Royal Majesty Home Health, Inc

The agency failed to ensure the agency followed a physician order for skilled nursing visits for 1 of 7 patients (Patient 1) and failed to acquire a walker and notify a physician according to pain level parameters ordered in the plan of care for 1 of 7 patients (Patient 5).

The agency failed to ensure it resolved issues regarding obtaining an assistive device and notified a physician regarding a pain level that exceeded parameters for 1 of 7 patients (Patient 5).

The agency failed to ensure a registered nurse authenticated clinical assessments for 1 of 7 patients (Patient 4).

The facility failed to confirm if their social worker was qualified for their positions for one of one Social Workers (Social Worker 1).

The agency failed to provide a plan that defined the agency's Quality Assessment and Performance Improvement Program scope.

The agency did not a conduct or document an annual performance improvement project.

The agency failed to ensure the infection control program maintained employee screening for tuberculosis and communicable diseases for 5 of 10 employees (Employee #4, #8, #9, #11 and #12).

The agency failed to ensure patients were assisted to establish end of life care preferences as evidenced by incomplete Advance Directive documents for 5 of 7 sampled patients (Patients #1, #3, #5, #2, #4 and #7).

The agency failed to ensure patient's Plan of Care included Advance Directives for 1 of 7 sampled patients (Patients #1).

The agency failed to develop a policy related to influenza and pneumococcal vaccines and accurately screen patients for immunizations for 2 of 7 sampled patients (Patient #2 and #7).

The agency failed to ensure the Physical Therapist completed a discharge summary to notify the physician for 1 of 7 sampled patients (Patient #6).

The agency did not ensure patient documentation was submitted in a timely manner according to policy for 1 of 7 sampled patients (Patient #1).

The agency failed to ensure Home Health Aide supervisory visits were provided at least every 14 days for 1 of 7 sampled patients (Patient #7).