Tender Home Health

The agency failed to ensure a Registered Nurse (RN) provided written patient care instructions to the home health (HH) aide for one of 8 sampled patients provided HH aide services (Patient 9).

The agency failed to ensure an ongoing interdisciplinary assessment or case conference participated by the registered nurse (RN), physical therapist (PT), and certified home health aide (CHHA) was conducted every 30 days according to the HHA policy and procedure for one of eight patients (Patient…

The Home Health Agency (HHA) failed to coordinate the oxygen therapy care and management with the durable medical equipment company (DME) for 1 of 8 sample patients receiving oxygen therapy (Patient 9).

The home health agency (HHA) failed to follow the plan of care (POC) for one of three sampled patients (Patient 1).

The facility failed to meet the Condition of Participation for Patient rights by failing to: Provide an advance written information to the patient before initial treatments were provided for two of 17 sampled patients, Patients 1 and 3. (Refer to G-410)Provide an advance written notice of the…

The Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: HHA failed to conduct an initial visit within 48 hours of the patients return home for 2 of 17 (Patient 7 and 8).

The Home Health Agency (HHA) failed to meet the Condition of Participation for Care planning, Coordination, and Quality of care as follows: HHA failed to ensure 6 of 17 sampled patients (Patients 1, 8, 9, 10, 11 and 12), received care according to their plans of care (G572).

This CONDITION was not met: Based on interview and record review, the agency failed to develop, implement, evaluate and maintain an effective and ongoing QAPI (Quality assessment and performance improvement) program to ensure the program reflects the complexity of its organization and services…

The HHA and its staff failed to disclose and inform the Department of Public Health or the survey team of their on-line staffing business which is located at same place as the home health agency.

The HHA failed to ensure information contained in the clinical records were accurate, adhered to current clinical record documentation standards of practice (refer to G1020, 1022, and 1024).

The HHA failed to ensure the OASIS data accurately reflected the patient’s condition at the time of assessment for 1 of 17 sampled patients (Patient 2).

The HHA failed to provide an advance written notice of transfer and discharge rights during the initial evaluation or prior to providing care for two of 17 sampled patients, Patients 1 and 3. This deficient practice had the potential that patient’s needs will not be properly assessed and determined…

The HHA failed to send all necessary medical information to the receiving health care practitioner of the patient's transfer to another service for 1 of 17 patients (Patient 3).

The facility failed to ensure each patient received treatments or services in accordance with the written plan of care for 6 of 17 sampled patients (Patient 1, 8, 9, 10, 11, and 12) by failing to: Ensure Patient 1 received treatments on the patient’s stage 4 pressure sores (deep wounds that reach…

The HHA failed to provide written information regarding the plans of care for 2 of 17 patients (Patient 1 and Patient 3). a.

The HHA failed to have the QAPI program that include procedure for measurement and analysis of indicators and address the frequency which measurement and analysis.

The HHA failed have the evidence to show that the HHA's governing body approved the frequency and detail of the data collection done by the HHA's QAPI program.

The HHA's governing body failed to be responsible for ensuring the following: (1) an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of…

The Home Health Agency (HHA) failed to ensure the Plan of Care was signed by the Physician for 7 of 17 sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7).

The HHA failed to provide an advance written information to the patient before the initial treatments were provided for two of 17 sampled patients, Patients 1 and 3. This deficient practice had the potential that patient’s needs will not be properly assessed and can potentially affect the quality…

The home health agency (HHA) failed to provide an advance written notice of the patient's bill of rights in a language easily understood to three of 17 sampled patients, Patients 1, 3, and 8. The deficient practice can result to patients and representative not understanding their rights and…

The home health agency (HHA) failed to provide their contact information including the administrator’s name, business address, and business phone number to receive complaints for 2 of 17 sampled patients, Patients 1 and 3. This deficient practice had the potential that patients under the home…

The HHA failed to obtain the signature of the patient or legal representative to confirm that they had received a copy of the notice of rights and responsibilities for two of 17 sampled patients, Patients 1 and 3. This failure had the potential that the affected patients and the other patients…

The home health agency (HHA) failed to provide services as indicated in the plan of care for three of 17 sampled patients, Patients 1, 5 and 8. This deficient practice can affect the quality of care provided to the patients and can result to a delayed healing due to missed treatments. b.

The HHA failed to conduct an initial assessment visit within 48 hours of the patients return home for 2 of 17 (Patient 7 and 8).

The HHA failed to ensure the comprehensive assessment accurately reflected the patient’s continuing need for home care for 2 of 17 sampled patients (Patient 2 & 10).

The home health agency failed to ensure the patients social needs were assessed and evaluated by a social worker for one of 17 sample patients (Patient 9).

The HHA failed to review and document all the medications the patient is currently using for 2 of 17 sampled patients (Patient 5 and Patient 6).

The HHA failed to document the information about the patients primary caregiver in the comprehensive assessment for 4 of 17 sampled patients (Patients 1, 4, 5, and 7). a.

The HHA failed to update the comprehensive assessment to when a change of condition occurred for 3 of 17 sampled patients (Patients 2, 3, and 5).

The HHA failed to ensure a comprehensive assessment at discharge would include a summary of the patient's progress in meeting the care plan goals for 2 of 17 sample patients ( Patients 11 and 12).

The HHA failed to include information required in the plan of care for 6 of 17 sampled patients (Patients 1, 8, 9, 10, 11, and 12).

The HHA failed to administer drugs, services, and treatments as ordered by the physician for 2 of 17 sampled patients (Patients 3 and 4). a.

The facility failed to ensure the physician was notified of treatments not provided to 6 of 17 patients (Patients 1, 8, 9, 10, 11, and 12).

The HHA failed to manage the pain during wound treatment for 1 of 17 (Patient 1) patients.

The HHA failed to coordinate care delivery to meet the patient's needs and representative in coordination of care activities of patients for one of 17 patients (Patient 1).

The HHA's QAPI program failed to provide to the survey team with evidence that the agency had QAPI program that focus on high risk, high volume, or problem-prone areas.

The HHA's QAPI program failed to have evidence that the agency considered incidence, prevalence and severity of problem areas.

The HHA's QAPI failed to measure success and track performance to ensure that improvements were sustained.

The HHA failed to perform supervisory visits for Home Health Aide (HHA) services for 1 of 17 patients (Patient 3).

The HHA failed to document the contact information of the patients' primary physicians in the comprehensive assessment for 4 of 17 sampled patients (Patient 1, Patient 4, Patient 5, and patient 7).

The HHA failed to send all necessary medical information to the receiving health care practitioner when transitioning to another service for 1 of 17 sampled patients (Patient 3).