Miracle Home Health Care, Inc

The Home Health Agency (HHA) failed to ensure the plan of care (POC, an individualized plan of care that summarizes the patients’ health condition, specific care needs, current treatments, and the disciplines providing the services) was implemented for two of seventeen sampled patients (Patient 1…

The Registered Nurse (RN) failed to conduct an initial assessment for one of seventeen sampled patients (Patient 3).

The Home Health Agency (HHA) failed to complete the comprehensive assessment for one of seventeen sample patients (Patient 3) within five days of admission.

The Home Health Agency (HHA) failed to evaluate and perform pain reassessment in accordance with the agency’s policies and procedure for one of seventeen sampled patients (Patient 9).

The Home Health Agency (HHA) failed to review, update, and document the patients' currently used medications and treatments for four of seventeen sample patients (Patient 2, Patient 7, Patient 12, and Patient 15).

The Home Health Agency (HHA) failed to ensure three of seventeen sampled patients (Patient 3, Patient 7, and Patient 12) plans of care (POC) included interventions needed to monitor the patients' health status.

The Home Health Agency (HHA) failed to ensure all doctor’s orders were recorded in the plan of care (POC) for two of seventeen sampled patients (Patient 2 and Patient 12).

The Home Health Agency (HHA) failed to notify the physician of a change of condition for one of seventeen sampled patients (Patient 1).

The HHA failed to ensure the plan of care reflected current information from the updated comprehensive assessment for one of seventeen sampled patients (Patient 4).

The agency’s skilled nurse (SN) failed to notify the physician of the patient's intense pain during the home visit for one of seventeen sampled patients (Patient 9).

Based interview and record review the Home Health Agency (HHA) failed to ensure clinical records reflected the care provided for two of seventeen sample patients (Patient 12 and Patient 13).

The home health agency (HHA) failed to meet the Condition of Participations for Comprehensive Assessment of Patients, as follows: The home health agency failed to: 1. Conduct a comprehensive assessment (an examination of social and behavioral influences, health risks and information needs of…

The home health agency failed to ensure the physician orders or plan of care were implemented for four of 17 sampled patients (Patient 1, 6, 12, 15).

The Home Health agency failed to ensure the Condition of Participation for the Organization and Administration of services was met as follows: The Home Health agency failed to: Ensure patient needs and services for one of 17 sampled patients, (Patient 1) was continually assessed.

The home health agency failed to conduct a comprehensive assessment (an examination of social and behavioral influences, health risks and information needs of patients and/or families/caregivers), for 1 of 17 sampled patients, (Patient 6).

The home health agency (HHA) failed to review, reconcile, and maintain an accurate list and supplies of all the medications 5 of 17 sampled patients, (Patients 1, 7, 8, 9, and 12) are currently taking.

The home health agency failed to ensure the physician orders or plan of care were implemented for four of 17 sampled patients (Patient 1, 6, 12, 15).

Case Manager 1 failed to notify the physician promptly when one out of 17 sample patients (1) had an existing aggravating pain as a result from running out of Baclofen medication.

The Home Health Agency (HHA) failed to coordinate care and services to meet the individualized plan of care for one of nine sampled home visit patients ( Patient 8) This deficient practice had the potential to result in a delay in implementing Patient 8's plan of care.

The Home Health Agency (HHA) failed to ensure the nursing staff provided instructions or health teaching to the patient's caregiver (PCG) and verified if Patient 6 was able to perform proper self-catheterization.

The home health agency (HHA) failed to ensure home visits were conducted according to the plan of care (POC) for one of 17 sampled patients (Patient 15).

The home health agency (HHA) nursing staff failed to assess the pain level (intensity) as indicated in the plan of care, for two of 17 sampled patients (Patients 12 and 13).

The Home Health Agency (HHA) failed to ensure designated attending physician was notified and notifications were documented when ordered home visits services were missed for two of 17 sampled patients (Patients 1 and 15).

The agency failed to: 1. Ensure the patient needs for one of 17 sampled patients, (Patient 1) was continually assessed.

The home health agency (HHA) failed to inform the patient the reason of delay of services and failed to visit the patient as scheduled for one of two sample selected patients (Patient 1).