Lee County Health Department

The agency failed to ensure clinical documents were completed within regulation time frames or per agency policy for 1 of 7 sampled patients (Patient #4).

The agency failed to ensure accurate completion of all pertinent components of the start of care comprehensive assessment within the regulated time frame for 1 of 7 sampled patients.

The home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 4 of 7 sampled patients (Patients #2, #5, #6…

The agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 1 of 7 sampled patients requiring a recertification assessment.

The agency failed to ensure agency staff completed a transfer summary and sent the transfer summary to the receiving facility for 1 of 2 sampled patients (Patient #5) reviewed requiring the completion of a transfer summary.

The agency failed to ensure agency staff notified the physician of the need to vary from the physician ordered Plan for Care for 2 of 7 sampled patients (Patients #5 and #6).

The assignment did not have a RN signature.

Agency clinicians failed to complete an update to the comprehensive assessment at recertification, between days 56 to 60 in the certification period, for 3 of 3 sampled patients requiring a recertification assessment (Patients #2, #4 and #5).

The agency failed to ensure accurate completion of all pertinent components of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient hospital admission for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #5).

The agency failed to ensure agency clinicians fully completed an update to the comprehensive assessment at the time of discharge for 1 of 1 sampled patients requiring a discharge comprehensive assessment (Patient #7).

The agency failed to ensure agency clinicians accurately completed all required components comprising the Plan of Care for 4 of 7 sampled patients (Patients #1, #4, #5 and #7).

The agency failed to update the Plan of Care with interim physician orders for 4 of 4 sampled patients (Patients #1, #5, #6 and #7) with interim orders.

The agency failed to report changes in patient clinical findings to the physician for 1 of 2 sampled patients (Patient #7) with wounds.

The agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address) for 3 of 3 sampled patients (Patients #1, #2 and #3) with a home visit observation.

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 2 of 5 sampled patients receiving home health aide services…

The agency failed to ensure the patient's clinical record included timely documentation of interventions and maintained pertinent current information in the patient record for 4 of 7 sampled patients (Patients #1, #4, #5 and #6).

The agency failed to send a transfer summary within 2 business days of a planned transfer or 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the home health agency becomes aware of the transfer for 1 of 1…

The Start of Care Comprehensive Assessment, dated 8/8/18, lacked documentation of an individualized emergency preparedness plan review. b.

The hospice failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation.

The agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency.

The agency failed to ensure training in emergency preparedness for all employed staff and all individuals providing services under arrangement (contract staff), consistent with their expected roles on or prior to November 15, 2017. The agency reported utilizing a total of 16 employed staff and 33…

The agency failed to notify the physician of changes in visit frequency ordered on the Plan of Care (missed visits) or perform interventions as ordered in the Plan of Care for 2 of 7 sampled patients (Patients #4 and #5).

The agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 1 of 2 sampled patients (Patient #1) with a home visit observation of skilled nursing staff.

The agency failed to provide individualized and specific written patient care instructions by a registered nurse (RN) to agency home health aides for 4 of 4 sampled patients receiving home health aide services (Patients #2, #4, #5 and #6).

The hospice failed to ensure all clinical entry notes included a date and time and staff signature with title for 4 of 7 sampled patients (Patients #2, #4, #5 and #6).

The agency failed to provide an initial assessment visit within 48 hours of receipt of referral and/ or return home, for 2 of 6 sampled patients (Patients #2 and #5) who were admitted since 10/29/15(the date of the agency's last recertification survey).

The agency failed to ensure the completion of all pertinent components of the start of care comprehensive assessments by the fifth day after the start of care for 3 of 6 sampled patients admitted after 10/29/15 (Patients #5, #6 and #7).

The agency failed to perform complete and accurate drug regimen reviews with corresponding comprehensive assessments for 2 of 7 sampled patients (Patients #3 and #7) with a home visit observation.

The agency failed to ensure accurate completion of all pertinent components of the resumption of care comprehensive assessments within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 2 sampled patients requiring a resumption of care assessment (Patient #4).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet his/her needs and an accurate list of the patient's current medications for 2 of 3 sampled patients with home visits (Patients #2 and…

The agency failed to update the Plan of Care with all new physician orders for 3 of 7 sampled patients.

The agency failed to ensure home health aides provided services according to the home health aide written assignment for 2 of 4 sampled patients (Patients #3 and #4) receiving aide services.

The agency failed to ensure the patient's clinical record included documentation of all nursing visits and interventions provided by the agency for 2 of 7 sampled patients (Patient #1 and #4).

The agency failed to complete and send a transfer summary to the physician or other health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of knowledge of the occurrence of the transfer for 2 of 2 sampled patients (Patients #4…