Sanford Home Health and Hospice Sheldon

The agency failed to provide a complete comprehensive assessment for patients with wounds during start of care, recertifications, resumption of care and discharge assessments for 1 of 1 sampled patient with wounds (Patient #3).

The agency failed to complete an accurate drug regimen review with each comprehensive assessment for 1 of 3 sampled patients with home observation visits (Patient #1).

The agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #6).

The agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 2 of 7 sampled patients (Patients #3 and #7).

The agency failed to ensure the accurate completion of all components compromising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 3 sampled patients with surveyor home visit observation (Patient #1, #2, and #3).

The agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 2 of 7 sampled patients with new verbal/interim orders.

The agency failed to provide agency patients with written contact information for the agency's administrator, including the administrator's name and contact information (telephone number and/or email address).

The agency failed to complete a thorough drug regimen review with each comprehensive assessment within the allowed time frames for 1 of 1 sampled patients (Patients #4) with a home visit observation for update of the comprehensive assessment.

The agency failed to ensure completion of the update of the comprehensive assessment at discharge within 2 calendar days of identification of the need to discharge a patient for 1 of 3 sampled patients requiring a discharge comprehensive assessment (Patients #8).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet his/her needs and an accurate list of the patient's current medications for 6 of 9 sampled patients (Patients #1, #3, #4, #5, #7 and…

The agency failed to update the Plan of Care with all new physician orders for 4 of 10 sampled patients with interim orders.

Patient interview and agency staff interview the agency failed to provide medications, treatments or services only as ordered by the physician for 5 of 9 sampled patients (Patients #1, #3, #4, #6 and #7).

The agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 2 of 9 sampled patients (Patient #6 and #8).

The agency failed to ensure home health aides furnished care following the registered nurses' (RNs) assigned tasks and documented the tasks completed for 3 of 5 sampled patients receiving home health aide services for longer than 14 days (Patients #1, #3 and #7).

The agency failed to ensure the patient's clinical record included documentation of all interventions, including medication administration, treatments, and services and responses to those interventions provided by the agency for 3 of 9 sampled patients (Patient #4, #7, and #8).

The agency failed to complete and send a transfer summary to the receiving facility in 2 business days of the patient's transfer and send a discharge summary to the physician responsible for providing care to the patient within 5 business days of the patient's discharge for 2 of 3 sampled…