Above and Beyond Home Health

The agency failed to coordinate care delivery to meet the patient's needs of 1 of 5 sampled patients (Patient #4).

Personnel file review and agency staff interview: I. the agency failed to ensure 3 of 3 sampled home health aides (Staff I, J and K), demonstrated completion of all of the required basic skills while observed by a registered nurse to determine competency in each task prior to being allowed to care…

The agency failed to provide an initial assessment visit within 48 hours of receipt of referral and/or known discharge date, or on the physician ordered start of care date for 2 of 9 sampled patients (Patients #2 and #5).

The Recertifications of care comprehensive assessments, dated 7/22/21 and 9/17/21, included documentation a drug regimen review had been completed but failed to identify the duplicate laxative medications.

The agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 3 sampled patients requiring a resumption of care assessment (Patient #9).

The agency failed to update the Plan of Care with interim physician orders for 2 of 7 sampled patients (Patients #8 and #9) with interim orders.

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 3 of 3 sampled patients receiving home health aide services…

10. Patient #3 had a start of care date of 12/8/16. The Recertification Comprehensive Assessments, dated 5/29/18, 7/30/18 and 9/24/18, lacked documentation the nurse completed or reviewed an individualized emergency preparedness plan with the patient.

The agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice for 1 of 4 patients (Patient #3) with home visit observations.

The agency failed to provide individualized and specific written patient care instructions by a registered nurse for home health aides for 3 of 10 sampled patients receiving home health aide services (Patients #4, #6 and #10).

The agency failed to provide an initial assessment visit within 48 hours of receipt of referral and/or return home from the hospital, for 1 of 1 sampled patients (Patients #8) who were admitted since 10/29/15 (the date of the agency's last recertification survey) and had only skilled therapy…

The agency failed to complete a drug regimen review, including all required components, with each discharge assessment for 1 of 2 sampled discharged patients (Patient #9).

The agency failed to ensure accurate completion of all pertinent components of the resumption of care comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 2 sampled patients requiring a Resumption of Care Assessment (Patient #5).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet his/her needs and an accurate list of the patient's current medications for 2 of 10 sampled patients (Patients #1 and #4).

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

The agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 3 of 10 sampled patients (Patients #3, #6 and #10).

The agency failed to ensure home health aides provided services according to the home health aide written assignment for 4 of 10 sampled patients (Patients #2, #7, #9 and #10) receiving aide services.

The agency failed to ensure all interim physician orders were signed by a physician for 2 of 10 sampled patients (Patients #4 and #10).

The agency failed to ensure the clinical record included pertinent documentation of home health aide interventions completed by the home health aide for 1 of 1 sampled patients with orders for weight checks at each home health aide visit (Patient #3).

The agency failed to complete and send a transfer summary to the physician or other health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of knowledge of the occurrence of the transfer for 3 of 3 sampled patients (Patients #5…