A W Holdings LLC

The agency failed to evidence the POC was developed in conjunction with the physician and that services were provided as directed in the POC in 6 of 6 active clinical records reviewed.

The agency failed to ensure the performance improvement activities focused on high risk and problem-prone areas.

The agency failed to evidence the HHA demonstrated competency before providing care to a patient in 1 of 5 HHA competencies reviewed.

The agency failed to ensure the RN assigned patient-specific tasks in writing to the HHA in 2 of 2 active clinical records reviewed with HHA services in a total sample of 6 active clinical records reviewed.

The agency failed to ensure the clinical record was completed to include the time of visits in 6 of 6 active clinical records reviewed.

The agency failed to document the existence of a complaint and the resolution of the complaint in 1 of 1 record review of a patient who verbalized a complaint.

The agency failed to provide an initial assessment within 48 hours of the referral in 2 of 2 active clinical records reviewed with HHA services in a total sample of 6 active clinical records reviewed (Patient #5, 6) The findings include: 1. A clinical record review for Patient #5 evidenced a…

The agency failed to ensure the comprehensive assessment included the physical status of the patient in 3 of 4 active clinical records reviewed with only SN services provided in a total sample of 6 active clinical records reviewed.

The agency failed to ensure the comprehensive assessment included the review of the medications to include potential drug interactions in 2 of 6 active clinical record reviews.

The agency failed to ensure the POC included all types and frequency of services provided in 1 of 2 active adult skilled clinical records reviewed with respite nursing services (Patient #4) and in 1 of 1 active clinical record reviewed with attendant care provided (Patient #6) in a total sample of…

The agency failed to ensure services were provided only as ordered by a physician in 2 of 2 active adult clinical records reviewed with SN services only in a total sample of 6 active clinical records reviewed.

The agency failed to ensure the POC was revised with necessary changes in 2 of 2 active clinical records reviewed with hospitalizations in a total sample of 6 active clinical records reviewed.

The agency failed to ensure documentation of the 16 hours of supervised practical training for 5 of 5 training records reviewed HHAs trained by the agency in a total sample of 30 active HHAs.

The agency failed to ensure the HHA provided services as directed in the HHA care plan in 2 of 2 active clinical records reviewed with HHA services in a total sample of 6 active clinical records reviewed.

The agency failed to ensure the home health aide (HHA) was supervised to ensure the aides furnished care that followed the patient’s plan of care in 2 of 2 active clinical records reviewed with HHA services.

The agency failed to ensure the clinical manager provide oversight of personnel assignments in 1 of 1 active clinical record reviewed with a resumption of care for HHA services.

The agency failed to ensure the RN followed current standards of practice in 1 of 1 home visit for the observation of medication administration via a gastrostomy tube (GT, a feeding tube surgically inserted into the stomach).

The agency failed to ensure patients received the home health services which were written in an individualized plan of care that identified patient-specific measurable outcomes and goals in 4 of 6 clinical records reviewed.

The home health agency failed to ensure the plan of care was individualized and complete to include all indications and doses for medications in 3 of 5 active clinical records reviewed.

The home health agency failed to ensure all orders were recorded on the plan of care in 1 of 5 active clinical records reviewed.

The home health agency failed to administer treatments only as ordered by the physician in 1 of 5 active clinical records.

The home health agency failed to promptly alert the physician of changes in the patient’s status in 4 of 5 active clinical records reviewed.

The home health agency failed to ensure the plan of care was revised to reflect the patient’s current medications in 4 of 6 clinical records reviewed (#1, #2, #5, #6) The findings include: 1. Review of an agency policy titled “Client Plan of Care,” revised 4/14/2020, stated “ … The Plan of Care…

The home health agency failed to provide services as specified in the individualized plan of care in 5 of 7 clinical records reviewed.

The home health agency failed to ensure conformance with physician orders in 1 of 2 records with wounds in a total sample of 7 clinical records reviewed.

The home health agency failed to ensure all employees followed acceptable standards of practice to prevent the transmission of infection including the use of standard precautions in 2 of 3 home visits.

The home health agency failed to maintain a program for identification, prevention, control, and investigation of infectious and communicable diseases specific to care and services provided in the home setting in 1 of 7 clinical records reviewed.

The home health agency failed to ensure all entries in the clinical record were complete and appropriately authenticated, dated, and timed to include a signature and title in 1 of 7 clinical records reviewed.

The home health agency failed to investigate complaints for care not performed made by the patient's representative in 1 of 7 clinical records reviewed.

The home health agency failed to document the existence and resolution of a complaint in 1 of 7 clinical records reviewed.

The home health agency failed to ensure the comprehensive assessment reflected the patient's current health status in 2 of 5 active clinical records with a feeding tube (#3, #4) and 1 of 2 (#4) active clinical records with a wound in a total sample of 7 clinical records.

The home health agency failed to ensure the plan of care was individualized and complete to include frequency and duration of visits, all medications including indications for use for medications taken as needed and where medication is to be applied, safety precautions, nutritional requirements and…

The home health agency failed to ensure all orders were recorded in the plan of care in 2 of 7 clinical records reviewed.

The home health agency failed to promptly alert the physician of changes in the patient's status in 2 of 7 clinical records reviewed.

The home health agency failed to coordinate care with the therapy agency in 2 of 2 clinical records receiving therapy services out of a total of 7 clinical records reviewed.

The home health agency failed to ensure the clinical record contained the contact information for the patient / patient's primary caregiver in 1 of 3 home visits.