Salem Memorial District Hospital Home Health Agency

The agency failed to document a complaint, conduct a complaint investigation, and document a resolution in one (Patient/Record #4) of six records reviewed.

The agency failed to ensure that staff follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in one (Record/Patient #2) of three home visit observations.

The agency failed to put in place a program/procedure for screening patients prior to home visits for COVID-19 (pandemic infection) who received home health services for two (Record/Patient #4 and #5) of six records reviewed.

The agency failed to ensure clinical record documentation was complete and/or accurate in one (Record/Patient #6) of six records reviewed.

The agency failed to ensure a rehabilitation skilled professional conducted an initial assessment visit to determine the immediate care and support needs of the patient; and for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status within 48…

The agency failed to ensure that staff perform a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and…

The agency failed to ensure that the individualized plan of care include, but not limited to, the following: The types of services, supplies, and equipment required; all medications and treatments; patient-specific interventions and education; measurable outcomes and goals identified by the HHA and…

The agency failed to ensure communication with all physicians involved in the plan of care (POC) in two (Records/Patients #4 and #5) of six records reviewed This deficient practice has the potential to affect the quality of care provided to all patients served by the agency.

The agency failed to ensure that when the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator.

The agency failed to ensure that the encoded OASIS (Outcome and Assessment Information Set) data accurately reflected the patient's status at the time of the assessment in two (Record/Patient # 1 and #3) of six records reviewed.

The agency failed to update the written notice of patient rights to include the patient's right to have information provided in plain language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and provision of auxiliary aides and services at…

The agency failed to advise the patient of the names, addresses, and telephone number of the Quality Improvement Organization (QIO) that serves the area where the patient resides.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 regarding the patient rights when the agency determines that the patient or other persons in the home has behavior that is disruptive, abusive or…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include information that if the patient is being considered for a discharge for cause, the agency must make efforts to resolve the problem.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for a discharge for cause, the agency must provide the patient or representative with contact…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for a discharge for cause, the agency must document the problem and efforts made to resolve the…

The agency failed to ensure the patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient were assessed/documented as part of the patient's comprehensive assessment in two…

The agency failed to ensure the individualized plan of care included all medications and treatments, a description of the patient's risk for emergency department visits, and patient-specific interventions and education in one (Record/Patient #1) of six records reviewed.

The agency failed to provide a visit schedule, including frequency of visits by home health agency personnel (HHA) and personnel acting on behalf of the HHA to the client in two (Record/Patient #1 and #4) of three observation visits performed.

The agency failed to provide services as ordered by the physician on the plan of Care (POC) in three (Record/Patient #1, #3, and #5) of six records reviewed.

The agency failed to ensure that services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice in one (Employee #1) of three employee files reviewed.

The agency failed to provide/send a completed discharge/transfer summary to the responsible physician and/or the hospital to which the patient was admitted within two business days of the patient's transfer in two (Record/Patient #2 and #6) of two applicable records reviewed.