Hannibal Regional Hospital Home Health Agency

The home health provider failed to update and revise the patient’s comprehensive assessment when the patient had a significant decline in condition in, one of five full records reviewed (Record/Patient #2).

The home health provider failed to ensure treatments were provided as ordered by the physician, when the staff educated the patient not to lift over 10 pounds and the physician ordered no lifting, in one of five full records reviewed (Record/Patient #4).

The home health provider failed to promptly alert the physician when the patient had a fall, in one of five full records reviewed (Record/Patient #3).

The agency failed to: - Promptly alert the relevant physician(s) to any changes in the patient's condition (590); - Coordinate care delivery to meet the patient's needs, and involve the patient, and caregiver, as appropriate in the coordination of care activities (G608); - Ensure that each patient…

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to show adequate governing body and administrative oversight to patients resulting in two condition level…

The agency failed to ensure a policy for emergency staffing strategies was developed for the agency's Emergency Preparedness (EP) plan.

The agency failed to ensure staff were provided annual Emergency Preparedness training in five (Employee #1, #2, #3, #4, and #5) of five employee files reviewed.

The agency failed to include the patient has the right to receive the patient rights information in plain language and in a manner that is accessible and timely.

The agency failed to put in place a program/procedure for screening for patients prior to home visits, and for visitors/non-employees for COVID-19 (pandemic infection) who entered the home health agency office.

The agency failed to document education provided for COVID-19 in the clinical record for one (Record/Patient #3) of three home visit clinical records reviewed.

The agency failed to maintain professional standards according to their agency policy when wound measurements were not performed and recorded in the clinical record and staff did not follow physician's orders to change the wound dressing every 72 hours for one (Record/Patient #5) of six clinical…

The agency failed to provide the patient and representative (if any) correct contact information for the current home health agency administrator, to receive complaints in, but not limited two (Record/Patient #1 and #2) of three home visits conducted.

The patient rights information failed to include that patients have the right to participate in, be informed about, and consent or refuse care in advance to and during treatment, where appropriate, with respect to: * vii: Any factors that could impact treatment effectiveness.

The agency failed to update the written notice of patient rights to include that the patient has the right to be advised of the name, address, and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides.

The agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment and that the medication profile was updated with medication changes in, two (Records/Patients #2 and #3) of five full records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Record/Patient #2) of five records reviewed.

The agency failed to ensure coordination of care delivery to meet the patient's needs in one (Record/Patient #2) of five records reviewed.

The agency failed to ensure staff provided ongoing education and training to the patient in, but not limited to, one (Record/Patient #2) of five records reviewed.

The agency failed to provide a written visit schedule that included disciplines that would visit and the frequency of visits in two (Record/Patient #2 and #3) of three home visits.

The agency failed to provide in writing the name and contact information of the clinical manager in, but not limited to, one (Record/Patient #2) of three home visit observations.

The agency failed to ensure that skilled professional services clinical notes contained documentation according to agency policy in one (Record/Patient #2) of five full records reviewed.

Based on the results of this extended level survey, resulting in noncompliance with two Conditions of Participation: Care planning, coordination of services and quality of care; and Organization and administration of services.

The agency failed to ensure an administrator was appointed by and reported directly to the governing body.

The agency failed to ensure the parent home health agency provided direct support and administrative control of its branch location in Hull, Illinois by assuring the branch was operational and provided the same services as the parent home health agency.

The agency failed to request and obtain current nursing licensure in the state of Illinois and failed to obtain results of findings of the Family Care Safety Registry (FCSR) for one (Employee #5), the vice president of nursing, of five employee files reviewed.

The agency failed to ensure a complete comprehensive discharge summary containing relevant information was sent to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge within five business days of the patient's…

The agency failed to ensure the registered nurse (RN) developed a complete aide care plan/assignment in one (Record/Patient #4) of one applicable records.

The agency failed to ensure all documented entries included appropriate authentication that included, the time plan of cares were completed, and the title of staff completing patient assessments in, but not limited to, seven patients (Record/Patient #1 through #7) of seven records.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of the names, addresses, and telephone numbers of Federal and State funded entities that serve…

The agency failed to ensure the registered nurse (RN) performed an accurate and complete review/update of all medications the patient was currently using in, but not limited to, one (Records/Patients #3) of five cases reviewed.

The agency failed to include on the patient's plan of care, a description of the patient's required equipment, patient identified goals, risk for emergency department visits and hospital re-admission and all necessary interventions to address the underlying risk factors, and/or information related…

The agency failed to provide the patient and/or caregiver a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel in one (Records/Patients #2) of three home visit observations conducted.

The agency failed to provide the patient and/or caregiver a copy of written instructions outlining the patient's medication schedule/instructions in plain language, to include the name, dosage, frequency and which medications would be administered by the agency personnel in two (Records/Patients…

The agency failed to ensure effective ongoing interdisciplinary assessment of the patient.

The agency failed to ensure the discharge summary was sent to the physician within five business days of discharge in one (Record/Patient #6) of one applicable case, and also failed to ensure the transfer summary was sent to the physician within two business days of becoming aware of an unplanned…