First Choice Home Care

The agency failed to ensure all elements of the POC were addressed at each visit for 1 of 17 patients (Patient #11) whose records were reviewed.

The agency failed to ensure the comprehensive assessment included a patient’s nursing needs for 1 of 2 patients (Patient #9) whose records were reviewed and who died.

The agency failed to ensure the POC included all relevant treatments and interventions for 1 of 2 patients (Patient #9) whose records were reviewed and who died and 1 of 7 patients (Patient #5) whose records were reviewed and for whom an observation was completed.

The agency failed to ensure accurate medication reconciliation was completed for 1 of 7 patients who had observational visits by surveyors.

The agency failed to ensure the home health aides were members of the interdisciplinary team and reported changes in the patient’s condition to a registered nurse or other appropriate skilled professional and completed appropriate records in compliance with the HHA’s policies and procedures.

The agency failed to capture and record unexpected patient deaths at home in 3 of 3 patients (Patient #13, #17, and #18) whose records were reviewed who died in their home.

The agency failed to ensure patients’ POCs were individualized for their needs for 1 of 18 patients (Patient #4) whose records reviewed.

The agency failed to ensure initial and updated comprehensive assessments accurately identified services and interventions to meet patients' needs.

The patient is at moderate or high nutrition risk." This policy was not followed.

The agency failed to maintain and document a comprehensive infection control plan to identify and control infections.

The agency failed to ensure ongoing interdisciplinary assessments of the patients, failed to ensure skilled services were provided as ordered by the physician, failed to ensure staff provided necessary education, and failed to ensure clinical notes were prepared, complete, and accurate.

The agency failed to ensure adequate overall management and administration.

The agency failed to ensure encoded OASIS data accurately reflected patients' status at the time of the assessment for 5 of 17 patients (#4, #5, #13, #14, and #17) whose records were reviewed.

Patient #5's medication profile was updated 9/11/19 with 1 medication, "Benzoate for cough and cold," rather than 2. His POC was not updated to reflect the new diagnosis of pneumonia and corresponding needs.

The agency failed to ensure each patient received services included in the POCs for 9 of 17 patients (#3, #4, #5, #7, #9, #13, #14, #16, and #18) whose records were reviewed.

The agency failed to ensure adverse patient events were tracked and analyzed for 3 of 4 patients (#1, #3, and #7) who had documented incidents and whose records were reviewed.

The agency failed to ensure accepted IC standards of practice were followed for 1 of 2 patients (Patient #3) whose wound care was observed.

The agency failed to ensure patient wound infections were incorporated into its IC and QAPI plans.

The agency failed to ensure home health aide initial competency evaluations addressed each of the required subjects for 3 of 3 home health aides (Aide A, B, and C) who were hired in 2019 and whose personnel files were reviewed for initial competency exam.

The governing body failed to ensure responsibility for 1 of 1 patient (Patient #3) who received agency PT services outside his home and whose record was reviewed.

The agency failed to ensure patients/representatives were provided with information on rights and responsibilities, admission consent, and privacy practices prior to the initiation of care for 17 of 18 patients (Patient #'s 1 - 14 and 16 - 18), whose records were reviewed.

The agency failed to ensure patients were informed in writing of home health charges they might have to pay for 1 of 10 patients (Patient #3) for whom traditional Medicare was not the payer and whose records were reviewed.

The agency failed to ensure the patient and the patient's PCP were notified in advance that a discharge for cause was being considered for 1 of 1 patient (Patient #14) who was discharged for cause and whose record was reviewed.

The agency failed to make efforts to resolve identified problems prior to discharging a patient for cause for 1 of 1 patient (Patient #14) who was discharged for cause and whose record was reviewed.

The agency failed to ensure a clean and consistent initial comprehensive assessment accurately identified goals and interventions to meet patients' needs, for 1 of 17 patients (Patient #17) whose records were reviewed.

The agency failed to ensure comprehensive assessments reflected patients' status for 4 of 17 patients (#2, #5, #10, and #16) whose records were reviewed.

The agency failed to identify relevant nursing and social needs of 2 of 3 patients (#5 and #16) who received therapy services only and whose records were reviewed.

The agency failed to ensure medications were reconciled at the time of admission and a medication list was kept current and reconciled for 6 of 17 patients (#4, #5, #12, #13, #14, and #17) whose records were reviewed.

The agency failed to ensure POCs were individualized and inclusive of required content for 12 of 17 patients (#3, #4, #5, #6, #7, #10, #12, #13, #14, #16, #17 and #18) whose records were reviewed.

The agency failed to ensure treatments were administered only as ordered by the physician for 5 of 17 patients (#3, #4, #9, #13, and #14) whose records were reviewed.

The agency failed to ensure physicians were promptly alerted to changes in patients' conditions or needs that suggested a need to alter the plan of care for 5 of 17 patients (#1, #3, #4, #9, and #13) whose records were reviewed.

The agency failed to ensure patient POCs were revised to reflect their change in health status and needs for 2 of 18 patients (#1 and #5) whose records were reviewed.

The agency failed to ensure communication with all physicians involved in the patient care of 1 of 11 patients (Patient #16) who had a diagnosis of DM and whose records were reviewed.

The agency failed to ensure coordination of patient care between PT, OT, and SN services for 2 of 7 patients (#3 and #9) who received wound care and whose records were reviewed.

The agency failed to ensure care was coordinated for1 of 7 patients (Patient #3) who received wound care and whose records were reviewed.

The agency failed to ensure skilled professional staff performed ongoing interdisciplinary assessment of 5 of 17 patients (#1, #4, #5, #16, and #18) whose records were reviewed.

The agency failed to ensure skilled services were provided as ordered by the physician on patients' POCs for 5 of 17 patients (#4, #5, #6, #16, and #18) whose records were reviewed.

The agency failed to ensure staff provided necessary education to 1 of 10 patients (Patient #16) with a diagnosis of DM and whose records were reviewed.

The prepared visit note was not accurate.

The agency failed to ensure appropriate aide documentation was completed for 1 of 1 patient (Patient #18) whose home health aide care was observed and whose record was reviewed.

The agency failed to ensure an RN or other appropriate skilled professional made an annual on-site visit to observe and assess the aide perform care for 2 of 2 aides (Aide D and E) who were employed by the agency for greater than 1 year and whose personnel files were reviewed.

The agency failed to ensure written designation of an individual who would assume responsibilities of the administrator when the administrator was not available.

Refer to G706 as it relates to the failure of the agency to assure patient needs were continually assessed.

Refer to G574 as it relates to the failure of the agency to assure complete POCs were developed.

The agency failed to ensure overall responsibility for the services provided under arrangement for 1 of 1 contracted services reviewed.