Saint Joseph Vna Home Care

The agency failed to ensure the accuracy of the medication profile for 1 of 2 home visit observations (Patient #3).

The agency failed to ensure assessments accurately reflected the patient’s current medical status in 1 of 4 active records reviewed of patients with wounds (Patient #2).

The agency failed to provide services as ordered by the physician and included in the plan of care (POC) for 1 of 5 active records reviewed (Patient #4).

The agency failed to ensure patient’s clinical records would be made available to the patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first) for 1 of 1 agency.

The home health agency failed to ensure: the Physical Therapist (PT) completed a full head to toe comprehensive assessment/reassessment (Please see tag G0528); the patient's clinical record contained a complete list of the patient's current medications, and/or the physician was promptly notified of…

The Administrator failed to ensure: the agency only accepted patients for services if the needs of the patient could be met and services were not provided absent of a physician's order (see tag G0570); all patients had individualized vital sign parameters specific to their needs (see tag G0572)…

The home health agency failed to ensure it showed measurable improvement in falls with major injury; and failed to include complaints in the agency's Quality Assessment Performance Improvement (QAPI) program, to assess processes of care, agency services, and operations (Please see tag G0642)…

The home health agency failed to ensure: administrative and supervisory functions were not delegated to another organization; and the agency's organizational chart failed to identify its organizational structure, to include all lines of authority (Please see tag G0940); failed to be responsible for…

The home health agency failed to ensure the agency's Emergency Plan was also based on, and included a documented, community-based Hazard Vulnerability Assessment (HVA), utilizing an all-hazards approach.

The home health agency failed to ensure its communication plan include the names and contact information for volunteers.

The home health agency failed to ensure a comprehensive reassessment was conducted for 1 of 1 home visit observed when the patient experienced a significant change in condition (Patient #9).

The home health agency failed to ensure all patients had individualized vital sign parameters specific to their needs for 20 of 20 clinical records reviewed (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20).

The home health agency failed to ensure it showed measurable improvement in falls with major injury; and failed to include complaints in the agency's Quality Assessment Performance Improvement (QAPI) program, to assess processes of care, agency services, and operations.

The home health agency failed to ensure the agency's governing body approved the frequency and detail of the data collection.

The home health agency failed to ensure performance improvement project(s) documented the reason the agency-specific performance improvement projects were chosen.

The home health agency failed to ensure all agency patients received contact information for the agency's Administrator, for 4 of 4 home visits observed with patients who had a Patient Information Handbook (Patient #3, 6, 17, 19).

The home health agency failed to ensure all agency patients received written notice of the patient's rights and responsibilities, and the agency's transfer and discharge policies, for 4 of 4 home visits observed with patients who had an agency Patient Information Handbook (Patient # 3, 6, 17, 19).

The home health agency failed to investigate complaints made by the patient and/or caregiver(s), for 1 of 1 clinical record reviewed with a complaint made to a clinician during a home visit (Patient #9).

The home health agency failed to document the existence and resolution of a complaint for 1 of 1 clinical record reviewed with a complaint made to a clinician during a home visit (Patient #9).

The home health agency failed to report the allegations of misappropriation of money to local authorities, for 1 of 1 clinical record reviewed with reported misappropriation of patient property (Patient #9).

The home health agency failed to ensure the Physical Therapist (PT) performed a full head to toe comprehensive assessment/reassessment for 8 of 9 clinical records reviewed (Patient #3, 4, 5, 10, 12, 13, 16, 19, 20).

The home health agency failed to ensure the patient's clinical record contained a complete list of the patient's current medications, and/or the physician was promptly notified of any significant potential drug interactions identified, for 8 of 20 clinical records reviewed (Patient #3, 6, 8, 12…

The home health agency failed to ensure the patient's plan of care included all required elements, for 13 of 20 clinical records reviewed.

The home health agency failed to promptly alert the physician of changes in the patient’s condition, for 6 of 20 clinical records reviewed (Patient #2, 10, 13, 14, 18, 19).

The home health agency's clinicians failed to assure communication with all physicians involved in the plan of care for 2 of 2 clinical records reviewed (Patient # 19, 20).

The home health agency's clinicians failed to coordinate with outside providers for 3 of 3 clinical records reviewed of patients receiving services outside the home health agency.

The home health agency failed to ensure it prepared and/or provided all patients with an up-to-date written medication schedule, for 5 of 7 home visits observed (Patient #3, 6, 8, 9, 20).

The home health agency failed to ensure it provided all patients with written information for all treatments administered by the agency, for 7 of 7 home visits observed (Patient #3, 6, 8, 9, 17, 19, 20).

The home health agency failed to ensure its performance improvement activities focused on agency-specific high risk, high volume, and/or problem-prone areas.

The home health agency failed to ensure its program activities led to immediate correction of any identified problem that directly and/or potentially threatened the health and safety of patients.

The home health agency failed to take action aimed at performance improvement for the problem prone area of the difficulty staffing nursing services.

The home health agency failed to ensure ongoing interdisciplinary assessments occurred, for 5 of 20 clinical record reviewed.

The clinician failed to accurately prepare clinical notes in 5 of 20 clinical records reviewed.

The Administrator failed to be responsible for the agency's day-to-day operations.

The Clinical Manager failed to provide oversite for making patient and personnel assignments.

The Clinical Manager failed to provide oversite for coordination of all patient referrals.

The home health agency failed to ensure all comprehensive assessments accurately reflected the patients' current health status (G528); and failed to ensure the comprehensive re-assessments were completed as often as the patients' condition warranted (G544).

The home health agency failed to ensure it conformed with physician orders (G578); failed to ensure all changes in the patients condition was promptly relayed to the primary care physician (G590); failed to coordinate care amongst the different disciplines/entities that provided care to the…

The agency failed to ensure the responsibilities of the governing body, administrator and clinical manager were not delegated to another organization or other person(s) on an on-going basis (See G942); the administrator failed to be appointed by and reported directly to the Governing Body (See…

The agency failed to ensure a comprehensive re-assessment (including the administration of the OASIS) was completed for all agency patients as frequently as the patients' condition warranted for 3 of 3 clinical records reviewed with a significant change in condition.

The agency failed to conform with physician orders for 10 of 15 records reviewed (#1, 3, 6, 7, 8, 9, 10, 11, 14, 16).

The skilled nurse failed to follow standard precautions (a group of infection practices that apply to all patients regardless of suspected or confirmed infection status at the time health care is delivered, and are based on the principle that all blood, body fluids, secretions, excretions, may…

The governing body failed to ensure the agency's overall management and oversight was not delegated to another person or organization, agency lines of authority for the delegation of responsibility were clearly identifiable and readily available, and provision of home health services was only…

The agency failed to ensure the physical therapist (PT) performed a complete comprehensive assessment that provided the agency with a total picture of the patient's current health status for 3 of 3 records reviewed with physical therapy as the only skilled service.

The agency failed to ensure the physician was notified of changes in the patient's condition for 6 of 15 records reviewed (#3, 7, 8, 9).

The home health agency failed to coordinate care amongst the different disciplines/entities that provided care to the agency's patients for 6 of 15 records reviewed (#1, 3, 6, 7, 8, 9).

The agency failed to ensure that all patients received written visit schedules, which included the frequency of visits by all agency staff assigned to the patients for 5 of 7 home visits observed (#1, 5, 6, 7, 13).

The agency failed to ensure that all patients had current/updated written medication schedule/instructions prepared by agency staff in the home for 5 of 7 home visits observed (#1, 5, 6, 7, 13,).

The agency failed to ensure that all patients received a current/updated written plan of care for 5 of 7 home visits observed (#1, 5, 6, 7, 13,).

The administrator failed to be appointed by and reported directly to the Governing Body (GB).

The administrator failed to be responsible for the day to day functions of the agency.

The clinical manager failed to coordinate agency referrals.

The agency failed to maintain overall responsibility for the services it provided under arrangement with home care agency D (a home care agency in Muskegon, Michigan with same corporate ownership as agency), and failed to maintain overall responsibility for the manner in which they were furnished.