Visiting Home Nurses, Inc

The agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for one of seven sampled patients (Patient 4).

The agency failed to ensure a review of all the medications the patients were taking was conducted for one of seven sampled patients (Patient 1) when the Medication Profile (MP), indicated: a.

The agency failed to ensure the patients' clinical record included all the physician's orders for one of seven sampled patients (Patient 1) when Patient 1's referral order was not in Patient 1's clinical record.

The agency failed to ensure the clinical record contained a completed discharge summary sent to the Primary Care Practitioner (PCP) within five business days of the patient’s discharge for one of seven sampled patients (Patient 6).

The home health agency (HHA) failed to document performance improvement projects (PIP-a concentrated effort on a particular problem in one area of the agency or agency wide, it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the HHA had…

The home health agency (HHA) failed to follow their policy and procedure when the HHA did not track and document the COVID-19 ( a respiratory disease which causes difficulty in breathing) vaccination status of staff who received COVID 19 vaccines and boosters doses.

The home health agency (HHA) failed to ensure the Skilled Nurse (SN) had the correct size of Foley catheter (a tube inserted into the bladder to drain urine) for one of seven (7) sampled Patients (Patient 5) when Patient 5’s Foley catheter was dislodged and the SN did not have replacement.

The home health agency (HHA) failed to provide information on how to access auxiliary aids and language services to one of 7 sampled Patients (Patient 5) when Patient 5 and Patient 5's Caregiver (CG) were Spanish speaking.

The agency failed to ensure a review of the medications was conducted for patients in the home for two (2) of seven (7) sampled patients (Patients 6 and 7) 1. For Patient 6, the medication, Ferrous Sulfate (a medication used to treat and prevent iron deficiency anemia), on the medication profile…

The agency failed to obtain criminal background checks on employees who have direct patient contact and/or access to patient records for six (6) of nine (9) employee files reviewed, (Registered Nurses 1,2,and 3, Licensed Vocational Nurse 1 and 2, Masters of Social Work 1).

The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials…

The agency failed to ensure that the Condition of Participation: G 510 484.55 Comprehensive Assessment of Patients was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's…

The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts to maintain an integrated response during a disaster or emergency in a universe of 53 patients.

The agency failed to develop procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, in a universe of 53 patients.

The agency failed to develop a back-up plan in the event of communications (phone service) failure during a disaster or emergency, in a universe of 53 patients.

The agency failed to develop a policy and procedure to provide information about the agency's occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, in a universe of 53 patients.

The agency failed to provide training to all staff, as well as contracted staff, on the emergency preparedness policies and procedures, in a universe of 53 patients.

The agency failed to develop policy and procedures on conducting full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation…

The home health agency failed to ensure the Standard G 512 484.55(a): Initial assessment visit was in compliance.

The Home Health Agency failed to ensure the Standard G 526 484.55(c): Content of the comprehensive assessment was in compliance.

The home health agency failed to ensure the Standard G 544 484.55(d): Update of the comprehensive assessment was in compliance.

The agency failed to document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken…

The home health agency failed to ensure the Standard G 1010 484.110(a): Contents of clinical record was in compliance.

The agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for one (1) of seven (7) sampled patients (Patient 1).

The Home Health Agency (HHA) failed to ensure medication was reconciled during the recertification assessment for one (1) of seven (7) patients (Patient 5).

The agency failed to update the comprehensive assessment with a discharge summary completed by a Registered Nurse for one (1) of seven (7) sampled patients (Patient 1).

The agency failed to provide a transfer summary to the new home health agency receiving a patient for care for one (1) of seven (7) sampled patients (Patient 2).