Traditions Health

The agency failed to meet the requirements for the Condition of Participation: Comprehensive assessment of Patients, when the agency failed to ensure: -The initial assessment visit must be held within 48 hours of referral, or within 48 hours of the patients return home, or on the physician or…

The agency failed to meet the requirements for the Condition of Participation: Care Planning, coordination of services, and quality of care when the agency failed to ensure: -Each patient must receive an individualized written plan of care including, but not limited to, all medications and…

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care, when the agency failed to show clinical manager oversight to patients resulting in an immediate jeopardy and three conditions of…

The agency failed to accurately reflect the patient's status and include relevant patient data in the comprehensive assessment in one (Record/Patient #3) of three home visit observations.

The agency failed to show that the clinical supervisor was responsible for assuring that the patient needs were continually assessed and the development, implementation and updates of the individualized plans of care were completed.

The agency failed to ensure all documented entries included legible, clear, complete, and appropriate authentication, dated and timed in, but not limited to, one (Record/Patient #3) of five full records reviewed.

The agency failed to ensure the patient received proper written notice, in advance of the home health agency (HHA) reducing or terminating on-going care in, but not limited to, one (Record/Patient #3) of three home visit observation.

The agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week) in the admission booklet.

The agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in three (Records/Patients #2, #3, and #5) of five full records reviewed.

The agency failed to ensure patient’s medical, nursing, rehabilitative, social, and discharge planning needs, were met in two (Records/Patients #3 and #5) of five records reviewed.

The agency failed to perform a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effect, significant drug interactions, duplicate drug therapy, and noncompliance with…

The agency failed to ensure the comprehensive assessment was updated at discharge including a complete medication review, in one (Record/Patient #3) of six records reviewed.

The agency failed to ensure an accurate and complete plan of care was developed in, but not limited to, three (Records/Patients #3, #4, and #5) of five full records reviewed.

The agency failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner in one (Record/Patient #1) of five full records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care (POC) should be altered, in two (Records/Patients #3 and #5) of five full records reviewed.

The agency failed to discuss/document notification to the patient of plans for discharge in one (Record/Patient #3) of six patients reviewed.

The agency failed to ensure coordination of care delivery to meet the patient's needs in two (Records/Patients #3 and #5) of five records reviewed.

The agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in one (Record/Patients #3) of three home visits.

The agency failed to ensure that physical therapy assistant (PTA) services were provided under the supervision of the physical therapist (PT) in one (Record/Patient #3) of five full records reviewed.

The agency may not train or competency evaluate their home health aides for a period of two (2) years following, the date of this survey.

The agency failed to ensure the administrator was available and/or responsible for all day to day operations of the agency.

The administrator (clinical manager and case manager) failed to provide oversight of patient care services that included, but not limited to, coordinating referrals in two (Records/Patients #3 and #5) of five full records reviewed.

The agency failed to ensure that master's degree social worker or supervised social work assistant was available as required by regulation to all patients served by the agency.

The agency failed to ensure that should MSW services be ordered or the need for MSW services assessed, these services would be available according to patient rights for all patients served by the agency.

Complaint log review and interview the agency failed to document the investigation and resolution of two (Complaints #1 and #2) of three complaints received.

The agency failed to develop a complete plan of care (POC) to include the assessment/documentation of daily weights and specific parameters to report to the physician in, but not limited to, one (Record/Patient #4) of five records reviewed.

The agency failed to ensure that care was coordinated between all disciplines seeing the patient and the caregiver in, but not limited to, two (Records/Patients #2 and #4) of five charts reviewed.

The agency failed to ensure that all clinicians performed and documented ongoing interdisciplinary assessments in, but not limited to, one (Record/Patient # 4) of five records reviewed when physical therapy (PT) and occupational therapy (OT) clinicians failed to perform/document complete pain…