Summit Home Health

The Agency failed to develop an emergency preparedness plan that had been reviewed and updated, at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency.

The Agency failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care and services for 2 (P-1 and P-8) of 5 patients observed during home visits, from a total of 13 sampled records reviewed, resulting in the potential for the development and…

The Agency failed to provide documented evidence that Infection Control education was provided to all staff employed by the agency, including contracted staff, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by this agency.

The Agency failed to ensure Occupational Therapy (OT) services were authorized only by the health care professional qualified to do so in 4 (P-5, P-6, P-9 and P-12) of 13 sample records reviewed resulting in a lack of appropriate skilled assessment, and the potential for unmet needs of the patient.

The agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 1 (P-1) of 1 patient observed during a home visit, who required assistance with grooming, from a total of 13 sampled records reviewed, resulting in the potential for loss of…

The agency failed to ensure the plan of care was complete and included all the required diagnoses, interventions and associated measurable goals to address the identified needs of the patient in 1 (P-1) record of a patient who required specialized care and monitoring from a total of 13 sampled…

The Agency failed to ensure verbal physician orders were accepted only by personnel authorized to do so according to agency policy in 1 (P-8) of 13 sample records reviewed resulting in unqualified personnel receiving physician referral orders and potentially resulting unmet needs for the patient.

The Agency failed to ensure the patient received services as ordered by the physician and indicated in the plan of care for 3 (P-1, P-7, P-12) of 13 sampled records reviewed potentially resulting in unmet care needs for the patient.

The agency failed to ensure a completed Discharge/Transfer summary was sent to the Physican within the required time frame, for 2 (P-3, P-7) patients who were either transferred to an inpatient facility or discharged from the agency's services, from a total of 13 sampled records reviewed, resulting…

The Agency failed to ensure Skilled Nursing, Occupational Therapy and Medical social Work services were provided as ordered in 1 (MR# 4) of 5 records reviewed, resulting in the potential for physical and psychological decline and unmet care needs.

The agency failed to ensure the Physical Therapists, Speech Therapist, Occupational Therapists and Medical Social Work assisted the Physician in evaluating the patient's level of functioning and helped to develop the Plan of Care for 5 (MR#'s 4, 5, 7, 11 and 12) of 7 patients reviewed with ordered…

The agency failed to have the individualized written plan of care signed by the physician for 3 of 13 records reviewed (MR# 8, 10 and 11), resulting in services and care being provided by the agency without a physician’s signature.

The Agency failed to ensure all clinical record entries were appropriately signed and authenticated, including the names and titles of the disciplines who authored the documents, in 7 (MR#'s 1, 2, 3, 4, 5, 6 and 7) of 7 records, from a total of 13 sampled records reviewed, resulting in the…

The Agency failed to ensure that 4 (MR's #1, 4, 5 and 6) of 4 patients observed during home visits were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 13 sampled records reviewed…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 6…

The agency failed to provide 3(MR#'s 1, 4 and 6) of 5 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, from a total of 13 sampled records reviewed, resulting in lack of…

The agency failed to ensure the Physical Therapists, Speech Therapist, Occupational Therapists and Medical Social Worker assisted the Physician in evaluating the patient's level of functioning and helped to develop the Plan of Care for 5 (MR#'s 4, 5, 7, 11 and 12) of 7 patients reviewed with…

The Agency failed to ensure Skilled Nursing, Occupational Therapy and Medical social Work services were provided as ordered in 4 (MR#'s 1, 4, 5, and 7) of 7 records reviewed, from a total of 13 sampled records reviewed, resulting in the potential for poor hygiene, physical and psychological decline…

The Agency failed to ensure the clinical record was completed and included detailed Physical Therapy and Skilled Nursing notes for 2 (MR #7 and 9) of 2 records with the ordered services, from a total of 13 sampled records reviewed, resulting in the potential for undocumented, unidentified health…

The Agency failed to provide documented evidence that the discharge summaries were complete and forwarded to the Physician within 5 days of the date of discharge for 5 (MR# 4, 10, 11, 12 and13) of 5 records in which the patient was discharged from services, from a total of 13 records reviewed…

The agency (HHA) failed to ensure the plan of care (POC) covered all pertinent treatments, and interventions with reportable parameters and measurable goals specific to the needs of the patient, for 3 records (MR's #9, 10 and 11), from a total of 17 sampled records reviewed, resulting in patients'…

The Agency (HHA) failed to ensure that the individuals who furnished Home Health Aide (HHa) services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse (RN), who observed the Aide's performance of the tasks…

The Home Health Agency (HHA) failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document their efforts in contacting these officials…

The Agency failed to include in its emergency plan the procedures needed to follow-up with staff and patients to determine services that are needed in the event services are interrupted due to an emergency and to inform state and local authorities of any on-duty staff or patients that the Agency is…

The Agency failed to have policies and procedures for the use of volunteers and other staffing strategies in its emergency plan, resulting in no directives in the event volunteers are utilized during an actual emergency.

The Agency failed to develop and maintain a communication plan that coordinated patient care within the Agency, across healthcare providers and with State and local emergency preparedness managers, resulting in compromising the Agency's ability to protect patient health and safety in the event of…

The Registered Nurse (RN #1) failed to provide care and services in conformance with the Physician's orders in 1 (MR #11) of 3 records, of a patient who required wound care, from a total of 17 sampled records reviewed, resulting in the potential for worsening of wound, development and spread of…

The Agency (HHA) failed to ensure that the individuals who furnished Home Health Aide (HHa) services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse (RN), who observed the Aide's performance of the tasks…

The agency (HHA) failed to ensure that 2 of 3 Home Health Aides (HHa's #2, and #3) employed by the Agency, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The agency failed to ensure skilled nursing (SN) prepared written patient care instructions that included safety precautions in 5 (MR #3, 6, 8, 16, and 17) of 7 records in which Home Health Aide (HHa) services were provided, from a total of 17 sampled records reviewed, resulting in the potential…

The agency (HHA) failed to ensure the plan of care (POC) covered all pertinent treatments, and interventions with reportable parameters and measurable goals specific to the needs of the patient, for 3 records (MR's #9, 10 and 11), from a total of 17 sampled records reviewed, resulting in patients'…

The Agency (HHA) failed to ensure all patient care orders were recorded in the plan of care (POC) for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST), and Home Health aide (HHa) services in 3 records (MR's #12, 14 and 15) with…

The agency (HHA) failed to ensure that personnel furnishing services, maintained liaison and communications in 2 records (MR #8, 16) in which Home Health Aide (HHa) services and Master of Social Work (MSW) services were continued after discharge from Agency services, from a total of 17 sampled…