Ssm Health at Home Home Health-St. Louis

The home health provider failed to ensure that the initial assessment visit was held within 48 hours of referral or within 48 hours of the patient's return home in three of five full records reviewed (Records/Patients #1, #2, and #3).

The home health provider failed to review all of the medications the patient was currently using in, but not limited to, one of three home visit observations conducted (Record/Patient #3).

The home health provider failed to ensure the plan of care (POC) was individualized and included the services, supplies, and equipment required for the patient in, but not limited to, two of five full records reviewed (Records/Patients #1 and #2).

The home health provider failed to ensure that a copy of written instructions outlining the visit schedule, including frequency of visits, was provided to the patient in two of three home visits conducted (Records/Patients #1 and #2).

The home health provider failed to provide the patient with a copy of written instructions outlining the patient’s dressing changes, ostomy appliance changes, urinary catheter changes, and therapy home exercise program in two of three home visit observations conducted (Records/Patients #1 and #2).

The agency failed to ensure that staff are fully vaccinated for Coronavirus Disease 2019 (COVID-19) (infectious disease) in one employee (E1) of three employee files reviewed.

The agency failed to promptly alert the physician to changes in the patient's needs that may suggest the plan of care (POC) should be altered in one (Record/Patient #1) of four records reviewed.

The agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one (Record/Patient #2) of four records reviewed.

The agency failed to ensure staff, reviewed all medications the patient is currently using in order to identify any potential adverse effects and drug reactions in two (Record/Patient #1 and #2) of three home visit records reviewed.

The agency failed to ensure staff promptly notified the physician for a change of condition of one (Record/Patient #3) of three applicable home visits.

The agency failed to ensure staff provided a written visit schedule to patients that included what discipline(s) were visiting, and the frequency of visits in two (Record/Patient #1 and #2) of three home visits.

The agency failed to provide the patient/caregiver with a copy of written and/or updated instructions outlining the patient's medication schedule/instructions, including name of the medication, dosage, and frequency in two (Record/Patients #1 and #2) of three home visit observations.

The agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in one (Record/Patient #3) of three home visit observations.

The agency failed to provide Alzheimer's disease training prior to the State COVID-19 waiver dated April 22, 2020, to one employee (Employee/E2) of four employee files reviewed.

The agency failed to ensure: - A completed transfer summary was sent within five business days of a discharge in one (Record/Patient #4) of two closed records reviewed; and - A completed comprehensive discharge summary to include all necessary components was sent to the primary care practitioner or…

The agency failed to document adequate discharge planning and education for one (Record/Patient #2) of one discharge record reviewed.

The agency failed to follow agency policy and procedures for infection control in, but not limited to, one (Record/Patient #1) of three home visit observations.

The agency failed to ensure their staff followed the plan of care in, but not limited to, one (Record/Patient #2) of five records reviewed.

The agency failed to notify the physician of changes in the patient's needs and/or follow-up with the physician to determine if changes to the plan of care (POC) were indicated in one (RECORD/PATIENT #4) of five records reviewed.

The agency failed to ensure all home health aides successfully completed all portions of the Missouri Home Health Aide Competency Evaluation (Part 2) Basic Skills Test prior to being assigned patient care in, but not limited to, one (Aide A) of two aide personnel files reviewed.

The agency failed to ensure the registered nurse (RN) assessed and documented an accurate and complete medication list, performed an accurate drug regimen review, or educated patients regarding high risk medications as part of the comprehensive assessment in, but not limited to, one (Record/Patient…