Skyline Center Inc Home Health

The home health agency failed to include the verbiage an individualized emergency plan must be included as part of the comprehensive patient assessment.

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 1 of 7 sampled patients.

The agency failed to ensure the comprehensive assessment was completed in a timely manner consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care for 2 of 4 sampled patients (Patients #2 and #6) with start of care assessments after the last survey…

The home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 1 of 7 sampled patients (Patient #7).

The agency failed to obtain physician orders for physical therapy services and treatment using heat and or ice for 1 of 7 sampled patients (Patient #7).

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 5 sampled patients receiving home health aide services (Patient…

The agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 5 sampled patients who received hands on personal care services in conjunction with skilled service provision (Patient #7).

The agency failed to ensure the clinical record included weekly wound measurements for 1 of 2 sampled patients (Patient #6) with wounds.

The agency failed to ensure authentication of hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature and electronic signatures were completed according to agency policy for 3 of 7 sampled patients (Patients #2, #3 and #6).

The agency failed to identify medication discrepancies when completing a drug regimen review with each comprehensive assessment within the allowed time frames for 5 of 7 sampled patients.

The agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 3 of 4 sampled patients requiring a recertification assessment (Patients #1, #2 and #5).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including information related to advance directives and frequency of services to be provided for 3 of 7 sampled patients (Patients #1, #4 and #7).

The agency failed to update the Plan of Care with all new physician orders for 1 of 2 sampled patients with therapy only interim orders.

The agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency.

The agency failed to transmit OASIS data within 30 days of the completion of the assessment (OASIS M0090) date for 3 of 6 sampled patients requiring transmission of OASIS data (Patients #3, #4 and #7).

The agency failed to notify the physician of changes in visit frequency ordered on the Plan of Care for 5 of 7 sampled patients (Patients #1, #2, #5, #6 and #7) . The agency reported a current census of 62 patients.

The agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 1 of 2 sampled patients who required wound assessments (Patient #1).

The agency clinicians failed to complete supervision of licensed practical nurses periodically to evaluate the services furnished to ensure the patient's needs are met for 4 of 4 patients sampled (Patients #1, #2, #6 and #7) receiving more than one visit by a licensed practical nurse during a 60…

The agency failed to ensure all documentation in the clinical record included a date, time, staff signature and staff title for 2 of 7 sampled patients (Patients #1 and #2).

The agency failed to ensure agency staff completed the comprehensive assessment at the start of care by the fifth day after the start of care for 2 of 5 sampled patients admitted after 3/1/17 (Patients #6 and #7).

The agency failed to ensure the completion of all pertinent components of the update to the comprehensive assessment at recertification in the last 5 days of each certification period for 5 of 7 sampled patients requiring a recertification (Patients #1, #2, #3, #4 and #7).

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 2 sampled patients requiring a discharge comprehensive assessment (Patient #7).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all medications used by the patient for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #5 and #6).

The agency failed to update the Plan of Care with all new physician orders for 4 of 5 sampled patients (Patients #1, #2, #6 and #7) with interim physician orders (orders obtained during a certification period).

The agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 2 of 7 sampled patients (Patients #1 and #5).

The agency failed to ensure 6 of 8 sampled home health aides (Staff E, J, K, L, M and N), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 2 of 4 sampled patients (Patients #2 and #5) with home health aide services, had documented evidence of…

The agency failed to ensure agency staff maintained documentation which verified how the home health aides completed competency evaluations in all basic home health aide skills for 3 of 4 sampled home health aides (Staff E, F and L) hired since the last survey (3/1/17) and for competency…

The agency failed to ensure the documentation of annual on-site supervision to the location where the patient is receiving care in order to assess each home health aide while the aide is performing patient care for 2 of 5 sampled home health aides (Staff M and N) employed with the agency for at…

The agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 4 of 7 sampled patients (Patients #1 and #4).

The agency failed to complete and send a transfer summary to the physician or other health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of knowledge of the occurrence of the transfer for 2 of 2 sampled patients requiring a…