Professional Care Home Health Services

The agency failed to ensure the comprehensive assessment was completed within 5 days of the start of care for 1 of 1 patient with occupational therapy.

The agency failed to ensure the comprehensive assessment included patient’s current health status in 1 of 1 Patient’s with a gastrostomy tube (a tube into the stomach for nutrition) (Patient #4).

The agency failed to ensure the plan of care included all treatments, nutritional/fluid requirements or restrictions in 3 of 4 active clinical records reviewed with a diagnosis of diabetes mellitus (high blood sugar that affects how the body processes glucose) (Patient #1, Patient #3, Patient #4).

The home health agency failed to ensure the emergency preparedness plan was based on and included a documented facility-based and community-based risk assessment utilizing an all-hazards approach and failed to include strategies for addressing emergency events identified by the risk assessment.

The agency failed to include individual emergency preparedness plans for each patient as part of the comprehensive assessment in 5 of 5 active clinical records reviewed.

The agency failed to develop and implement emergency preparedness policies and procedures which included procedures to inform state emergency preparedness officials about patients in need of evacuation from their residences based on patient’s medical condition and home environment.

The agency failed to maintain an emergency preparedness communication plan which included names and contact information for staff and patient’s physicians.

The agency failed to provide emergency preparedness training to all staff at least every 2 years and failed to document emergency preparedness training.

The agency failed to participate in a full-scale exercise or functional exercise every 2 years and failed to conduct an additional exercise every 2 years, on years opposite the year the full-scale or functional exercise was conducted.

The agency failed to ensure the comprehensive assessment accurately reflected the patients’ status in 2 of 3 home visits conducted.

The agency failed to send all necessary information pertaining to patients’ current course of treatment, including medications, to the receiving facility or healthcare practitioner in 2 of 2 discharge records reviewed.

The agency failed to ensure the patients received the services which were written in an individualized plan of care in 5 of 5 active clinical records reviewed.

The agency failed to complete a review of all medications the patients were using to identify drug reactions, including significant drug interactions and ineffective drug therapy in 4 of 5 active clinical records reviewed.

The agency failed to ensure the comprehensive assessments included patients’ primary caregiver, including their willingness and ability to provide care and their availability and schedules in 3 of 5 active clinical record reviewed.

The home health agency failed to ensure the individualized plan of care included all pertinent diagnoses, type of supplies/equipment required, activities permitted, nutritional requirements, all medications and treatments, safety measures, and information related to advanced directives, in 6 of 7…

The home health agency failed to ensure all patient care orders were recorded in the plan of care for 2 of 7 clinical records reviewed.

The home health agency failed to coordinate care delivery and involve the patient in coordination of care activities in 1 of 1 clinical records for patients who received dialysis.

The agency failed to ensure patients received written medication schedule/instructions including: medication name, dosage and frequency in 2 of 3 home visits conducted.

The agency failed to provide patients with written instructions outlining treatments to be administered by home health personnel in 3 of 3 home visits conducted.

The agency failed to ensure clinicians accurately prepared clinical notes in 3 of 7 clinical records reviewed.

The agency failed to ensure communication with all physicians involved in the plan of care related to the current plan of care in 2 of 5 active clinical records reviewed.

The agency failed to ensure supervisory home health aide visits were conducted no less than every 14 days in 1 of 6 clinical records reviewed with skilled patients who received home health aide services.

The home health agency failed to ensure all agency staff practiced standard/universal precautions in 1 of 3 home visits observed.

The home health agency failed to ensure they met all of the patient's rehabilitative needs at the start of care, in 1 of 7 clinical records reviewed.

The home health agency failed to ensure the skilled nurse completed the review of medications to include route and indications for PRN [as needed] medications, in 1 of 7 clinical records reviewed.

The home health agency failed to ensure that all patient medications were listed correctly on the medical plan of care in 1 of 7 clinical records reviewed.

The skilled nurse failed to notify the physician of a medical symptom reported by the physician in 1 of 7 clinical records reviewed.

The skilled professional failed to follow the medical plan of care signed by the primary care physician in 2 of 7 clinical records reviewed.

The home health agency failed to ensure the skilled professional filed accurate and complete clinical notes on all patients, in 1 of 7 clinical records reviewed.

The home health aide failed to follow the aide care plan established by the registered nurse, in accordance with the plan of care in 1 of 4 patients with home health aide services, out of a total sample of 7 clinical records reviewed.