Residential Clinical Services Inc

The agency failed to follow a plan of care established and reviewed by the physician in 6 of 10 patient records reviewed (Patient #1, 2, 4, 5, 7, 8 ).

The home health agency failed to ensure accepted standards of practice and standard precautions were implemented by all clinicians to prevent the possible spread of infectious diseases in 2 of 3 home visits conducted (Home health aide #1, RN #2) The findings include: 6. Observation of a skilled…

The agency failed to maintain a program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases in 4 of 4 records reviewed with known or obtained infection (Patient #4, 5, 6, 7).

The agency failed to ensure the skilled professional informed patient and caregiver discharge education in 2 of 10 patient records reviewed (Patient #2, 9).

The agency failed to ensure the involvement of all skilled professional staff in the patient's plan of care in 1 of 2 active patient records receiving IV [intravenous] antibiotics (Patient #5).

The agency failed to provide services as ordered in the plan of care in 3 of 7 active patient records reviewed (Patient #4, 5, 7).

The nurse failed to prepare current, complete, and accurate clinical notes in 7 of 10 patient records reviewed (Patient #2, #4, #5, #6, #7, #8, #10).

The skilled professionals failed to communicate pertinent information regarding the patient’s plan of care to the physician for 3 of 7 active clinical records reviewed (Patient #2, #3, #6).

The skilled professional failed to provide oversight to ensure all assistants followed written instructions for 1 of 1 HHA supervised by a Physical Therapist (PT #1).

The agency failed to ensure skilled professional services practiced according to the agency's policies and procedures in 5 of 5 active patient records with a wound or IV [intravenous] antibiotics (Patient #4, #5, #6, #7, #10).

The home health agency failed to ensure patients were provided the contact information for the agency's administrator including the administrator's name; patients were informed of and consented to in advance the changes in the care and services that were being furnished by the home health agency…

The home health agency failed to ensure all the patients medical and nursing needs were met in their place of residence; the plan of care was individualized and followed by all agency staff as directed by the primary care physician; the plan of care contained all safety precautions, DME [durable…

The agency's Quality assessment and performance improvement (QAPI) program failed to identify and address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors, monitor the effectiveness of quality of care, identify opportunities of improvement…

The home health agency failed to ensure all employees practiced standard/ universal precautions and failed to maintain a program for identification, prevention, control and investigation of infectious and communicable diseases specific to care and services provided in the home setting.

The home health agency failed to ensure the plan of care was followed and individualized in 9 of 13 clinical records reviewed.

The home health agency failed to ensure the patients are provided written instructions in 4 of 5 home visits conducted.

The home health agency failed to ensure all employees practiced standard/ universal precautions in 2 of 5 home visits observed.

The home health agency failed to maintain a program for identification, prevention, control and investigation of infectious and communicable diseases specific to care and services provided in the home setting in 1 of 1 home health agency.

The home health agency failed to ensure home health aides (HHA) furnished home health services only after successfully completing a competency evaluation program for 1 of 1 home health agency.

The home health agency failed to ensure all entries in the clinical record are complete and appropriately authenticated to include a signature and tile, dated and timed in 10 of 13 clinical records reviewed.

The home health agency failed to provide the contact information for the agency's administrator including the administrator's name in order to receive complaints in 5 of 5 home visits.

The agency failed to ensure the patient was informed of and consented to in advance the changes in the care and services that were being furnished in 10 of 13 records reviewed.

The home health agency failed to ensure the patient was discharged appropriately and in agreement with the physician responsible for the plan of care that the patient's measurable outcomes and goals set forth in the plan of care have been achieved in 2 of 2 discharged records reviewed with a…

The home health agency failed to ensure the comprehensive assessment included a complete assessment of a patient's urinary status in 1 of 2 active clinical records with a urinary catheter (#3) and a complete assessment of a patient's wound 1 of 2 clinical records with a wound.

The home health agency failed to ensure a review of the patient's current medications included drug interactions during the comprehensive assessment in 1 of 5 home visits.

The home health agency failed to ensure the plan of care contained all safety precautions, dme [durable medical equipment]/supplies, medications, patient-specific interventions for their patients, and identified goals in 7 of 13 clinical records reviewed.

The home health agency failed to ensure there were physician orders in place for all drugs, treatments, and services provided by the home health agency in 10 of 13 clinical records reviewed.

The home health agency failed to ensure the physician was promptly alerted to changes in patients vital signs outside of acceptable ranges, abnormal respiratory symptoms, abnormal lab levels, and skin impairments in 11 of 13 clinical records reviewed.

The home health agency failed to communicate discharge plans with the patient / caregiver and the physician responsible for the plan of care in 4 of 4 closed records.

The home health agency failed to integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient in 1 of 2 clinical records reviewed with wounds.

The home health agency failed to coordinate amongst the different disciplines/ entities that provided care to the patient to assure identification of patient needs and factors that could affect patient safety and treatment effectiveness in 9 of 13 clinical records reviewed.

The home health agency failed to ensure that a patient/ patient caregiver received accurate training and education identified in the plan of care in 1 of 3 clinical records reviewed of patients with feeding tubes.

The home health agency failed to provide a written visit schedule to include the frequency of visits by agency personnel in 5 of 5 home visits.

The home health agency failed to provide written instructions to the patient outlining the name and contact information of the agency's clinical manager in 5 of 5 home visits.

The home health aide failed to report changes in the patient condition to a registered nurse in 2 of 5 clinical records providing home health aide services.

The clinical manager failed to provide oversight in regards to making patient and personnel assignments in 1 of 1 home health agency.

The home health agency failed to complete and send a discharge summary to the primary care physicians within 5 days of the patient's discharge in 4 of 4 closed records.