Nova Home Health Care, Inc

The agency failed to review or update Emergency Preparedness policies and procedures for the emergency plan.

The agency failed to conduct exercises to annually test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; and failed to analyze the clinic's response to and maintain documentation of all drills, tabletop exercises, emergency events…

The agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 3 of 7 (P-3, 4, 5) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by…

The agency failed to document submission of the discharge summaries to the physician in 2 of 2 discharge records (P-1, 2), from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs.

The Agency failed to ensure the Registered Nurse (RN) prepared complete written instructions for patient safety needs in 1 of 1 record in which home health aide services were provided (MR#2), from a total of 7 records reviewed, resulting in the potential for unsafe, substandard care and unmet care…

The agency failed to ensure a Registered Nurse or Physical Therapist performed an initial assessment of the patient within 48 hours of the referral date, facility discharge date or on the physician's ordered start of care date in 1 of 7 records reviewed out of a total sample of 7 records (MR #6).

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

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, and failed to provide documented evidence that the physician was notified of identified drug interactions in 1 (MR #2) of 7 sampled records reviewed, resulting in the…

The agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes in 4 of a total of 7 sampled records reviewed (MR#s: 1, 2, 3, 4), resulting in difficulty determining the patient's progress toward the achievement of goals.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 3 of 3 (MR#s 2, 3 and 4) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health…

The agency failed to develop, implement, review and update policies and procedures for the emergency preparedness plan, that was based on the risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section, which had the potential for agency staff to…

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in…

The agency failed to inform the patient in advance of the disciplines that will furnish care and the proposed visit frequency in one of seven sampled records reviewed (MR#3), resulting in the patient not having knowledge of the disciplines providing services and the frequency and duration of the…

The agency failed to inform the patient/caregiver before care was initiated of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient in two of seven sampled records…

The agency failed to ensure that skilled nursing (SN) conducted the initial assessment visit to determine the immediate care and support needs of the patent in one (MR #6) of four sampled patients reviewed in which nursing services were provided, resulting in the delay of nursing services and the…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine major drug interactions, any adverse effects, failed to document the findings of the drug regimen review as required, and failed to ensure the physician was notified of potential drug…

The registered nurse, or the physical therapist failed to document on the comprehensive assessment the primary and other caregivers' willingness, ability, their availability, and scheduled hours and days to provide care for the patients in one of seven sampled records reviewed (MR#2), for a…

The agency failed to ensure the plan of care (POC) covered all pertinent services, supplies, treatments, interventions with reportable parameters, objectively measurable goals, patient/caregiver education and training for three (MR#s 2, 3, and 6) of seven patients reviewed for plan of care…

The agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care (POC) for frequency and duration of visits and for late start of care and evaluations in four of seven sampled records reviewed (MR#s 1, 2, 3, and 4), resulting in a lack of physician…

The agency failed to communicate plans for discharge with the patient, physician, and other disciplines providing services for the patient in two of three sampled discharge records reviewed (MR#s 1 and 3), and one of 7 sampled records where SN discharged the patient and Physical Therapy continued…

The agency failed to ensure the clinical record was complete, submitted timely and included all assessments and clinical notes for skilled nursing, physical therapy, and occupational therapy in one of seven sampled records reviewed (MR#1), resulting in an incomplete clinical record that fails to…