Lewis County Home Health Agency

The home health provider failed to ensure a complete and accurate medication list was maintained in, two of three home visit observations (Records/Patients #1 and #4).

The home health provider failed to follow the plan of care (POC) when they discharged a patient without a physician order in one of two discharge records reviewed (Record/Patient #5).

The agency failed to ensure staff were provided emergency preparedness training at orientation for three (Employee #1, #2, and #3) of three agency employee files reviewed.

The agency failed to provide evidence that collection of quality data was on-going to: - Monitor the effectiveness and safety of the services and quality of care; and - Identify opportunities for improvement.

The agency's Quality Assessment and Performance Improvement (QAPI) activities failed to show the agency conducted at least one performance improvement project to reflect the scope, complexity, and past performance of the agency's services/operations with measurable progress achieved.

The agency failed to provide evidence that the governing body was responsible for ensuring the agency had an ongoing program for quality improvement and patient safety.

The agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in one (Record/Patient #1) of three home visit observations, and the agency failed to post signage on the entrance door related to COVID-19 recommendations, and failed to…

The agency failed to put in place a program for screening visitors/non-employees who entered the home health agency office for COVID-19 (pandemic infection) signs and symptoms.

The agency failed to maintain a coordinated agency-wide infection control program that included infection control education at orientation for three (Employee #1, E#2, and E#3) of three employee files reviewed.

The agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in, but not limited to, two (Record/Patient #1 and #2) of two home visit observations.

The agency failed to conduct an initial admission assessment within 48 hours of the referral date in one (Record/Patient #3) of five full records reviewed.

The agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in two (Record/Patient #1 and #4) of five full records reviewed.

The agency failed to conform with physician orders when the treatment provided did not follow the orders on the plan of care (POC) in one (Record/Patient #1) of five records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Record/Patient #1) of five records reviewed.

The agency failed to provide evidence that actions aimed at performance improvement occurred, and that the agency measured its success and tracked performance to ensure that improvements are sustained.

The agency failed to provide skilled nursing (SN) services as ordered by the physician on the plan of care (POC) in one (Record/Patient #5) of five full records reviewed.

The agency failed to ensure that skilled professional services clinical notes contained timely documentation according to agency policy in two (Record/Patient #5 and #7) of five full records reviewed.

The agency failed to assure the home health aide (HHA) only provided services that were ordered by the physician and included in the plan of care in one (Record/Patient #1) of one applicable record reviewed.

The agency failed to ensure a complete, comprehensive transfer summary containing relevant information was sent to the other health care facility the patient was receiving care at within two business days of the agency becoming aware of the patient's transfer for one (Record/Patient #7) of two…

The agency failed to ensure that the home health skilled professional staff completed/maintained an accurate patient-specific home health aide (HHA) assignment sheet in one (Patient/Record #3) of one record reviewed for aide services.

Plan Of Care Must Include The Following

The agency failed to ensure ongoing interdisciplinary assessment of the patient in two (Patients/Records #1 and #4) of six records sampled.

The agency failed to ensure that the home health aide (HHA) performed duties as assigned by the registered nurse in one (Patient/Record #3) of one HHA record reviewed.

The agency failed to: - Ensure staff had a criminal background check per the Family Care Safety Registry (FCSR)performed prior to hire in, but not limited to, two (Employees: E-1 and E-2) of four employee files reviewed; and - Ensure staff had an Employee Disqualification List (EDL) background…