Trinity River Valley Home Health

The agency failed to ensure the assessment for the Physician ordered weight goal was completed as ordered in 1 (#2) of 14 (#1-#14) clinical records reviewed.

The Agency failed to assure all medications were included in a comprehensive medication review to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with…

The Agency staff did not follow the attending physicians orders contained in the Plan of Care (POC) for 4 (#6, #10, #11 and #12) of 13 (#1-#13) clinical records reviewed.

The Occupational Therapy (OT) staff failed to conduct OT Evaluations within 5 days of the Start of Care (SOC) as part of the Comprehensive Assessment in 1 (#6) of 5 (#1,#6, #7, #9 and #10) Clinical Records reviewed with orders for OT services.

Therapy Services failed to adhere to the Agency process to ensure written information specific to the patients Plan of Care (POC) was provided to patients or caregivers in 2 (#5 and #6) of 3 (#5, #6 and #7) visits conducted in the home with orders for Therapy services.

The Skilled Nurse (SN) did not provide services related to weights and blood glucose as ordered by the Physician on the Plan of Care (POC) for 3 (#2, #4 and #8) of 10 (#1-#10) Clinical Records reviewed.

Therapy staff did not participate in the Agency's Quality Assurance Performance Improvement (QAPI) Program.

The Registered Nurse (RN) failed to provide timely oversight of the Home Health Aides (HHA) through on-site Supervisory Aide Visits (SAV) every 14 days in 1 (#6) of 3 (#6, #8 and #9) Clinical Records reviewed with orders for HHA services.

The Agency staff failed to ensure documentation of care coordination and communication between the healthcare team members and documentation of all medications currently used by the Patient in 2 (#2 and #8) of 10 (#1 - #10) Clinical Records reviewed.