Rochester Regional Health Home Care

The agency failed to ensure the assessments were of sufficient scope to identify current patient needs.

The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs.

For one (1) of five (5) patients (Patient #1) the agency failed to provide documented evidence the patient and/or patient representative received written notice of the patient's rights and responsibilities before care is furnished.

The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs.

The agency failed to ensure the OASIS data accurately reflects the patient's status at the time of the assessment; specifically, the Registered Nurse (RN) failed to accurately stage two (2) unhealed pressure ulcers at the time of discharge.

The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs.

15 and 16) the agency failed to ensure the comprehensive assessment is updated and revised to reflect changes in the patient's health status.

The agency failed to provide services in accordance with physician orders.

The agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's status.

The agency failed to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice.

Agency staff did not inform three (3) of seventeen (17) patients (Patient #'s: 3, 6, 7) of the extent of insurance coverage for various services available through home care.

The agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the Start of Care (SOC).

17) lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns.

The agency failed to ensure Plans of Care (POCs) are of sufficient scope to address all patient needs.

The agency failed to ensure services and treatments are administered in accordance with physician orders.

The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest that the Plan of Care (POC) may need to be altered.

The agency failed to coordinate care delivery and ensure patient needs are addressed.

The agency failed to ensure patients and/or caregivers receive appropriate education regarding the care and services identified in the plan of care (POC).

The Skilled Nurse (SN) failed to prepare or document complete clinical and progress notes.

The agency failed to ensure the HHA provides services as directed on the aide plan of care (POC).

The agency failed to follow agency policies and procedures, current clinical practice guidelines and accepted professional standards when providing services.

Specifically, the Registered Nurse (RN) failed to identify and reconcile all medication discrepancies identified in the referral for services and the Plan of Care (POC).

5) the agency failed to develop individualized plans of care (POC) that are complete and accurate and address the total needs of the patients.

One (1) of five (5) patient records (Patient #2) lacked evidence an order was obtained to update the Plan of Care (POC) to reflect the patient's status.

The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the Plan of Care (POC) may need to be altered.

The agency failed to coordinate care delivery to meet the patient's needs.

The agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care (POC).

The agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes.

The agency failed to ensure agency staff communicated with the patient's physician regarding the failure to administer a medication as ordered.

The agency failed to ensure the Home Health Aide (HHA) provides services as directed on the aide plan of care (POC).

The agency failed to send the completed discharge summary to the primary care practitioner within 5 (five) business days of the date of the order for discharge.

The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs.

Staff interview for two (2) of seventeen (17) patients (Patient #'s: 14 and 16) the agency failed to ensure the comprehensive assessment is updated and revised to reflect changes in the patient's health status.

The agency failed to provide services in accordance with physician orders.

The agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's current status.

Agency staff did not inform (8) of seventeen (17) patients (Patient #'s: 5, 8, 11, 12, 13, 14, 16 and 17) of the extent of insurance coverage for various services available through home care.

The clinical record lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns.

The agency failed to ensure Plans of Care (POCs) are of sufficient scope to address all patient needs.

15) lacked evidence an order was obtained to update the Plan of Care (POC) to reflect the patient's current status.

The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the Plan of Care (POC) may need to be altered.

The agency failed to ensure the Registered Nurse (RN) provided the patient with appropriate education regarding the care and services identified in the plan of care (POC).

The agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes.

The agency failed to ensure the Home Health Aide (HHA) provides services as directed on the aide plan of care (POC).

The Registered Nurse (RN) failed to ensure the Plan of Care (POC) is updated and revised to reflect the patient's current status.

The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs.

The agency failed to ensure the primary caregiver(s) were assessed on their ability to provide care.

The agency staff failed to promptly alert the physician to any changes in the patient's condition that suggests the need to alter the plan of care (POC).

Staff interview for one (1) of three (3) clinical records (Patient # 1) the agency failed to ensure agency staff communicated with the patient's physician regarding the patient's weight gain.

Agency staff interview for one (1) of three (3) patients (Patient #: 1) the agency failed to ensure the patient received a copy of the patient's clinical record (hard copy or electronic form) upon request at the next home visit or within four (4) business days (whichever comes first).

The agency failed to provide services in accordance with the Plan of Care (POC)/physician orders.