Safe Hands Home Health Care

The agency failed to ensure the registered nurse (RN) conducted an initial assessment visit within 48 hours of referral, the patient’s return home, or physician ordered start of care date in 2 (P-1 and P-6) of 10 sample records reviewed resulting in a delay in determining the patient’s immediate…

The agency failed to ensure the rights of the patient regarding participation in, being informed about, and consenting, or refusing care furnished by the agency in 1 (P-1) of 4 patient's in which a joint visit occurred, resulting in the patient’s preference not being respected.

The agency failed to ensure the registered nurse (RN) conducted an initial assessment visit within 48 hours of referral, the patient’s return home, or physician ordered start of care date in 2 (P-1, 6) of 10 sample records reviewed resulting in a delay in determining the patient's immediate care…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status in 4 (P-3, P-4, P-5, and P-6) of 10 sampled records reviewed resulting in incomplete clinical information for determining the needs of the patient and the potential for poor patient…

The agency failed to ensure the comprehensive assessment accurately reflected medications the patient was currently taking in 4 (P-1, P-2, P-7, and P-8) of 10 sample records reviewed resulting in the agency being unaware of medications taken by the patient and the potential for harmful medication…

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 5 (P-4, 5, 8, 9, 10) of 10 records reviewed; patient specific and individualized orders based on referral and assessment of needs in 1 (P-10) of 10 records reviewed; and safety precautions in 3…

The agency failed to ensure the physician was promptly alerted to changes in the patient’s needs which suggested outcomes were not being met and the plan of care should be altered in 1 (P-2) of 10 sample records reviewed resulting in unmet patient needs and pain for this patient.

The agency failed to ensure skilled professionals performed complete on-going assessments of the patient’s health status and needs in 2 (P-4, 6) of 10 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure that skilled services were administered in accordance with the physician's orders and the Plan of Care in 4 (P-4, 5, 6, 9, 10) of 10 sampled patients reviewed for skilled services, resulting in the potential for decline in physical functioning, unidentified health…

The agency failed to ensure the Home Health Aide provided care in accordance with the plan of care for 1 (P-8) of 4 patients in which Home Health Aide services were provided, resulting in the potential for patients to receive sub-standard services from the agency.

See: (Rev. 219; Issued: 04-12-24; Effective: 04-12-24; Implementation: 04-12-24) Based on record review and interview, the agency failed to ensure the registered nurse (RN) completed onsite supervisory assessments of home health aide services in 2 (P-2 and P10) of 4 sample records reviewed in which…

The agency failed to ensure the clinical record contained completed assessments and visit notes for 4 (P-7, 8, 9, 10) of 10 records reviewed, resulting in a lack of information for the physician and all agency staff caring for the patient.

The agency failed to ensure the clinical record contained all interventions, treatments, and services in 1 (P-5) of 10 records reviewed, resulting in an incomplete and inaccurate medical record.

The Agency failed to ensure a discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 1 (P-9) of 3 closed records, resulting in the potential for unidentified…

The agency failed to ensure the LPN #1 (licensed practical nurse) provided wound care only as ordered by the physician in 1 (P-1) of 4 records reviewed with wound care out of a total of 10 records reviewed (See G 580); failed to ensure the patient's Plan of Care (POC) was updated and revised as…

The agency failed to ensure the clinical record was accurate and individualized to the patient during the time(s) when health care was provided in 1 (P-1) out of a total sample of 10 records reviewed, resulting in unrecognized increased medical needs of the patient at the time of discharge from…

The agency failed to ensure the LPN (licensed practical nurse) provided wound care only as ordered by the physician in 1 (P-1) of 4 records reviewed with wound care, out of a total sample of 10 records reviewed, resulting in deteriorating wound status and unmet patient needs.

The agency failed to ensure the patient's Plan of Care (POC) was updated and revised as required in a time of health status decline for 1 (P-1) 1 of record reviewed with a change in wound status and severe UTI (urinary tract infection) symptoms, from a total sample of 10 records reviewed, resulting…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 (P-1) of 1 record reviewed with SCIC (significant change in condition) concerning wound and UTI (urinary tract infection) from a total sample of 10 records reviewed, resulting in a poor patient outcome.

The agency failed to ensure services were integrated to assure the identification of patient needs and proper coordination of care with other disciplines in 2 (P-1, P-10) of 10 records reviewed out of a total sample of 10 records, resulting in the potential for unmet care needs.

The agency failed to ensure the RN (registered nurse) supervised the care provided by the LPN (licensed practical nurse) in 1 (P-1) of 1 record reviewed in which LPN services were provided from a total sample of 10 records reviewed, resulting in a lack of clinical supervision, and unmet patient…