Yadkin Valley Home Health

Staff interview the agency failed to follow the plan of care for assessing vital signs for 2 of 22 records reviewed (#3 and #6).

The agency failed to review all current medications for 1 of 2 home visits (#14).

The agency failed to assist the patient to find provider to meet needs when the patient was identified as needing a higher level or care for 1 of 1 patient discharged due to needing a higher level of care [#4]. The findings included: The policy, Discharge Criteria and Process [10/7/22] was provided…

Staff interviews the agency failed to resolve non-compliance issues before discharging patient for cause for 1 of 2 discharged patients [#3]. The findings included: The policy, Discharge Criteria and Process [10/7/22] was provided by the assistant director on 4/23/24 at 11 am.

The agency failed to identify a patient with a fluid restriction during the initial assessment for 1 of 1 patient with a fluid restriction (#11).

The agency failed to review all current medications for 6 of 7 patients that received a home visit (#12, 13, 11, 14, 9, and 6).

The agency failed to coordinate with the physician on needed equipment/medications/services for 2 of 17 patients (#14 and 17).

The PTA did not have orders to apply a dressing.

The agency failed to review all current medications for 4 of 7 patients that received a home visit (#16,17, 11, and 15).

The nursing staff failed to provide care in accordance with condition of skilled professional services for 5 of 9 patients [# 1, 3, 6, 7 and 9]. The following tags are cross referred: G 710 and G718 The findings included: G 704 Based on clinical records review, hospital record review, Physician…

The agency failed to follow Physician's order related to visit frequency for 2 of 9 patients [# 7 and 8]. Findings included: Patient # 7 had a start of care date of 1/5/17 and diagnoses of Pressure Ulcer of Sacrum [low back] Stage 4 [pressure injury is deep, reaching into muscle and bone causing…

Physician interview and staff interview the Registered Nurse failed to identify a wound during the comprehensive assessment for 1 of 1 patient who was admitted to the hospital with an undocumented Stage 3 sacral pressure ulcer [#1] and to follow-up with 1 of 1 patient's that had signs of a urinary…

The Registered nurse [RN] failed to update the comprehensive assessment in the proper time frame for 1 patient [#1]. The findings included: Patient # 1 had a start of care date of 1/30/16 and diagnoses of Multiple Sclerosis, Pressure Ulcer of Other Site Stage 2 and Encounter for Fitting and…

Prefilling insulin syringes [# 9] and applying dressing to elbow/heel [# 3] which were not listed on the Plan of Care for 3 of 9 charts . Findings included: The policy Care Planning Process dated 1/20/17 was provided on 7/24/18 by the agency Administrator.

The registered nurse [RN] failed to notify the physician of a new stage 1 decub on 1 of 1 patients [#3]. Findings included: 1. Patient #3 was admitted on 5/31/18 with a stage 2 pressure ulcer on buttocks, hypertensive heart disease, heart failure, and Parkinson's.

Agency policy review and staff interviews the Registered Nurse [RN] failed to do aide supervisory visits every 14 days for 2 of 2 patients who had aide services ordered [#1 and 6]. The policy Home Health Aide Supervisory Visits dated 1/20/17 was provided by the agency director on 7/24/18 at…

The registered nurse [RN] failed to monitor the quality of care provided by the home health aide which resulted in patient only being shaved by the home health aide [#1]. The findings included: 1. Patient # 1 had a start of care date of 1/30/16 and diagnoses of Multiple Sclerosis [a chronic disease…

The agency failed to include wound measurements in the clinical record for 2 of 9 patients [#1 and 4]. The findings included: 1. Patient # 1 had a start of care date of 1/30/16 and diagnoses of Multiple Sclerosis, Pressure Ulcer of Other Site Stage 2 and Encounter for Fitting and Adjustment of…

The agency failed to follow physician's orders for 1 of 1 patients who received a Vitamin B 12 injection [#1]; failed to follow the physician's orders for 2 of 2 patients who had OT [occupational therapy] orders [#5 and 10]; failed to follow orders for a home health aide for 1 of 1 patients with…

The agency failed to include all medications the patient was using at the time of the comprehensive assessment for 5 of 7 home visits [#2, 4, 5, 6 and 7]. The findings include: The policy Medication Profile dated 9/1/17 was provided by the Agency director on 4/1/18 at approximately 2:00 pm.

The agency failed to include information regarding advance directives [a written statement of a person's wishes regarding medical treatment should that person be unable to communicate them to the physician] on the Plan of Care [POC] to be reviewed and signed by the physician for 12 of 17 charts…