Burgess Home Health

The agency failed to notify the physician of changes in patient condition or needs that suggest an alteration to the Plan of Care for 2 of 3 sampled patients with medications set up/monitoring (Patient #1 and #2) and 3 of 4 sampled patients with monitoring of weights (Patient #2, #6 and #7).

The agency failed to ensure skilled professional staff involved in the patient's plan of care completed an ongoing interdisciplinary wound assessment as required by agency policy and expectation for 1 of 2 sampled patients with wounds (Patient #2).

Staff interview the home health agency failed to ensure the clinician assessed the patient's individualized needs related to emergency preparedness with each comprehensive assessment for 2 of 7 sampled patients (Patients #3 and #5).

The agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the…

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 2 of 7 sampled patients (Patients #2 and #7).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 5 of 7 sampled patients (Patients #1, #2, #3 #5 and #6).

The agency failed to ensure skilled professional staff involved in the patient's plan of care completed an ongoing interdisciplinary wound assessment as required by agency policy and expectation for 1 of 4 sampled patients with wounds (Patient #6).

The agency failed to complete and send a transfer summary and discharge to the physician or other health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of knowledge of the occurrence of the transfer for 2 of 3 sampled patients…

The agency: 1) failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care (G710); and 2) failed to ensure the agency skilled staff promptly alerted the physician to changes that may suggest a need to alter the Plan of Care and/or coordinate care with other…

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 3 of 3 sampled patients receiving home health aide services (Patients #4, #5 and #7).

The home health agency failed to authenticate electronic clinical record documents with accurate date and time of electronic signature and/or completion of documentation requiring date and time within visit notes for 7 of 8 sampled patients (Patients #1, #2, #4, #5, #6, #7 and #8).

The agency failed to complete a drug regimen review, including all required components, with each comprehensive assessment for 2 of 3 sampled patients with home visit observations (Patients #1 and #2).

The agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 3 of 4 sampled patients requiring a recertification assessment (Patients #2, #3 and #4).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care and/ or failed to ensure the Plan of Care contained all services, supplies, equipment, medications and treatments for 5 of 8 sampled patients (Patients #2, #3, #4, #6 and #7).

The clinicians failed to update patient Plans of Care to reflect accurate, up to date information for 5 of 8 sampled patients (Patients #1, #4, #5, #6 and #7).

The agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 2 of 7 sampled patients receiving a skilled service (Patients #2 and #7).

The agency skilled staff failed to promptly alert the physician to changes that may suggest a need to alter the Plan of Care or coordinate care with other staff caring for the same patient for 3 of 8 sampled patients (Patients #4, #5 and #7) . The agency reported a census of 90 patients, including…

The agency failed to ensure a registered nurse completed home health aide supervision at least every 60 days while observing the home health aide present and providing direct patient care for 1 of 1 sampled patients who received hands on personal care services with no skilled service provision.