Stonerise Home Health

The facility failed to follow accepted standards of practice to prevent infection in one (1) of one (1) patient, (#9), observed during a peripherally inserted central catheter (PICC) line dressing change.

The facility failed to update or maintain their Emergency Management Plan with current required information.

The facility failed to maintain a clinical record with current information for every patient receiving services and failed to ensure the information was accurate and adheres to current clinical record documentation of standards of practice (See Tag 1012).

The facility failed to ensure the patient or patient's representatives were afforded the right to participate in their care with respect to the completion of all assessments.

The facility failed to ensure an initial assessment was conducted within forty-eight (48) hours.

The facility failed to ensure staff obtained a verbal order prior to providing services to the patient.

Physical therapy failed to provide services as ordered by the physician.

The facility failed to maintain a clinical record with current patient information, including clinical notes and physicians orders.

The facility failed to include advance directives including Cardiopulmonary Resuscitation (CPR) status in patient's plan of care (See Tags G 574 and G 576).

The facility failed to maintain an Emergency Preparedness communication plan.

The facility failed to conduct a functional Emergency Preparedness exercise every two (2) years.

The facility failed to include advance directives including Cardiopulmonary Resuscitation (CPR) status in the plan of care in six (6) out of fourteen (14) patients (patients #2, 4, 10, 11, 12, 13 and 14).

The facility failed to include Cardiopulmonary Resuscitation (CPR) orders in the plan of care (POC) in six (6) out of fourteen (14) patients (patients #2, 4, 10, 11, 12, 13 and 14).

The facility failed to ensure their skilled professional staff provided healthcare services that are ordered by the physician as indicated in the plan of care in four (4) of sixteen (16) clinical records reviewed (patients #5, 7, 12 and 14).

The facility failed to ensure nursing staff document the weekly skilled nursing visit assessment and services provided in one (1) of sixteen (16) clinical record reviewed (patient #6).

The facility failed to ensure nursing staff documented the weekly skilled nursing visit interventions and services provided in one (1) out of sixteen (16) clinical record reviewed (patient #6).