Pocahontas County Public Health

The agency failed to ensure participation an emergency preparedness exercises annually.

The hospice failed to ensure 3 of 4 sampled home health aides (Staff E, Staff J and Staff K) satisfactorily demonstrated competency on the written skills examination prior to the home health aide providing service to patients.

The home health agency failed to ensure all clinical documentation was completed and appropriately authenticated in a timely manner for 2 of 7 sampled patients (Patients #1 and #4).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 5 of 7 sampled patients (Patients #1, #2, #3, #6 and #7).

The agency failed to administer treatments and services only as ordered by the physician for 2 of 3 sampled patients with home visits (Patients #1 and #2).

The agency failed to ensure home health aides provided care to patients only as ordered by a physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 4 sampled patients receiving home health aide services (Patients #2…

The agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who…

Agency staff failed to ensure patients and their representatives received information on the agency's transfer and discharge policies.

The agency failed to ensure agency staff completed a transfer summary and sent the transfer summary to the receiving facility for 1 of 3 sampled patients (Patient #6) reviewed requiring the completion of a transfer summary.

The agency failed to notify the physician of changes in visit frequency ordered on the Plan of Care for 2 of 7 sampled patients (Patients #2 and #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 3 of 7 sampled patients (Patients #4, #5 and #6)).

The agency clinician's failed to assess, including wound measurements, each wound at least weekly as identified by agency policy for 2 of 4 sampled patients with wounds.

The agency: 1) failed to ensure all supplies/equipment/medications/treatments required by the patient to meet his/her needs were included on each patient's Plan of Care (G574); 2) failed to include all verbal orders in a working Plan of Care used by all clinicians to reflect current orders (G576)…

The agency: 1) failed to develop a Quality Assessment and Performance Improvement (QAPI) program which included measurable improvements in indicators for which there is evidence that improvement may improve patient health and safety outcomes and increase quality of care.

The agency failed to: 1) supervise home health aides every 14 days when provided in conjunction with a skilled services (G808); 2) determine satisfactory competency with all basic skills by direct observation of such skills while providing care to a home health patient prior to allowing the aide to…

The agency failed to: 1) complete discharge summaries and send to the physician caring for the patient and any other health care provider within 5 business days of the patient's discharge (G1022). 2) appropriately authenticate hand written documentation (G1024); 3) maintain original documentation…

The agency did not ensure the emergency preparedness program included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach specific for the rural health clinic.

Staff interview the agency failed provide documentation that reflected the agency included assessment information that addressed the facility client population including identification of at-risk clients.

The agency failed to complete a written emergency preparedness plan.

The home health agency failed to ensure the clinical record included a copy of the patient's individualized emergency plan developed as part of the comprehensive assessment for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7) with a record review which included a comprehensive…

The agency failed to complete a written emergency preparedness plan.

The agency failed to complete a written emergency preparedness plan.

The agency failed to complete a written emergency preparedness plan.

Staff interview the agency failed provide documentation that the agency developed and maintained an emergency preparedness communication plan that complied with Federal, State and local laws.

Staff interview the agency failed provide documentation that the agency developed and maintained an emergency plan that included primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies.

Staff interview the agency failed provide documentation that the agency developed and maintained an emergency communication plan that included a method of sharing information and medical documentation for the agency clients to maintain the continuity of care.

Staff interview the agency failed provide documentation that the agency developed and maintained an emergency communication plan that included a means of providing information about the agency's occupancy, needs and its ability to provide assistance, to the authority having jurisdiction, the…

The agency failed to ensure all contracted therapists, home health aides received training in the agency's emergency preparedness policies and procedures.

The agency failed to complete a written emergency preparedness plan.

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program which included measurable improvements in indicators for which there is evidence that improvement may improve patient health and safety outcomes and increase quality of care.

The agency failed to use quality indicator data derived from Outcome and Assessment Information Set (OASIS) and other relevant data when designing it's Quality Assessment and Performance Improvement (QAPI) program.

The agency failed to identify performance improvement activities to track adverse patient events, analyze cause and implement preventative actions.

The agency failed to document reasons for conducting performance improvement projects and the measurable progress achieved on these projects which reflect the scope, complexity and past performance of the home health agency's services and operations.

The agency failed to ensure the governing body oversees an ongoing Quality Assessment and Performance Improvement (QAPI) program that addresses priorities for improved quality of care and patents safety, all improvement actions are evaluated for effectiveness; clear expectations are established…

The agency failed to ensure a registered nurse or other appropriate skilled professionals in consultation with a registered nurse as appropriate performed direct observation of home health aide performance of all required basic home health aide skills on a home health patient to determine…

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 3 of 5 sampled patients receiving home health aide services (Patients #1, #3 and #4).

The agency failed to ensure authentication of hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7).

The agency failed to maintain original patient care documents after changes are made to the document.

The agency failed to ensure that all patient clinical record documentation was maintained in a secure and confidential manner for patients receiving home care services from the agency.

The agency failed to identify medication discrepancies when completing a drug regimen review with each comprehensive assessment within the allowed time frames for 1 of 3 sampled patients with home visits during the survey (Patient #2).

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 5 sampled patients requiring a recertification assessment (Patient #5).

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 4 of 7 sampled patients (Patients #1, #2, #3 and #7).

The agency failed to update the Plan of Care with all new physician orders for 5 of 6 sampled patients with interim orders.

The agency failed to obtain physician orders for the addition of over-the-counter medications to the patient's medication regimen for 2 of 7 sampled patients (Patient's #3 and #6).

The agency failed to coordinate care provided by all disciplines and integrate services to assure patient needs are being met for 3 of 3 sampled patients with physical therapy or occupational therapy (Patients #1, #3 and #4).

The agency clinician's failed to assess, including wound measurements, each wound at least weekly as identified by agency policy for 3 of 3 sampled patients with wounds.

The agency failed to focus performance improvement activities on high risk, high volume or problem prone areas.

The agency failed to consider incidence, prevalence and severity of a problem.

The agency failed to identify a problem that directly or potentially threaten the health and safety of patients.

The agency failed to aim actions at performance improvement and measure the success of implementation of those actions, tracking performance to ensure the improvements are sustained.

The agency failed to ensure a registered nurse (RN) or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 5 sampled patients who received hands on personal care services in conjunction with skilled service provision (Patient #2).

The agency failed to complete and send a discharge summary to the physician or other health care professionals responsible for providing care to the patient after discharge within 5 business days of the patient's discharge for 2 of 2 sampled patients requiring discharge after the change in…