Cedar County Memorial Hospital Home Health Agency

Cedar County Memorial Hospital Home Health failed to ensure OASIS data was accurately collected and report, when the agency failed to ensure OASIS assessments were completed and signed by the clinician completing the assessment and failed to ensure staff accurately encoded OASIS data items during…

The agency failed to ensure a complete and accurate patient specific comprehensive assessment was completed for each patient.

Cedar County Memorial Hospital Home Health failed to: -Ensure each patient received an individualized plan of care that identifies patient-specific measurable goals (G572); -Each patient's individualized plan of care included items listed in 484.60(a)(2) (G574); -Ensure drugs, services, and…

Cedar County Memorial Hospital Home Health failed to: -Provide accurate ongoing interdisciplinary assessment of the patient (G706); -Provide relevant patient and caregiver education (G714); and -Communicate effectively with physicians involved in the plan of care with changes in condition (G718).

Cedar County Memorial Hospital Home Health failed to: -Ensure the governing body maintained effective oversight for all home health services (G942); -Ensure the administrator was responsible for the day-to-day operations of the agency (G948); -Assure patient needs are continually assessed…

Cedar County Memorial Hospital Home Health failed to ensure OASIS (Outcome and Assessment Information Set) data items were accurately encoded, when the agency failed to ensure accurate completion of the OASIS comprehensive assessment in four of seven cases (Records/Patients: #3, #4, #5 and #6 ).

The agency failed to ensure each patient received home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, in four of seven records (Records/Patients: #1, #4, #5, and #7).

Findings included: Based on the current survey findings of 06/29/18, the governing body failed to ensure substantial compliance with the following conditions of participation: - §484.105 Organization and administration of services - §484.45 Reporting OASIS Information; - §484.55 Comprehensive…

The agency failed to ensure clinical record entries were complete including the patient's name, and the clinicians' name/title/signature, dates and times were documented.

The agency failed to ensure that the administrator's name was provided to the agency's patients in order to receive complaints in two of seven cases (Records/Patients: #1 and #7).

The agency failed to ensure that when therapy was discharged for non-compliance that the efforts and plans made to resolve the problems were documented in one of two discharge for cause cases (Patient/Record: #1).

The agency failed to ensure that complaints made by agency patients were investigated in one of three home visit observations/interviews.

The agency failed to ensure that the initial assessment visit occurred within 48 hours of referral or patients return home from the hospital (Record/Patient: #6) and/or the agency requested a different start of care date from the physician to accommodate the convenience of the agency…

The agency failed to ensure a complete and accurate patient specific comprehensive assessment reflected the patient's current health, psychosocial, functional and cognitive status, in three of seven cases.

The agency failed to ensure the patient specific comprehensive assessment and updates to the comprehensive assessment included an accurate review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, in three of seven cases.

The agency failed to ensure updates to the comprehensive assessment were completed within 48 hours of the patient's return home from hospital admission, in one of seven cases (Record/Patient #3).

The agency failed to ensure the patient's individualized plan of care included: -the types of services, supplies, and equipment required; -functional limitations; -activities permitted; -all medications and treatments; -safety measures to protect against injury; and -patient and caregiver education…

The agency failed to ensure drugs and treatments are administered only as ordered by the physician, in four of seven records (Records/Patients: #1, #3, #4 and #5).

The agency failed to ensure verbal orders were documented by the clinician in the patient's clinical record including signature, date and time the order was received.

The agency failed to promptly alert the physician to changes in the patient's condition that suggest that outcomes are not being achieved and/or that the plan of care should be altered in two of seven records (Records/Patients: #4 and #7).

The agency failed to ensure integration of services and coordination of care between all disciplines caring for the patent, whether provided directly or under arrangement, in one of seven records (Records/Patients: #7).

The agency failed to provide therapy staff to meet the basic needs of the patient in two of seven sampled cases (Patient/Record #1 and #3).

The agency failed to ensure accurate written information to the patient which included medication name, dose and frequency, in three of seven records (Records/Patients: #1, #3, and #7).

The agency failed to ensure skilled professional services effectively assessed agency patients.

The agency failed to ensure effective patient and caregiver education to agency patients in two of seven sampled patients (Patients/Records: #3 and #7).

The agency failed to ensure communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care in three of seven records (Records/Patients: #3, #4 and #5).

The agency failed to ensure the administrator on file with the state agency (SA) was responsible for the day-to-day operation of the agency.

The agency failed to ensure the clinical manager supervised effective assessment of agency patients.

The agency clinical manager failed to ensure development, implementation, and updates to the individualized plan of care in two of seven cases sampled.