John Paul Home Health Care

The agency failed to ensure the registered nurse supervised the care of the licensed practical nurse for 1 (P-1) of 17 records reviewed, resulting in a lack of oversight regarding the services provided by the licensed practical nurse.

The agency failed to ensure the registered nurse prepared an aide care plan that contained patient information and instructions for 2 (P-2, 3) of 8 records reviewed in which aide services were provided, resulting in the potential for unsafe, substandard care, and unmet care needs.

The agency failed to ensure that clinical records were safeguarded against loss or unauthorized use for 2 of 17 records reviewed (P-4, 11), resulting in the potential compromise of protected health information.

The agency failed to ensure that 1 (P-10) of 17 records reviewed were included in their overall planning of care including informing the patient/caregiver in advance of which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of…

The agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the start of care in 2 (P-4, 7) of 17 records reviewed, resulting in a delay in determining the immediate care and support needs for this patient.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission to for 5 (P-1, 5, 6, 7, 12) of 17 records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients to assist in…

The agency failed to ensure the comprehensive assessment included a review of all medications to identify any potential adverse effects, drug reactions, duplicate drug therapy, or interactions for 8 of 17 (P-1, 3, 4, 5, 7, 9, 13, 15) records reviewed, resulting in the potential for harmful…

The agency failed to ensure a plan of care was developed for 1 of 17 (P-13) records reviewed and failed to ensure the plan of care included parameters to notify the physician, allergies, interventions, measurable goals and wound care for 9 of 17 (P-2, 5, 6, 8, 11, 12, 14, 16, 17) records reviewed…

The agency failed to ensure the physician was notified of findings that fell outside the parameters ordered in the patient’s plan of care in 1 of 17 (P-15) records reviewed, resulting in the potential for poor patient outcomes.

The agency failed to ensure ongoing communication between Skilled Nursing and Home Health Aide in 1 (P-8) of 17 records reviewed, which resulted in the potential for unidentified patient needs.

The agency failed to ensure all services were provided as ordered by the physician or allowed practitioner as indicated in the plan of care in 1 (P-5) of 17 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs.

The agency failed to ensure the clinical record was complete and included detailed notes for 4 (P-1, 2, 3, 10) of 17 records reviewed, resulting in lack of continuity of care and undocumented health concerns.

The agency failed to ensure the physical therapist communicated with the physician regarding pain for 1 of 2 (P-14) post-operative records reviewed, resulting in a lack of physician involvement in directing the appropriate care for this patient, and failed to ensure skilled nursing communicated…

The agency failed to ensure they adequately documented on-site supervisory visit to the patient's home to supervise the services that were provided by the home health aide for 2 (P-2, 8) of 8 records reviewed in which aide services had been provided, from a total sample of 17 records reviewed…

The agency failed to ensure home health aide services were provided as ordered in 1 (P-1) of 8 records reviewed with aide services, resulting in the potential for unmet care needs.

The agency failed to ensure clinical manager oversight of coordinating patient care services and personnel for 1 (P-1) of 17 records reviewed, resulting in the potential for inappropriate care.

The agency failed to ensure clinical notes were accurate for 5 of 17 (P-2, 5, 7, 10, 11) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 4 of 5 (P-1, 8, 9, 16) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status…

The agency failed to ensure the plan of care included medical social work services for 1 of 1 (P-1) records reviewed with an identified need for social work services, resulting in a lack of community resource information for this patient.

The agency failed to ensure the physician was notified of significant changes in the condition of the patient's wounds for 1 of 3 (P-1) records reviewed with wound care, resulting in the potential for a poor patient outcome: Findings include: P-1: This 78-year-old patient was admitted to home care…

The Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 1 (MR# 2) of 7 records in which Home Health Aide services were ordered, from a total of 17 sampled…

The agency failed to ensure the registered nurse conducted the initial assessment visit to determine the immediate care needs of the patient, including homebound status for 1 of 14 (MR#4) records reviewed in which both skilled nursing and therapy services were ordered from a total sample of 17…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 5…

The agency failed to ensure the physician was notified of potential drug interactions and failed to ensure a registered nurse reviewed patient medications for 10 of 17 (MR#'s 1, 2, 4, 7, 8, 9, 10, 14, 16 and 17) records reviewed, resulting in the potential for harmful medication effects for these…

The agency failed to ensure the registered nurse assessed pressure ulcers for 1 of 1 (MR#8) patients with pressure ulcers; and failed to ensure that skilled nursing, physical therapy, and occupational therapy performed timely initial assessments of the patient's functional status and needs for 4 of…

The agency failed to ensure that Home Health Aide (HHa) services were provided at the frequency ordered by the physician in the plan of care for 1 of 7 (MR#'s 15) records reviewed with HHa services, resulting in the potential for physical decline and unmet care needs.

The agency failed to ensure transfer summaries were sent within 2 business days to the receiving facility/physician for 1 of 5 (MR #4) records reviewed in which the patient was transferred, and failed to ensure a discharge summary was sent to the primary care practitioner within 5 business days of…

The agency failed to ensure the patient received services as ordered in the plan of care for 2 of 17 records reviewed (MR# 2, 15), from a total sample of 17 records reviewed, resulting in the potential for unmet care needs and the potential for failure to achieve the goals and measurable outcomes…

The Registered Nurse (RN) failed to prepare clearly written patient care instructions and include safety precautions on the aide's care plan in 3 of 7 records in which Home Health Aide (HHa) services were provided (MR#s 3, 4 and 6) resulting in the potential for the provision of unsafe care and…

The Home Health Aide failed to provide services as ordered on the plan of care and failed to notify the registered nurse of missed visits in 3 of 7 records reviewed with home health aide services (M.R. #3, 4 and 6), for a potential of unmet care needs.