Herman Area Hospital District

The agency failed to: -Write an individualized plan of care that identified patient-specific measureable outcomes and goals, and which is established, periodically reviewed, and signed by a physician (G572); -Ensure that drugs, services, and treatments are administered only as ordered by a…

The agency failed to meet the requirements for the Condition of Participation: Organization and Administration of Services when the agency failed to ensure: - The administrator assumed responsibility for all day-to-day operations (G948); - The home health agency employed qualified personnel…

The agency failed to update the written notice of patient rights to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no…

The agency failed to accurately reflect the patient's status and include relevant patient data in the recertification assessment in one (Record/Patient #6) of five full record reviews.

The agency failed to complete an individualized plan of care that specified the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment in three (Patients/Records #1, #3, and #4) of five full record reviews completed.

The agency failed to update the written notice of patient rights to include the patient has the right to receive all services outlined in the plan of care.

The agency failed to update the written notice of patient rights to include the patient has the right to be advised of financial liability changes as soon as possible, in advance of the next home health visit and the agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2)…

The agency failed to document the existence of a complaint and resolution of the complaint.

The agency failed to ensure that the medication profile was updated with medication changes in three (Records/Patients #1, #2, and #3) of three home visits conducted.

The agency failed to incorporate the current version of the Outcome and Assessment Information Set (OASIS) items into the recertification assessment in one (Record/Patient #6) of five full record reviews.

The agency failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner in two (Records/Patients #2 and #3) of five full records reviewed.

The agency failed to ensure the plan of care was revised/updated to address patients' needs for two (Record/Patient #1 and #3) of five full records reviewed.

The agency failed to assure integration of services and coordination of care between all disciplines caring for the patient whether provided directly or under arrangement in one (Record/Patient #1) of five full records reviewed.

The agency failed to provide the patient/caregiver with a copy of written instruction outlining the visit schedule, including frequency of visits in, but not limited to, two (Records/Patients #1 and #3) of three home visit observations.

The agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in two (Records/Patients #1 and #3) of three home visit observations.

The agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey.

The administrator has effectively assumed responsibility for the overall administration, supervisory functions and overall operations of the home health agency.

The administrator failed to ensure the agency hired qualified staff and ensured that adequate staff education was provided.

The agency failed to ensure a qualified, pre-designated person who is authorized in writing by the administrator and the governing body assumes the same responsibilities and obligations as the administrator when the administrator is not available.

Coordination of Services and Quality of Care-G570) the clinical manager failed to: - Ensure completion of individualized care plans that specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment (G572); - Ensure verbal orders are…

The agency failed to provide evidence that a completed comprehensive discharge summary to include all necessary components was sent to the primary care physician after discharge from the agency's services within five business days of the patient's discharge in one (Record/Patient #5) of two…

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. The patient rights folder failed to include that information must be provided to patients in a language and in a manner that is accessible and…

The agency failed to ensure agency staff complied with accepted professional standards and principles related to performing care and maintaining adequate and appropriate infection control measures in, but not limited to, two of three patient observations (RECORDS/PATIENTS #1 and #2).

The agency failed to ensure an accurate medication review and/or update of patient medications was completed in, but not limited to, two (Records/Patients #2 and #3) of five records reviewed.

The agency failed to ensure each patient received home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals related to patients pain, and/or blood pressure parameters, in two of five records (Records/Patients: #2, and #3).

The agency failed to obtain and/or follow orders and ensure all physician orders were timed when received in, but not limited to, one (Record/Patient #2) of five records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition that suggest that outcomes are not being achieved and/or that the plan of care should be altered in two of five (Record/Patient #2 and #3) records.

The agency failed to provide the name and contact information for the clinical manager in two (Record/Patient #2 and #3) of three home visits conducted with patients.

The agency failed to ensure the registered nurse (RN) or other appropriate skilled professional completed home health aide supervisory visits within the required time frame for one (Record/Patient #5) patient who had home health aide services.

The agency failed to perform an employee disqualification list (EDL) check prior to hire for one employee (RN 1).