Complete Home Health of Stigler

The Agency failed to provide an individualized POC to include patient specific vital sign parameters based on the assessed needs of each patient for five (#2, #4 - #7) of seven (#1- #7) records reviewed.

The Skilled Nurse failed to monitor weights and CBG results as ordered on the POC for two (#4 and #6) of seven (#1 - #7) records reviewed.

The Skilled Nurse failed to prepare and submit timely the clinical visit notes for two (#1 and #4) of seven (#1 - #7) records reviewed.

The RN failed to conduct onsite supervisory visits to the patient's home no less frequently than every 14 days for one (#2) of two (#2 and #5) records reviewed with orders for Home Health Aide services.

The agency failed to ensure an all hazard risk assessment: 1. identified the agency by name and; 2. was dated when completed effecting 107 patients and all staff members.

The agency failed to ensure emergency preparedness disaster table top exercises and drills conducted for fiscal years 2019 and 2020 documented agency staff participation effecting 107 patients and all staff members.

The agency failed to ensure: 1. physician notification of SN wound care visits for one (Patient #1); and 2. physician notification of BS levels greater than the ordered reporting parameter of 225 for two (Pt's #2 and #5) of seven patients.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for 107 patients and all employees.

The agency failed to ensure their Infection Control Program: 1. was included in QAPI activities and; 2. included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for 107…

The agency failed to ensure clinical records were complete for one (Patient #4) of seven patients.

The agency failed to ensure a SOC assessment was conducted within 48 hours of referral for one (Patient #1) of seven patients.

The agency failed to ensure medication embedded wound care supplies were included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for three (Pt's #1, 2 and #5) of seven patients.

The agency failed to ensure SN visits were conducted as ordered by the physician for one (Patient #1) of seven patients.

The agency failed to ensure completed transfer/discharge summaries were provided for three (Pt's #5, 6 and #7) of seven patients.

The agency failed to communicate frequent missed PTA visits with the Physical Therapist and physician for one (Pt #4) of three patients with PT services.

The agency failed to ensure OT and ST evaluations were completed in accordance with the plan of care for one (Patient #4) of seven patients.