Interim Healthcare of Southeastern Colorado Inc

The agency failed to ensure the plan of care included all required services and supplies.

The agency failed to provide services and treatments only as ordered by a physician or allowed practitioner for 2 of 5 records reviewed (Patients #1 and #2).

The agency failed to ensure an accurate and complete clinical record for 2 of 5 sample patients (Patient #1, #2).

The agency failed to ensure the registered nurse (RN) conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care date, for 5 of 12 active clinical records reviewed (Patients #4, #7…

The agency failed to ensure nursing staff promptly alerted the physician of changes in the patient's condition that suggested a need to alter the plan of care for 1 of 1 patients whose record was reviewed and who received intravenous (IV) therapy (Patient #1).

The agency failed to ensure all nursing interventions, treatments and services provided to patients were accurately documented and included within the clinical record for 1 of 1 patient records reviewed receiving intravenous (IV) therapy (Patient #1).

The agency failed to ensure services and treatments were provided in conformance with physician's orders for 2 of 4 patient records reviewed (Patients #1 and #2).

G580 - Standard: Only as Ordered by the Physician - The agency failed to ensure drugs, services and treatments were administered only as ordered by a physician affecting 4 of 17 patients whose records were reviewed (Patients #2, #5, #9 and #17).

A pattern of failure by the agency to ensure skilled professionals participated in the oversight of patient care and services to ensure delivery of care in accordance with the plan of care; failed to ensure professional nurses supervised the care provided by licensed practical nurses; failed to…

The administration failed to provide basic functional oversight of the operations of the agency.

The agency failed to ensure the supervising nurse (who is also the Director of Health Care Services) appropriately managed and participated in all activities relevant to the professional services furnished, implementation of physician orders, supervision of licensed practical nurses (LPN)…

The agency failed to ensure drugs, services and treatments were administered only as ordered by a physician, affecting 4 of 17 patients whose records were reviewed (Patients #2, #5. #9, and #17).

The agency failed to ensure professional staff promptly alerted the physician to any changes in the patient condition that suggested a need to alter the Plan of Care for 2 of 5 patient records reviewed receiving insulin administration (Patients #2 and #9).

The agency failed to implement performance improvement activities which considered incidence, prevalence, and severity of problems; and complied with the requirements of Quality Assessment and Performance Improvement (QAPI).

The agency failed to ensure the performance improvement activities lead to an immediate correction of an inaccurate insulin dose on Patient #2's medication profile.

The agency failed to ensure the registered nurse (RN) provided care in conformance with physician's orders and as indicated in the Plan of Care for 3 of 5 patient records reviewed receiving insulin administration (Patient #9, #17, and #B).

The agency failed to ensure clinical records contained accurate and complete documentation of pertinent past and current findings in accordance with accepted professional standards for 5 of 17 patient records reviewed (Patients #2, #4, #9, #12 and #17).

The agency failed to ensure nursing professional services communicated with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current Plan of Care for 1 of 1 patient record reviewed with a medication error that resulted in an adverse…

The agency failed to ensure the supervising registered nurse (RN) provided consistent and appropriate day-to-day oversight and supervision of licensed practical nurses (LPN) providing patient care to ensure patient case management and care coordination needs had been met for 5 of 17 patient records…

The Administrator failed to organize and direct the agency's day to day operations.

The DHCS failed to ensure patient needs were continually assessed for 2 of 3 patient records reviewed when patients experienced a change in condition from a fall (Patients #4 and #12).