1ST State Home Healthcare, Inc

The agency failed to maintain documentation of emergency preparedness training, resulting in the potential for inappropriate, unprepared responses to emergencies and an interruption in the provision of needed patient care and services.

The agency failed to ensure the frequency of visits ordered on the Plan of Care (POC) were followed in 3 of 7 records reviewed (P-5, P-6 and P-7), resulting in the potential for unmet patient needs.

The agency failed to ensure that 2 (P-1, P-4) of 7 patients were included in the overall planning of their care, resulting in a lack of inclusion in planning their care, the potential for missed visits and unmet care needs.

The Home Health Agency (HHA) failed to inform their patients of the names, addresses and phone numbers of the Federally funded and State funded entities, in the areas where their patients reside, resulting in failure to provide access to community resources and services for the agency's patients.

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status in 6 of 7 records reviewed (P1, P2, P3, P4, P5, P7), resulting in incomplete clinical information to aide in determining the needs of the patient.

The agency failed to ensure the comprehensive assessment included a review of all the patient's prescribed medications to determine any untoward interactions, for 4 (P-1, P-2, P-3 and P-5) of 7 patient's records reviewed, resulting in the potential for harmful medication effects.

The agency failed to ensure the Plan of Care (POC) included all safety measures for 1 of 1 (P-7) records with oxygen ordered, resulting in the potential for negative patient outcomes related to oxygen use.

The agency failed to ensure a detailed discharge summary was included in the record for 1 of 2 discharge patient (P-2) records reviewed, resulting in a lack of information to the receiving facility or the patient's physician to ensure continuity of care.

The agency failed to ensure a detailed discharge or transfer summary was included in the record and sent to the receiving facility or the patient's physician within 5 business days of discharge for 2 of 2 transfer or discharge patient (P-1, P-2) records reviewed, resulting in a lack of information…

The agency failed to ensure the initial assessment visit was completed within 48 hours of the referral or within 48 hours of the patient's return home for 2 of 7 (MR# 6 and 7) records reviewed (refer to G514); failed to conduct a patient-specific, comprehensive assessment that accurately reflected…

The agency failed to ensure that the plan of care included objectively, measurable outcomes and goals specific to the patient's needs in 3 of 7 (MR#s 2, 5, and 6) records reviewed; failed to include hearing as a functional limitation in 1 of 7 (MR#7) records reviewed; failed to include nutritional…

The agency failed to ensure that the skilled professional staff provided complete assessments and re-assessments with objective measures to accurately assess the patient's health status and function in 5 of 7 (MR#s 2, 3, 4, 5, 7) records reviewed (see G706); failed to ensure that the services of…

The agency failed to ensure the clinical record contained completed assessments and visit notes for 5 of 7 (MR# 2, 3, 4, 5, and 6) records reviewed (refer to G1012); failed to ensure that patient goals were specific and measurable in the patient's plan of care and that the patient's progress…

The agency failed to ensure their emergency preparedness plan was reviewed and updated at least every 2 years.

The agency failed to ensure to have current information critical to first responders.

The agency failed to ensure the update to the comprehensive assessment warranted recertification for an additional episode of care for 1 of 4 (MR# 3) records reviewed in which patient care was recertified for additional episodes of care, resulting in the provision of home care services to a patient…

The agency failed to conform to the visit schedule as ordered by the physician in 1 (MR#6) of 7 records reviewed, resulting in patients not receiving care as ordered in the Plan of Care.

The agency failed to conduct performance improvement projects in 2022, resulting in no coordinated efforts to improve patient outcomes for the 17 patients admitted to the agency in the past 12 months.

The agency failed to ensure the Physical Therapist provided supervision of the Physical Therapy Assistant in 2 of 7 (MR#s 3 and 6) records reviewed, resulting in a lack of communication and oversight regarding the status of these patients.

The agency failed to ensure documents in the clinical records were legible, clear, complete, and appropriately authenticated with a signature and title, dated, and timed in 5 (MR#s 1, 3, 4, 5, 6) of 7 records reviewed, resulting in records that are not authenticated, accurate, timely, and do not…

The agency failed to ensure the initial assessment visit was completed within 48 hours of the referral or within 48 hours of the patient's return home in 2 (MR#s 6 and 7) of 7 total records reviewed.

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on the patient's past medical history that included dates of onset, treatments and outcomes, history of events leading to the need for current home care…

The agency failed to ensure the comprehensive assessment included a review of medications completed by the registered nurse to determine any adverse interactions in 5 of 7 records reviewed (MR#s 1, 2, 3, 4, and 6), resulting in the potential for harmful medication reactions or negative outcomes for…

The agency failed to provide Home Health aide services to patients with needs for assistance with Activities of Daily Living in 2 (MR#s 6 and 7) of 7 total records reviewed.

The agency failed to ensure the comprehensive assessment was updated to include an assessment of the patient's current health status and continuing needs for home health services for 1 (MR #6) of 1 record reviewed in which a request for recertification of the patient by the agency was submitted as…

The agency failed to provide an updated comprehensive assessment of the patient at discharge for 2 of 2 (MR# 5, 2) discharge records reviewed, resulting in a lack of updated information to summarize the patient's progress in meeting the care plan goals and to inform the physician of any continuing…

The agency failed to ensure that the plan of care included objectively, measurable outcomes and goals specific to the patient's needs in 3 of 7 records reviewed (MR#s 2, 5, and 6), failed to include hearing as a functional limitation in 1 of 7 records reviewed (MR#7), and failed to include…

The agency failed to ensure that the skilled professional staff provided complete assessments and re-assessments with objective measures to accurately assess the patient's health status and function in 5 of 7 records reviewed (MR # 2, 3, 4, 5, 7), resulting in the inability to determine patient…

The agency failed to ensure that the services of the skilled professionals were provided as indicated by the physician in the plan of care in 4 of 7 records reviewed (MR# 4, 5, 2, 3), resulting in a potential for poor outcomes for these patients.

The agency failed to ensure that the skilled professionals prepared clinical notes in 2 of 7 records reviewed (MR# 4, 3), resulting in the clinical record not providing an accurate and up to date clinical picture of the patient and the potential for unidentified health concerns.

The clinical manager failed to provide oversight of patient care services and personnel to ensure that patient needs were continually assessed for 1 of 7 (MR# 3) records reviewed, resulting in a lack of assurance that the needs of this patient were assessed and met.

The agency failed to ensure the clinical record contained completed assessments and visit notes for 5 of 7 (MR# 2, 3, 4, 5, and 6) records reviewed, resulting in a lack of information for the physician and all agency staff caring for these patients.

The agency failed to ensure that patient goals were specific and measurable in the patient's plan of care and that the patient's progress towards achieving these goals was documented in 2 of 7 records reviewed (MR #4, #5), resulting in an inability to accurately assess patient's status and need for…

The agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 2 of 2 (MR# 2, 5) discharge records reviewed, resulting in a lack of information to ensure continuity of care for the 11 patients discharged from the agency in the past 12…