Country Manor Extended Services

The agency failed to complete a comprehensive assessment within 5 calendar days of the registered nurse start of care visit as required for 1 of 7 patients (P7) receiving skilled care services.

The agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 1 of 3 patients (P5) whose medications were reviewed during home visits and record review.

The agency failed to ensure the plan of care (POC) included rehabilitation potential and discharge plan for 3 of 7 patients (P3, P4, P5) whose records were reviewed.

The agency failed to ensure visits were conducted in accordance with physician orders for 1 of 9 patients (P7), and failed to notify the physician when the visits were not conducted according to the plan of care (POC).

The agency failed to ensure appropriate infection control prevention measures including hand hygiene, were followed for 1 of 1 patient (P5) observed to have wound care provided during a home visit.

The agency failed to ensure 5 of 9 patients (P2, P3, P5, P6, P9) were informed or consented to services or care being provided, including any ongoing changes in services.

The agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 2 of 9 patients (P6, P1) whose medications were reviewed during home visits and record review.

The agency failed to ensure the plan of care (POC) included a description of the risk for emergency department visits and hospital re-admissions, psychosocial status, and advanced directives, for 9 of 9 patients (P1, P2, P3, P4, P5, P6, P7, P8, P9), whose records were reviewed.

The agency failed to ensure supervisory visits of home health aides (HHAs) were completed every 14 days by a registered nurse, for 2 of 7 patients (P6, P9) who received skilled services.

The agency failed to ensure direct supervision of the home health aide (HHA) was completed every 60 days for 1 of 2 non-skilled patients (P3) reviewed.