Health Source Home Care, Inc

The agency failed to attempt to reschedule missed visits to ensure patients received services as ordered in the plan of care for 1 (P-6) of 7 patients reviewed, resulting in the potential for unmet care needs.

The agency failed to provide annual infection control training for 4 (Staff D, Staff E, Staff F, and Staff G) of 4 contracted staff reviewed, resulting in the potential for poor infection control practices.

The agency failed to ensure staff followed accepted standards of infection control for 1 (Staff C) of 3 staff observed during home visits, resulting in the potential for an increased risk for spread of infection to all patients receiving services from this agency.

The agency failed to ensure that all entries into the clinical record were appropriately authenticated and signed in 6 (P-1, P-3, P-4, P-5, P-6, and P-7) of 7 patient records reviewed, resulting in incomplete entries and physician orders which were not reviewed or approved by the author and / or…

The agency failed to ensure the patient was able to consent to or refuse care in advance of treatment for 1 (P-6) of 7 patients reviewed, resulting in the potential for unmet care needs.

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status in 3 of 7 records reviewed (P-3, P-4, and P-5), resulting in incomplete clinical information to aide in determining the needs of the patient.

The agency failed to ensure a review of all medications was performed for 1 (P-6) of 7 patients reviewed, resulting in the potential for dangerous medication interactions and poor patient outcomes.

The agency failed to ensure the plan of care included safety measures to protect against injury for 1 (P-7) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure all services were provided as ordered by the physician in 1 (P-6) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure skilled professionals provided services as ordered in the plan of care for 2 (P-6 and P-7) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure that the patient and caregiver were provided education and able to demonstrate an understanding of the care instructions needed to safely manage the clinical needs for 3 (P-2, P-6, & P-7) of the 7 patient records reviewed, resulting in the potential of unmet patient care…

The agency failed to ensure the clinical record contained a record of all treatments rendered for 1 (P-7) of 7 patients reviewed, resulting in the potential for an incomplete medical record.

The agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 2 of 2 (P-1, P-3) discharge records reviewed; and failed to ensure a transfer summary was sent to the receiving facility within 2 business days of a transfer in 1 (P-6) of 2…

The Registered Nurse (RN) failed to prepare clearly written patient care instructions and include safety precautions on the aide's care plan, in 1 of 3 records in which Home Health Aide (HHa) services were provided (MR# 1) resulting in the potential for the provision of unsafe care and unmet care…

The agency failed to conduct a comprehensive assessment that accurately reflected the patient's current health status based on a past medical history that included dates of onset, exacerbations, treatments, outcomes, and history of events leading to current home care needs in 4 of 10 records…

The agency failed to ensure that the registered nurse completed a comprehensive drug review for 2 of 2 (MR#s 4 and 7) records reviewed for which therapy only cases were assigned, resulting in the potential for undetected harmful medication side effects or interactions.

The agency failed to ensure the goals on the Plan of Care were objectively measurable to determine the patient's progress towards obtaining goals in 6 of 10 (MR#s 1, 2, 6, 8, 9, and 10) records reviewed potentially resulting in insufficient information to adequately assess patient progress.

The agency failed to include the name of the facility of which the patient was transferred; failed to document the reason for the transfer; and failed to document notification of the transfer to the patient's physician and if the physician had been sent the transfer summary.

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 4…

The agency failed to ensure that the comprehensive assessment was updated and revised appropriately in 1 of 1 record reviewed (MR# 7) in which the patient had a resumption of care after being transferred to an inpatient facility, resulting in the lack of information of the status and reason the…

The agency failed to ensure the plan of care included measurable skilled nursing outcomes and goals for 9 of 17 (MR#'s 7, 8, 9, 11, 13, 14, 15, 16, and 17) records reviewed resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress…