Adoration Home Health

The agency failed to identify a process for coordination and collaboration with emergency preparedness officials for 1 of 1 agency surveyed.

The Governing Body failed to appoint a qualified Administrator for 1 of 1 agency surveyed.

The home health agency failed to review and update the EP plan at least every two years (Tag E0004); failed to review and update the EP policies and procedures at least every two years (Tag E0013); failed to develop and implement EP policies and procedures which included procedures to inform State…

The home health agency failed to ensure the patients/patient representatives received the home health agency administrator’s name and contact information to report complaints (See G414); failed to ensure patients were informed about and received the initial therapy assessment (See G434); failed to…

The home health agency failed to ensure the plan of care was reviewed by the attending practitioner at recertification (See G572); failed to ensure the POC included measures to address all safety concerns, accurate wound treatment orders, patient-specific interventions, and measurable outcomes and…

The agency failed to ensure a clinical manager was available during operating hours (See G950); failed to ensure a qualified alternate clinical manager was identified and available in the absence of the clinical manager (See G952); failed to ensure the clinical manager was involved in daily…

The agency failed to review and update the EP plan at least every two years for 1 of 1 agency.

The agency failed to review and update the EP policies and procedures at least every two years for 1 of 1 agency.

The agency failed to develop and implement EP policies and procedures which included procedures to inform State and local EP officials about patients in need of evacuation from their residences due to an emergency situation for 1 of 1 agency.

The agency failed to develop EP procedures to follow up with on-duty staff and patients to determine services that are needed, in the event there is an interruption in services during or due to an emergency for 1 of 1 agency.

The agency failed to develop a system of medical documentation that preserves patient information, protects the confidentiality of patient information, and secures and maintains the availability of medical records in an emergency situation for 1 of 1 agency.

The agency failed to develop procedures for the use of volunteers and other emergency staffing strategies to address surge needs during an emergency situation for 1 of 1 agency.

The agency failed to ensure the EP communication plan included the names and contact information for staff and patients’ physicians for 1 of 1 agency.

The agency failed to develop an EP communication plan which included a primary and alternate means for communicating with agency staff and Federal, State, tribal, regional and local emergency management agencies for 1 of 1 agency.

The agency failed to develop an EP communication plan which included a method for sharing information and medical documentation for patients under the agency's care with other health providers and failed to develop a means for providing information about the general condition and location of…

The agency failed to develop an EP communication plan which included a means of providing information about the agency's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee for 1 of 1 agency.

The agency failed to ensure all employees completed EP training for 1 of 2 PT personnel files reviewed (PT 1).

The home health agency failed to ensure OASIS transmissions were submitted on time for 1 of 1 agency.

The agency failed to ensure the plan of care was reviewed by the attending practitioner at recertification for 1 of 1 active record reviewed who didn’t have a signing practitioner (Patient #2).

The home health agency failed to ensure staff followed agency infection control policies and procedures and manufacturer’s recommendations of use related to hand hygiene and/or bag technique for 4 of 5 home visit observations (Patient #1, #2, #3, and #5).

The agency failed to ensure a Clinical Manager had been clearly identified to provide oversight of patient care services and personnel for 1 of 1 home health agency surveyed.

The home health agency failed to ensure that all verbal orders for POCs were complete and accurate for 3 of 5 active records reviewed with home visits (Patient #2,3,5).

The agency failed to ensure the patients/patient representatives received the home health agency administrator’s name and contact information to report complaints for 1 of 2 home visits with SOC in the past 90 days (Patient #1, 5).

The home health agency failed to ensure patients were informed about and received their initial therapy assessment for 3 of 5 active records reviewed with a referral for therapy services in the past 90 days (Patient #1, 2 and 4) and 2 of 5 discharge records (Patient #9 and 10).

The home health agency failed to ensure patients received services as ordered in the POC for 6 of 10 active records reviewed (Patient #1, 2, 3, 4, 5 and 10).

The home health agency failed to evidence they met and followed their discharge policy, related to discharge for cause, for 1 of 1 patient discharged for cause in the previous six-month period (Patient #10).

The home health agency failed to advise the patient and the patient’s provider that discharge for cause was being considered for 1 of 1 patient discharged for cause in the previous six-month period (Patient #10).

The home health agency failed to make efforts to resolve the problems presented by the behavior of the patient’s caregiver for 1 of 1 patient discharged for cause in the previous six-month period (Patient #10).

The home health agency failed to provide the patient or the patient’s representative with contact information for other agencies or providers who may have been able to provide care for 1 of 1 patient discharged for cause in the previous six-month period (Patient #10).

The home health agency failed to ensure patient’s wounds were measured during each initial and/or recertification comprehensive assessment (CA) for 4 of 7 active patients with wounds reviewed (Patient #3, # 6, #8, and #11).

The home health agency failed to ensure an accurate review of all medications for 3 of 4 records reviewed with home visit observations with a RN (Patient #1, 2 and 3).

The home health agency failed to ensure the POC included measures to address all safety concerns, accurate wound treatment orders, patient-specific interventions, and measurable outcomes and goals for 5 of 10 active records reviewed (Patient #1, 2, 3, 5 and 8). 5.Review of the clinical record of…

The home health agency failed to ensure all wound clinic orders were recorded into the POC for 1 of 2 active patients reviewed with wound clinic orders (Patient #3).

The home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 3 of 10 active patient records reviewed (Patient #2, 3 and 15). 4.Review of the clinical record for Patient #15 with SOC date 12/18/2024 included a POC completed by OT 1, for…

The home health agency failed to ensure a physician or allowed practitioner reviewed and revised the POC no less frequently than once every 60 days, beginning with the start of care date for 3 of 4 active records reviewed that received SN, PT, and OT services (Patient #2, 4, 11).

The home health agency failed to provide the patient and/or caregiver with accurate clinical manager information for 2 of 2 active patients with home visit observations who have been admitted in the past 60 days (Patient #1 and 5).

The home health agency failed to ensure the patient’s wounds were measured accurately and/or at least weekly for 2 of 7 active patients with wounds reviewed (Patient #3 and #7) and the RN failed to adequately assess heart tones, lungs and bowel sounds for 1 of 4 RN home visit observations (RN 2).

The RN failed to provide wound care as ordered for 2 of 3 home visit observations with a RN providing wound care (Patient #2 and 3).

The home health agency failed to maintain documentation which demonstrates the HHA completed a skills competency evaluation prior to caring for agency patients for 1 of 1 HHA reviewed (HHA 1).

The Administrator failed to ensure a clinical manager was identified and available to all staff and patients in the role of CM for 1 of 1 home health agency surveyed.

The Administrator failed to ensure a qualified alternate clinical manager was identified and available in the absence of the clinical manager for 1 of 1 home health agency surveyed.

The Clinical Manager failed to oversee patient and personnel assignments to ensure the patient received all services according to the plan of care for 6 of 10 active records reviewed (Patient #1, 2, 3, 4, 5, and 10).

The agency failed to ensure the Clinical Manager oversaw the coordination of care for all patients discharged for cause for 1 of 1 records reviewed of a patient discharged for cause (Patient #10).

The agency failed to ensure the Clinical Manager coordinated referrals to ensure patients were informed of and received all initial therapy assessments for 3 of 5 active reviewed with a referral for therapy services in the past 90 days (Patient #1, 2, 4) and 2 of 5 discharge records reviewed…

The agency failed to ensure the Clinical Manager assured patient needs were continually assessed, including measuring all wounds during the initial and recertification comprehensive assessment, for 4 of 7 active records reviewed of patients with wounds (Patients #3, 6, 8, 11).

The agency failed to ensure the Clinical Manager oversaw the development, implementation, and updates of the individualized plan of care for 3 of 10 active patient records reviewed (Patient #2, 3, 15).

The home health agency failed to submit the discharge summary to the physician with 5 days of discharge for 1 of 1 hospital discharge record reviewed (Patient #9).