Wayne County Public Health Nursing Service

The agency failed to ensure the development of a policy and procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation.

The agency failed to ensure training in emergency preparedness to existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 4 of 4 sampled employees (Staff A regular employee and Staff D, F, G contracted staff).

The agency failed to conduct and/or document any exercises to test their emergency plan in 2022 and 2023. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency.

The agency failed to ensure 1 of 3 sampled home care aides (Staff D), completed a home health aide training program that addressed all areas identified in the Medicare Conditions of Participation.

The agency failed to ensure accurate and through completion of pertinent components of the initial comprehensive assessment for 2 of 3 sampled patients with wounds at start of care.

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 8 sampled patients (Patients #1, #2, #4).

The agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 4 of 4 sampled patients with new verbal/interim orders.

The agency failed to authorize in writing by the administrator and the governing body a qualified pre-designated person who assumes the same responsibilities and obligations as the administrator.

The agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who…

The agency failed to ensure the clinical record included documentation staff developed, reviewed and/or revised the patient's individualized emergency plan as part of each comprehensive assessment for 2 of 7 sampled patients (Patients #4 and #5), and the agency failed to ensure the emergency plan…

The agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation.

The agency failed to ensure the written emergency preparedness plan included procedures to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency.

The agency failed to ensure training in emergency preparedness for 4 of 4 contracted therapy staff (all contracted since prior to the last survey, dated 1/3/18), 3 of 3 current contracted home health aide staff, 2 of 2 terminated contracted home health aide staff (both terminated in 2020) and 3 of…

The agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 1 of 1 sampled patients with medication set up (Patient #2).

Agency policy review and staff interview the hospice failed to ensure all clinical entry notes included a staff signature with title for 5 of 7 sampled patients (Patients #1, #2, #3, #5 and #6).

The agency failed to ensure agency staff completed the comprehensive assessment at the start of care by the fifth day after the start of care for 2 of 7 sampled patients (Patients #3 and #6).

The agency failed to perform complete and accurate drug regimen reviews with corresponding comprehensive assessments for 1 of 3 sampled patients (Patient #3) with a home visit observation.

Agency clinicians failed to complete updates to the comprehensive assessment at recertification in the last 5 days of each certification period for 2 of 3 sampled patients requiring a recertification assessment (Patients #2 and #4).

The agency failed to ensure the timely completion of all pertinent components of the update to the comprehensive assessment at the resumption of care within 48 hours of the agency's knowledge of the patient's return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption…

The agency failed to ensure agency staff accurately completed all components comprising the Plan of Care, including identifying all supplies/equipment used by the patient for 3 of 7 sampled patients (Patients #1, #3 and #4).

The agency failed to update the Plan of Care with all new physician orders for 4 of 6 sampled patients with interim/verbal orders.

The agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address).

The agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions, assigned tasks and maintained pertinent current information in the patient record for 2 of 7 sampled patients (Patients #6 and #7).

The agency failed to: 1) maintain adequate documentation of compliance with the regulation for home care aides (G210); 2) ensure all staff providing hands on personal care/home health aides received a performance evaluation at least every 12 months (G214); 3) ensure all contracted staff providing…

4. Patient #7 had a start of care date of 5/25/11. The clinical record contained a Recertification comprehensive assessment, dated 12/18/17, which lacked evidence of completion of a risk assessment for emergencies.

The home health agency failed to ensure training in emergency preparedness policies and procedures to all staff and individuals providing services under arrangement.

The agency failed to ensure patients received clear verbal and written identification of any potential out of pocket expenses the patient could expect to pay for services prior to the initiation of home care services for 4 of 10 sampled patients who were admitted to the agency after the last survey…

The agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice for 1 of 5 patients with home visit observations during the survey (Patient #1).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care and/or failed to ensure the Plan of Care contained current, accurate information for 9 of 10 sampled patients (Patients #2, #3, #4, #5, #6, #7, #8, #9 and #11).

The agency failed to administer medications and treatments only as ordered by the physician for 2 of 10 sampled patients (Patients #3 and #9).

The agency failed to ensure registered nurses provided care as ordered by the physician in the Plan of Care for 7 of 10 sampled patients receiving a skilled nursing service (Patients #1, #2, #3, #5, #8, #9 and #11).

The agency failed to ensure the agency's nurses adequately reevaluated the patient's status and response to care, in order to provide appropriate individualized care for 3 of 5 sampled patients with an open wound (Patient #2, #8 and #9).

The agency failed to ensure that registered nurses coordinated between other services offered by the home health agency and with physicians for 5 of 10 sampled patients (Patients #3, #4, #5, #7 and #8).

The agency failed to document whether extra skills competencies were evaluated in a laboratory setting using a pseudo patient or in a home setting while being performed on an actual patient for 5 of 5 sampled contracted home health aides (Staff F, G, H, I and J).

The agency failed to ensure 5 of 5 sampled home health aides (Staff F, G, H, I and J), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 4 of 5 sampled patients (Patients #4, #7, #8 and #9); had documented evidence of competency by a registered…

The agency failed to ensure the completion of a performance review of each contracted home health aide no less frequently than every 12 months for 4 of 4 sampled aides providing care to agency patients for more than 1 year (Staff F, G, I and J).

The agency failed to provide individualized and specific written patient care instructions from a registered nurse to agency home health aides for 4 of 5 sampled patients receiving home health aide services (Patients #3, #4, #7 and #8).

The agency failed to ensure home health aides provided services according to the home health aide written assignment for 4 of 5 sampled patients (Patients #4, #7, #8 and #9) receiving aide services.

The agency failed to transmit accurate Outcome Assessment and Information Set (OASIS) data items collected with each comprehensive assessment for 6 of 8 sampled patients who required the transmission of OASIS data (Patients #1, #2, #3, #4, #9 and #11).

The agency failed to ensure accurate completion of all pertinent components of the start of care comprehensive assessment within the required time frame for 4 of 9 sampled patients (#3, #4, #9 and #11) with a start of care date after the last survey (2/19/15).

The agency failed to ensure completion of all pertinent components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 2 of 5 sampled patients requiring a recertification assessment (Patients #3 and #9).

The agency failed to ensure accurate completion of all pertinent components of the transfer comprehensive assessment with OASIS (Outcome and Assessment Information Set) data within the required time frame for 1 of 3 sampled patients who required completion of a transfer assessment (Patient #8).

The agency failed to assure the start of care, resumption of care, recertification and discharge comprehensive assessments with Outcome and Assessment Information Set (OASIS) included an integration of the OASIS data set into the agency's own comprehensive assessment in a clinically meaningful…