Sterling Medcare Home Health Inc

The agency failed to ensure the individualized plan of care included complete orders for interventions or treatments, in 1 of 1 patients receiving Foley (urinary) catheter care (Patient #5).

The agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician in 5 of 7 patient records reviewed (Patients #1, #2, #3, #6 and #7).

The agency failed to ensure each patient received home health services in accordance with a written plan of care established and periodically reviewed by a physician.

The agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 1 of 1 patient records reviewed who received certified nurse aide (CNA) services (Patient #4).

The agency failed to implement a quality assessment and performance improvement (QAPI) which evaluated all agency services and complied with the requirements and standards set forth in CFR 484.65. The failure created the potential for the agency to overlook trends which affected the quality of…

The agency failed to provide emergency preparedness training at least annually.

The agency failed to ensure each patient received home health services in accordance with a written plan of care established and periodically reviewed by a physician.

The agency failed to ensure services and treatments were provided in conformance with physician's orders for 1 of 2 active patient records reviewed requiring lab work to be drawn (Patients #5).

The agency failed to ensure the registered nurse (RN) or other appropriate skilled professionals prepared and updated patient-specific written care instructions for the home health aide (HHA)/certified nurse aide (CNA) for 2 of 2 patient records reviewed where the patient was receiving CNA services…

The agency failed to ensure a comprehensive assessment was completed no later than five calendar days after each patient's start of care for 1 of 7 patient records reviewed (Patient #1).

The agency failed to ensure home health aides (HHAs)/certified nursing aides (CNAs) provided services included in the Plan of Care as ordered by the physician for 1 of 2 patients who required CNA services (Patients #3).

The Administrator failed to adequately and effectively organize and direct the agency's day-to-day operations.

Based in interview and record review, the agency failed to ensure clinical records contained a current comprehensive assessment, accurate documentation of patient's clinical notes and plans of care for 4 of 7 patient records reviewed (Patients #1, #4, #5 and #7).

The agency failed to ensure a completed discharge summary was provided within five business days to the physician responsible for the care of the patient in 1 of 1 discharged patients reviewed (Patient #6).