Up Health System Home Care and Hospice Portage

The agency failed to include objectively measurable goals on the plan of care for 5 of 10 records reviewed (P-1, P-2, P-4, P-8, P-10) resulting in the inability to determine the patient's progress towards obtaining the goals.

The skilled nurse failed to provide baseline data in the Comprehensive Assessment to use in determining if the patient's Diabetes was improving or worsening with each visit assessment during the course of care in 1 of 7 records reviewed (P-3).

The agency failed to ensure the skilled professionals provided services as ordered by the physician in the plan of care for 1 (P-8) of 10 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure a transfer summary was sent to the receiving facility within 2 days of becoming aware of an unplanned transfer for 1 of 1 (P-6) records reviewed in which the patient was transferred, and failed to ensure a discharge summary was sent to the physician within 5 business…

The agency failed to contact the physician in 1 of 10 records reviewed (P-10) for wound care, from a total of 10 records reviewed, resulting in the potential for unresolved healthcare concerns.

The Agency failed to ensure the Registered Nurse (RN) prepared complete written instructions for patient safety needs in 3 of 4 records in which aide services were provided, from a total of 10 records reviewed, (MR's #2, 8, 9) resulting in the potential for unsafe, substandard care and unmet care…

The agency failed to ensure patients were informed in advance of the disciplines that will furnish care and the proposed visit frequency in 9 of 10 (MR# 2, 3, 4, 5, 6, 7, 8, 9, 10) records reviewed, resulting in these patients not having knowledge regarding their plans for treatment.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 3 of 10 (MR# 8, 9, 10) records reviewed, resulting in incomplete clinical information to aid in determining the needs of this patient and for measuring the patient's progress toward…

The agency failed to ensure the goals on the plan of care were patient specific and measurable in 10 of 10 records reviewed (MR# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) out of 10 total records sampled; and failed to include pertinent safety precautions and reportable parameters on the plan of care in 5 of…

The agency failed to ensure the Home Health Aide provided services only as ordered by the physician in 1 of 8 records (MR's #16) out of a total sample of 17 records, which resulted in the Home Health Aide providing services not ordered by the physician.

The agency failed to ensure the discharge summaries included the patient's status, specific care provided and response/outcomes in 2 of 3 discharged records (MR# 3, 6) ), resulting in the potential for unmet post-discharge needs.

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 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 failed to ensure the RN (registered nurse) prepared written patient care instructions alerting the home health aide (HHa) to the safety precautions that were applicable to each patient, for 4 of 7 records reviewed (MR#'s 3, 6, 9 and 10) in which HHa services were provided, from a total…

The Home Health Agency failed to advise their patients of the hours of operation for the state's toll free hot line number, for the 86 current active patients that are receiving services by the home health agency, for the potential of the state agency to not receive complaints or questions…

The home health agency failed to advise the 86 current active patients of the names, addresses, and telephone numbers of the Federally-funded and state-funded entities that service the area where their patients resides.

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; and…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable and all safety measures were included on the Plan of Care in 4 of 10 records reviewed (M.R.#s 6, 7, 9 and 10), resulting in the potential for a plan of care not meeting the patient's needs.