Three Rivers Health Homecare

The agency failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the start of care in 1 (P-8) of 8 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 4 (P-1, 2, 3, 8) of 8 records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients and assisting with…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any potential adverse effects and drug interactions in 5 (P-1, 2, 3, 6, 8) of 8 records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this…

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 4 (P-4, 5, 6, 7) of 8 records reviewed; safety precautions in 4 (P-2, 3, 6, 7) of 8 records reviewed; and covered all pertinent interventions with reportable parameters in 1 (P-7) of 8 records…

The agency failed to ensure the clinical record contained all assessments from the most recent home health admission in 1 (P-8) of 8 records reviewed, resulting in the potential for unmet or overlooked care needs.

The Agency failed to ensure the transfer/discharge summaries were complete, detailed, and provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 2 (MR# 8, 9) of 2 records in which the…

The agency failed to ensure the Home Health Aide followed accepted standards of practice in Infection Control for 1 (MR #6) of 1 patient observed during a home visit, from a total of 10 records reviewed, resulting in the potential for the development and spread of infection.

The Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the Home Health Aide regarding client needs, visit frequency and frequency of tasks to be performed in 2 (MR#'s 6 and 9) of 3 records in which Home Health Aide services were ordered, from a total of…

The Agency failed to ensure that 3 (MR's #6, 7 and 8) of 5 patients observed during home visits, from a total of 10 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting…

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (MR# 9) of 3 patients who was discharged from the agency's services, resulting in the patient being denied the right to appeal…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, and failed to provided documented evidence that the physician was notified of identified drug interactions in 4 (MR's # 3, 7, 8, 9) of 10 sampled records reviewed…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 3 (MR's # 8, 9 and 10) records, from a total of 10 sampled records reviewed, resulting in…

The agency failed to ensure services were provided only as ordered by the physician in 1 of 10 (MR# 3) records reviewed, resulting in the potential for the provision of inappropriate care and services.

The agency failed to provide 3 (MR#'s 6, 7 and 8) of 3 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 10 sampled records reviewed, resulting in lack of…

The agency failed to ensure the professional staff provided ongoing reassessment in 1 of 3 records (MR# 4) in which the patient had Diabetes Type 2, out of a total of 10 records reviewed, which resulted in the potential for unidentified patient needs.

The registered nurse failed to supervise the home health aides' services no less frequently than every 14 days for 1 of 3 records reviewed (MR# 3) with home health aide services, for a potential of unmet and unsafe patient care.

The agency failed to ensure clinical notes were accurate for 1 of 10 (MR# 4) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The Agency failed to ensure the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 2 (MR# 8, 9) of 2 records in which the patient was…

The agency failed to ensure the initial assessment visit was conducted within 48 hours of the referral for 1 of 7 records reviewed (MR# 2), from a total sample of 7 records, resulting in the delay of nursing services; a delay in determining the patient's immediate care and support needs, and the…

Physical therapy failed to consult the physician to approve additions to the therapist's plan of care after completion of the evaluation in 2 of 6 records reviewed (MR#1 and 3) with Physical Therapy services out of a total sample of 7 records reviewed, for a potential of unmet goals, outcomes, and…

The Agency (HHA): failed to ensure the Registered Nurse (RN) prepared clear written patient care instructions that included safety precautions, in 1 of 2 Home Health Aide (HHa) records in which aide services were provided, from a total of 7 records reviewed, (MR #7) resulting in the inability of…

The Agency (HHA) failed to develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section.

The Agency (HHA) failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to…

The Agency (HHA) failed to provide documentation for the required annual tabletop and community based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan since its initiation in 2009, resulting in the potential to affect all patients and…

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 3…

Physical therapy failed to consult the physician to approve additions to the therapist's plan of care after completion of the evaluation in 2 of 6 records reviewed (MR#1 and 3) with Physical Therapy services out of a total sample of 7 records reviewed, for a potential of unmet goals, outcomes, and…

The agency failed to ensure the registered nurse (RN) provided care as ordered by the physician in the plan of care for 1 of 7 records reviewed (MR#4) in which care was provided by a skilled nurse, from a total sample of 7 records reviewed, resulting in a poor outcome for the patient.

The Agency (HHA) failed to ensure the Registered Nurse (RN #2) and Home Health Aide (HHa #2) followed accepted Infection Control standards of practice during the provision of care and services for 2 patients observed during a home visit, from a total of 7 sampled records reviewed (MR's #5, 7)…

The Agency (HHA) failed to ensure the Registered Nurse (RN) prepared clear written patient care instructions and included safety precautions, in 1 of 2 records in which Home Health Aide (HHa) services were provided, from a total of 7 records reviewed, (MR #7) resulting in the potential for the…

The agency failed to provide evidence of Governing Body meeting minutes that demonstrated documentation of the dates of the governing board meetings, the names of committee members, provided evidence of names of those responsible for the agency's overall management and operations of home health…

The agency failed to document resolutions to complaints lodged by patient's receiving care from the agency.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of the referral for 1 of 7 records reviewed (MR# 2), from a total sample of 7 records, resulting in the delay of nursing services; a delay in determining the patient's immediate care and support needs, and the…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine major drug interactions, any adverse effects, failed to document the findings of the drug regimen review as required, and failed to ensure the physician was notified of potential drug…

The Agency (HHA) failed to ensure that the comprehensive assessment (Discharge Oasis) was updated/completed at the time of discharge from the agency in 1 of 3 discharged records (MR#4), from a total of 7 sampled records reviewed resulting in an incomplete assessment of the patient's health status…

The agency failed to ensure the plan of care included reportable parameters; individualized interventions based on the patients initial assessment; and individualized measurable goals and outcomes in 7 of 7 records reviewed (MR#s 1, 2, 3, 4, 5, 6 and 7) for a potential of unmet goals, outcomes, and…

The agency failed to ensure all patient care orders, including and verbal orders, were recorded in the plan of care (POC) for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), and Home Health aide (HHa) services in 4 of 7 records reviewed with SN…

The Agency (HHA) failed to ensure the physician was promptly notified of the patient's weight loss/gain for 2 patients (MR#'s 6 and 1) who required weight and fluid retention monitoring, and 1 patient (MR #7) with complaints of unrelieved pain, and 1 patient (MR#4) with bradycardia from a total of…

The Agency (HHA) failed to include contact information for the Home Health Agency's Clinical Manager on the Plan of Care in 4 of 7 records reviewed (MR#s 1, 2, 3, 4), resulting in the potential for unaddressed patient concerns.

The agency failed to ensure the professional staff performed complete assessments and reassessments of the patient's health status including objectively measuring the patient's edema in 1 of 1 records reviewed in which the patient had fluctuating edema (MR#1); and objectively monitoring of weights…

The Agency (HHA) failed to ensure on-site supervisory visits to the patient's home were made in order to supervise the care provided by the Home Health Aide for 2 of 2 records with Home Health Aide (HHa) services ordered, from a total of 7 sampled records reviewed (MR#s 2 and 7) resulting in the…

The Agency (HHA) failed to ensure the skilled discipline made an annual joint onsite observation visit at the patient's residence to observe the care being provided, for 3 of 3 Home Health Aides (HHa's 1, 2, and 3) employed by the Agency, resulting in the potential for the provision of substandard…

The agency failed to ensure the clinical record was complete, submitted timely, and included all assessments and clinical notes in 1 of 7 records reviewed (MR# 2) out of a total of 7 sampled records reviewed for occupational therapy and speech therapy, resulting in an incomplete clinical record…

The SN discharge summary, dated 1/25/18, was vague and did not address any of the above diagnoses or assessments and documented, "Patient seen surgeon last week..., Not driving yet but will soon..., Coumadin being monitored by Coumadin clinic..., Lives with wife who is very attentive..." There was…