Heaven Sent Home Health Care LLC

The home health agency failed to ensure the POC included specific medication box set-up orders for 1 of 1 home visit observation with a SN (Patient #1) and failed to ensure the patient received all HHA services as ordered in the plan of care for 1 of 4 records reviewed with HHA services only…

The home health agency failed to ensure staff followed agency infection control policies and procedures related to equipment cleaning and hand hygiene for 2 of 2 home visit observations performed (RN 1 and HHA 1).

The home health agency failed to ensure the POC included all medications for 1 of 1 active record reviewed with a HHA home visit observation (Patient #2).

The agency failed to ensure the plan of care was reviewed by the attending practitioner at SOC for 1 of 1 discharge record reviewed who didn’t have a signing practitioner (Patient #9).

The agency failed to ensure employees followed standards of practice for hand hygiene to reduce the spread of infections for 2 of 3 home visit observations (RN 1 and HHA 1).

The home health agency failed to ensure the HHA supervisory visits were performed and recorded accurately for 5 of 5 active records reviewed with HHA services (Patients #1, 2, 3, 5 and 6).

The home health agency failed to conduct an initial assessment to determine the patient's immediate care and support needs within 48 hours of referral for 1 of 4 active records receiving HHA services only (Patient #6).

The RN failed to conduct a thorough and complete ongoing assessment for 1 of 1 home visit observations with a skilled professional performing the visit (Patient #1).

The home health agency failed to ensure the physician was notified of the need to alter the POC related to possible discharge for 2 of 2 discharge for non-compliance records reviewed (Patients #7 and 8).

The home health agency failed to ensure the HHA provided services as ordered in the HHA care plan for 1 of 2 HHA home visit observations (Patient #3).

The agency failed to ensure the plan of care was created in conjunction with the primary care physician after an assessment for 5 (patients 1, 2, 3, 4, and 5) of 5 active records reviewed in a sample of 7. Findings include: 5. A review of the clinical record of patient # 3, revealed a start of care…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's hearing status, psychosocial status and functional capacity within the community; impact on the delivery of services; ability to participate in their own care; and failed to ensure assessments accurately…

The agency failed to ensure the comprehensive assessment demonstrated the continuing need for the home health services in 1 (patient 3) in 3 patient home visit observations made.

The agency failed to ensure services were provided only with physician authorization/approval in 5 of 5 active clinical records reviewed in a sample of 7. (Patients #1, 2, 3, 4, and 5) Findings include: 5. A review of the clinical record of patient #3, revealed a start of care date of 11/29/21…

The agency failed to ensure the individualized plan of care was reviewed/revised by the ordering physician at the time of recertification of services in 3 (patients 1, 3, and 4) of 5 active clinical records reviewed in a sample of 7. Findings include: 5. A review of the clinical record of patient #…

The Director of Clinical Services failed to ensure coordination of patient referrals for hospitalization and failed to document consideration of referral for patients with fall risks for 3 (Patient #1, 2, and 4) of 5 active records in a sample of 7. Findings include: 5. A review of the clinical…

The agency failed to ensure that home health aides were competencied prior to providing hands on care to the patient for 1 of 1 home health aides (HHA) hired after 1/16/19 (employee D).

The agency failed to ensure that homemaker only patients did not receive personal care for 1 of 13 homemaker only records reviewed (#13).

The agency failed to ensure that home health aides (HHA) were qualified to provide personal care for 1 of 1 HHA placed on aide registry since 1/16/19. Findings include: During review of employee files on 5/29/19, the list of current employees included employee D, home health aide (HHA) hire date…

The agency failed to ensure proof of initial competency and test for home health aides (HHA) was obtained from the issuing agency for 1 of 1 HHA's reviewed with issued certifications from another agency.

The agency failed to; ensure patient right documents included the right to participate in, be informed about, and consent or refuse care in advance of and during treatment (See Tag G434); ensure patient right documents included the right to receive all services outlined in the plan of care (See Tag…

The registered nurse (RN) failed to ensure that the comprehensive assessment contained; the patient's current health and psychosocial status (See Tag G528); contained individual patient strengths, preferences, and goals (See Tag G530); contained a complete review of medications and that the…

The agency failed to ensure that needs of the patient were met for 1 of 3 home visit observations (#3)(See Tag G570); failed to accurately complete the plan of care to include all pertinent diagnoses, ensure the goals were measurable and present for all identified needs, to include all…

The skilled nurses failed to perform a complete physical assessment per professional standards and the registered nurse (RN) failed to complete an intramuscular injection per professional standards the skilled nurse (See Tag G706; (SN) failed to include the patient and / or representatives in…

The agency failed to ensure documents created were authenticate and accurate for 1 of 8 (#3) active and full records reviewed and 1 of 3 (#9) focused records reviwed and 1 of 1 (#7) discharged record reviewed (See Tag G1008); failed to ensure clinical records contained all visit notes (See Tag…

The agency failed to ensure all staff followed infection control policies and standard precautions for 3 of 3 home visits observed (#1, 2, 3).

The registered nurse (RN) failed to ensure that an aide careplan was completed for each shift and the home health aide (HHA) documented which shift tasks were completed for 1 of 6 active patients receiving home health aide service (#1) and failed to ensure that the aide care plan was individualized…

The agency failed to ensure clinical records contained all visit notes in 1 of 1 discharged record reviewed. #7) Findings include: The clinical record of patient #7 was reviewed on 1/7/19 and indicated a start of care date of 6/4/18. The record contained a plan of care for the certification period…

The agency failed to ensure physician and patient signatures were authenticated for 1 of 5 record reviewed with physicians notification (#3) and 1 of 1 discharged record reviewed (#7) in a total sample of 12 records reviewed.

The agency failed to ensure patient right documents included the right to participate in, be informed about, and consent or refuse care in advance of and during treatment for 2 of 2 home visits of patients admitted after 1/13/18 for 1 of 1 agency.

The agency failed to ensure patient right documents included the right to receive all services outlined in the plan of care for 1 of 1 agency.

The agency failed to ensure patient right documents included the right to a confidential clinical record for 2 of 2 home visits of patients admitted after 1/13/18 for 1 of 1 agency.

The agency failed to ensure patient right documents included the right to be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the home health agency or an outside entity for 2 of 2 home visits of patients admitted after 1/13/18 for 1 of 1 agency.

The agency failed to ensure patient right documents included the right to be informed of the right to access auxiliary aids and how to access them for 2 of 2 home visits of patients admitted after 1/13/18 for 1 of 1 agency.

The registered nurse (RN) failed to ensure that the comprehensive assessment contained the patient's current health and psychosocial status for 3 of 3 records reviewed with home visits (#1, 2, 3) in a sample of 8 active and full records reviewed.

The registered nurse (RN) failed to ensure that the comprehensive assessment contained individual patient strengths, preferences, and goals for 3 of 3 records reviewed of patients with home visits (#1, 2, 3) in a sample of 8 active and full records reviewed.

The registered nurse (RN) failed to ensure that the comprehensive assessment contained a complete review of medications and that the medication list was maintained for 1 of 3 records reviewed of patient's with home visits (#3) and 3 of 8 active and full records reviewed.

The registered nurse (RN) failed to complete the recertification comprehensive assessment the last 5 days of the certification period for 1 of 8 active and full records reviewed.

The Registered Nurse (RN) failed to accurately complete the plan of care to include all pertinent diagnoses for 6 of 8 (#1, 2, 3, 4, 6, 8) active and full records reviewed and 1 of 1 discharged record reviewed, ensure the goals were measurable and present for all identified needs for 7 of 8 active…

The agency failed to ensure the physician was notified when there was a change in the plan of care and orders obtained in regards to changes in medication and diet for 2 of 8 active and full records reviewed (#1, 8).

The agency failed to ensure they did not accept orders from their home health aide who attended a physician's visit with a patient for 1 of 1 records reviewed (#1) of an aide attending an appointment and failed to ensure orders received were from a known representative of a physician's office and…

The agency failed to ensure the skilled nurse (SN) failed to notify the physician with changes in patient conditions for 3 of 8 active and full records reviewed.

The agency failed to communicate with all physicians involved in the patients care for 1 of 1 interviewed patients regarding coordination (#3) in a sample of 8 active and full records reviewed.

The agency failed to ensure the Registered Nurse coordinated with other/ sharing agencies providing care to their patients for 3 of 8 (#2, 4, 8) active and full records reviewed, 1 of 1 (#7) discharged record reviewed and full records reviewed and 1 of 3 (#9) focusd records reviewed in a total…

The agency failed to ensure that a medication list was provided to the patient for 3 of 3 home visits observed (#1, 2, 3).

The agency failed to ensure that a plan of care was provided to the patient for 3 of 3 home visits observed (#1, 2, 3).

The skilled nurse (SN) failed to perform a complete physical assessment per professional standards for 2 of 2 skilled nurse visits (#2, 3); and the registered nurse (RN) failed to complete an intramuscular injection per professional standards for 1 of 1 nurse injection visits observed (#2).

The agency failed to include the patient and / or representatives in developing the plan of care to be provided for 1 of 3 home visit observations (#3) Findings include: During a home visit observation on 1/3/19 at 12:55 PM, with patient #3, employee E, licensed practical nurse (LPN), was observed…

The skilled nurse (SN) failed to conduct visits in accordance with the plan of care for 1 of 8 active and complete records reviewed (#8) and 1 of 1 (#7) discharged record reviewed in a total of 12 records reviewed.

The skilled nurse (SN) failed to prepare clinical notes completely and accurately for 2 of 2 skilled nurse home visit observations (#2, 3).

The skilled nurse (SN) failed to communicate with the nurse practitioner for 1 of 1 patients interviewed who sees a nurse practitioner (#3) in a sample of 8. Findings include: Based on observation, record review and interview, the skilled nurse (SN) failed to communicate with the nurse practitioner…

The home health aide (HHA) failed to follow the plan of care for 1 of 1 observed HHA visits (#1) observed in a sample of 3 home visits.

The agency failed to ensure skilled nurses (SN) performed a complete physical assessment per professional standards for 2 of 2 skilled nurse visits (#2, 3); and failed to ensure the registered nurse (RN) provided an intramuscular injection per professional standards for 1 of 1 nurse injection…