Heritage Home Health Services

The agency failed to ensure the emergency preparedness program met all requirements to meet the health, safety, and security needs of their staff and patient population (E0001), failed to ensure an Emergency Preparedness Plan was in place and reviewed every 2 years (E0004); failed to ensure a…

The agency failed to ensure the agency's governing body was delineated from other agency's governing body for 1 of 1 home health agency governing body.

The agency failed to ensure the comprehensive assessments were completed and reflected the patient's health status for 3 of 3 active clinical records reviewed with an OASIS Recertification and Resumption of Care (ROC) assessment completed by RN 1. Findings Include: 3. A review of the clinical…

The agency failed to ensure the physician had been notified of a discharge of services for 1 of 1 inactive clinical records reviewed involving a hospitalization transfer that had not been discharged.

The agency failed to ensure the RNs completed wound measurements assessment timely for 2 of 3 active clinical records reviewed of patients receiving wound care.

The agency failed to ensure the administrator was appointed by the governing body for 1 of 1 governing body.

The agency failed to ensure the Alternate Administrator was appointed by the governing body for 1 of 1 governing body.

The Governing Body failed to assume full responsibility for the parent agency and its branch, failed to evidence documentation of the relocation of the agency, and failed to address the existence of a branch office, for 1 of 1 home health agency.

The Administrator failed to be responsible for all day-to-day operations of the Home Health Agency (HHA), delegating administrative responsibilities to other, non-contracted entities, for 1 of 1 home health agency.

The agency failed to ensure the Parent office had direct oversight of the Branch office for 1 of 1 home health agencies.

The agency failed to ensure the physician received a complete transfer and discharge summary inclusive of goals and interventions for 2 of 3 inactive clinical records reviewed.

The agency failed to ensure all orders were followed from the referral source for 1 of 4 active records reviewed without a home visit.

The agency failed to ensure the Registered Nurse (RN) practiced proper hand hygiene, gloving, infection control practices, and bag technique while providing intravenous therapy to a patient in 1 of 1 patient observed receiving intravenous therapy by the agency.

The agency failed to ensure the patient’s clinical record contained a complete list of the patient’s current medications, and/or that the physician was promptly notified of any significant potential drug interactions identified, in 2 of 8 active clinical records reviewed.

The agency failed to ensure the patient’s plan of care included all the required elements for 4 of 8 active clinical records reviewed.

The agency failed to promptly alert the physician of changes in the patient’s condition, for 1 of 1 active clinical record reviewed with changes in condition.

The agency failed to ensure the patient clinical records included information about the services the patient receives by other agencies and failed to ensure they coordinated care delivery to meet the patent’s needs for 4 of 4 active patients receiving other agency services records reviewed.

The agency failed to ensure it prepared and/or provided all patients with an up-to-date written medication schedule, for 4 of 4 home visits observed.

The agency failed to ensure wound care interventions were documented in skilled visit notes for 2 of 3 active clinical records reviewed with orders for wound care.

The agency failed to ensure the after-hours-on-call number was operating and available to the public, patients, and employees as noted after 2 of 2 unsuccessful attempts to reach the after-hours phone number.

The agency failed to ensure that all Nurses appropriately and accurately assessed their patients according to professional standards for 1 of 2 nurse home visits completed.

The home health agency failed to disclose a change to the ownership structure of the agency at the time the changes were made (See G 852;) failed to disclose to the state agency, the names and addresses of all persons involved when the agency had a change in ownership structure (See G 854;) failed…

The agency failed to develop a policy and procedure ensuring staffing to meet the needs of the patients when needed during an emergency, such as COVID-19 Outbreak.

The agency failed to develop and implement emergency plan ensuring staffing to meet the needs of the patients when needed during an emergency, such as COVID-19 Outbreak.

The agency failed to ensure the plan of care (POC) identified patient specific measurable outcomes and goals for 1 (Patient #9) of 3 closed patient records reviewed in a sample of 10. Findings include: Patient #9 clinical record review was completed on 11/16/2020 for the certification period of…

The agency failed to ensure policies and procedures were put into place for Pre-Covid screening of visitors and failed to ensure they followed their policies and procedures in screening patients upon arrival of a home visit for 1 of 4 home visits conducted.

The Registered Nurse failed to ensure they included dietary and fluid restriction on a home health aide care plan for 1 (Patient #7) of 1 patient record review of a patient receiving dialysis treatments and home health aide services in a sample of 10. The finding included Review of the clinical…

The agency failed to disclose a change to the ownership structure of the agency at the time the changes were made, 6-1-2020, for 1 of 1 home health agency.

The agency failed to operate a home health agency only with a valid state license by having failed to submit a complete renewal application, to include the license fee, to renew its license prior to the expiration date, for 1 of 1 home health agency.

The governing body failed to ensure 3 policies of 20 policies reviewed were updated to comply with federal and state requirements.

Employee E indicated a request was sent on admission but was not approved.

The agency failed to notify patients of their Outcome and Assessment Information Set (OASIS) rights at the start of care for 10 (Patients # 1-10) of 10 patients whose clinical records were reviewed.

The agency failed to provide written notice to patients of the disciplines and frequency of anticipated visits prior to furnishing services for 10 (Patients # 1-10) of 10 patients whose clinical records were reviewed.

The comprehensive assessment failed to be accurate and complete in the assessment of all patients current health status, psychosocial status, and cognitive status, including dialysis access site and treatments for 2 (Patient #1 and 7) of 7 active records reviewed and 1 (Patient #9) of 3 closed…

The agency failed to include the patient's care preferences and strengths in the plan of care in 1 (Patient #9) of 3 closeed records reviewed in a sample of 10. Findings include: Patient #9 clinical record review was completed on 11/16/2020, for the certification period of 8/31/2020 to 10/29/2020…

The agency failed to ensure all medications were reviewed for potential adverse effects, drug reactions, ineffective drug therapy side effects, significant drug interactions, and duplicative drug therapy for 1 (Patient #7) of 7 active patient records reviewed and 1 (Patient #10) of 3 closed patient…

The agency failed to ensure the plan of care included care orders the patient's fluid intake and diet restrictions 1 (Patient #7) of 1 patient who received dialysis treatments, in a total sample of 10 patients.

The agency failed to include all patient care orders in the care orders and failed to followed their policy to verify to ensure services were furnished, for 2 (Patients #1 and 5) of 7 active patient records reviewed in a sample of 10. Findings included: 1. Review of a policy, "Physician Orders,"…

The agency failed to ensure services were furnished only after obtaining a physician's order for disciplines, frequency of visits, duration of visits, and care orders, for 5 (Patients #1 2, 4, 6, 8) of 7 active patients records reviewed and 1 (Patient #9) of 3 closed patient records was reviewed.

The agency failed to ensure the attending physician was notified of a change in the patient's condition that might warrant a revision to the plan of care (POC) for 1 (Patient #9) of 3 closed patient records reviewed in a sample of 10. Findings include: Review of the clinical record for patient #9…

The agency failed to ensure revisions to the discharge plan were communicated to the patient and/or caregiver and primary care physician (PCP) prior to discharging the patient in 1 (Patient #9) of 3 closed patient records reviewed in a sample of 10. Findings include: Review of the clinical record…

The facility failed to coordinate care delivery to meet the patient's needs, and involve the patients, representative, and caregiver(s), as appropriate, in the coordination of care activities ( Patient #7) 1 of 1 patient's reviewed who receive dialysis in a sample of 10. The finding included…

The agency failed to ensure that the patient and patient's caregiver were included in the re-evaluation of the plan of care (POC) in 1 (Patient #9) of 3 closed patient records reviewed.

The Physical Therapist failed to ensure they documented within their visit notes all teaching and patient/caregiver response to the teaching for 1 (Patient #1) of 7 active records reviewed in a sample of 10. Findings include: During a home visit with employee E, (OT,) occupational therapist, on…

The agency failed to disclose to the state agency, the names and addresses of all persons involved when the agency had a change in ownership structure for 1 of 1 home health agency.

The agency failed to disclose a change in the officers, director, and managing agent of the home health agency at the time the changes were made, 6-1-2020, for 1 of 1 home health agency.

The administrator failed to recognize and report to the governing body the need for the home health agency to update 3 of 20 policies reviewed.

The administrator failed to ensure day to day operations of the agency could continue with a valid state license, by having failed to timely submit the mandatory fee with the state licensure application for renewal, for 1 of 1 home health agency.

The parent location of the home health agency failed to exercise its supervisory responsibility to oversee, monitor, and take corrective measures to manage the intake process conducted at the branch office, which caused 1 out of 2 lab orders at the start of care (Patients #5) and 1 out of 1…

The agency failed to include volunteers or emergency staffing protocols in its emergency preparedness plan.

The agency failed to include volunteers in a communication plan.

The agency failed to provide visit frequencies in the plan of care to adequately meet the patient's needs in 3 of 7 records reviewed.

The agency failed to ensure the physician reviewed an updated plan of care in 1 of 7 records reviewed.

The agency failed to ensure the physician was notified of a change in skilled nursing visit frequencies in 1 of 7 records reviewed.

The agency failed to ensure a plan of care was revised and/or updated for the current certification period in 1 of 7 records reviewed.

The agency failed to ensure the patient was educated in accordance to the plan of care in 1 of 7 records reviewed.

Administration failed to ensure an updated plan of care was present in clinical records of 1 of 7 records reviewed.

The agency failed to ensure an updated plan of care was included in clinical records in 1 of 7 records reviewed.

The agency failed to include all goals pertinent to the patient's diagnoses or progress towards achieving goals on the plan of care in 1 of 7 records reviewed.