Southwest VA Home Health Care

The agency failed to ensure patients were informed about and consented to the frequency of proposed visits in advance of starting care for one (1) of seven (7) clinical records in the survey sample (Clinical record # 1).

The agency failed to ensure the initial assessment for each patient was completed within 48 hours of the referral/inpatient discharge for one (1) of seven (7) clinical records in the survey sample (Clinical record #1).

The agency failed to ensure that each patient's individualized plan of care included all required elements for seven (7) of seven (7) clinical records in the survey sample (Clinical Records #1, #2, #3, #4, #5, #6, and #7) Findings: Seven (7) clinical records were reviewed in the agency on…

The agency failed to ensure the patient's individualized plans of care included a qualifier for PRN (as needed) orders and/or medications included on the patient's plan of care and supplemental verbal orders for ten (10) of ten (10) clinical records reviewed in the survey sample.

The patient's medication profiles failed to include the reason the as needed [PRN] medications should be administered for six (6) of ten (10) clinical records in the survey sample.

The agency failed to ensure each home health aide supervisory visit conducted contained documentation the Registered Nurse evaluated each of the six (6) required elements to ensure aides furnished care in a safe and effective manner for four (4) of four (4) clinical records of patient's receiving…