Osf St Francis Hospital Home Health Care

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 4 of 10 records reviewed (Patient #s 2, 5, 6 and 7), resulting in a potential for failure to measure progress toward achievement of desired outcomes.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 1 (Patient #9) of 10 records reviewed, resulting in a delay in determining the immediate care and support needs for the patient.

The agency failed to provide a complete comprehensive assessment that accurately reflected the patient's current health status based on a past medical history that included dates of onset and exacerbations in 9 of 10 (Patient #s 1, 2, 3, 5, 6, 7, 8, 9 and 10) records reviewed resulting in…

The agency failed to ensure services and treatments found in the plan of care were provided only as ordered by the physician in 3 of 10 (Patient #’s 1, 2, and 7) records reviewed resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure coordination of care for the identification of patient needs and communication to the appropriate professional, and to the physician in 2 of 10 (Patient #2, 8) records reviewed resulting in potential for decline in the patient's health status and negative outcomes.

Based and record review and interview, the agency failed to ensure the aide provided care as instructed for 1 (Patient #8) of 3 records reviewed in which aide services were provided, resulting in the potential for poor patient outcomes.

The agency failed to provide documented evidence that an agency administrator was appointed by the governing body, resulting in no definitive lines of authority and the potential for lack of oversight in patient care and operations.

The agency failed to ensure clinical notes were accurate for 1 of 10 (Patient #’s 5) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure the clinical record contained all interventions and treatments for the patient in 2 (Patient #9, 10) of 10 records reviewed, resulting in a lack of information for all agency staff caring for the patient as well as an inaccurate clinical record.

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 15 of 17 records reviewed (MR#s 1, 2, 5, 6, 7, 8, 9, 10, 11, 12, and 13) out of a total of 13 records reviewed, resulting in a potential for failure to measure progress toward achievement of…

The Registered Nurse failed to prepare clearly written patient care instructions and include all safety measures on the aide's care plan in 5 of 5 records reviewed in which Home Health Aide services were provided (MR#s 2, 3, 4, 5, and 11), from a total sample of 13 records reviewed, resulting in…

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…