Affinity Home Care Agency, Inc

The agency failed to conduct a full-scale community-based exercise or a facility-based functional exercise every 2 years, resulting in the potential for an unprepared response in the event of an actual emergency.

The agency failed to ensure accepted standards of practice for infection control were followed for 1 (P-8) of 4 patients with home visits, resulting in the potential for transmission of infectious and communicable diseases to all patients receiving services from this agency.

The agency failed inform the patient in advance of which disciplines that would furnish care in 2 (P-3, 6) of 10 records reviewed, resulting in the potential for patients not being able to fully participate and consent to their care.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-7, 9) of 10 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patients to assist in developing the…

The agency failed to ensure the comprehensive assessment accurately reflected medications the patient was currently taking in 1 (P-1) of 10 sample records reviewed resulting in the agency being unaware of medications taken by the patient and the potential for harmful medication effects.

The agency failed to ensure the plan of care was individualized to the patient's identified needs for 3 (P-2, 5, 7) of 10 records reviewed resulting in an inaccurate plan of care and the potential for poor patient outcomes.

The agency failed to ensure communication with physicians involved in the plan of care in 2 (P-2, 10) of 10 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure services were provided as ordered per the plan of care in 5 (P-1, 3, 6, 7, 10) of 10 records reviewed and failed to accurately assess and reassess pain in 1 (P-1) of 10 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the clinical record contained all interventions, treatments, and services in 4 (P-6, 7, 9, 10) of 10 records reviewed, resulting in an incomplete and inaccurate medical record.

The agency failed to ensure a discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge within 5 days of the patient's discharge in 3 (P-1, 2, 10) of 3 closed records reviewed…

The agency failed to ensure there was a physician order for aide services for 1 of 4 (MR#4) records reviewed with aide services, resulting in no physician order for services to be provided to this one patient.

The Agency failed to ensure the Initial Comprehensive Assessment was complete and accurately reflected the patient's health status at the time of admission for 6 (MR #'s 5, 6, 7, 8, 9 and 10) records, from a total of 10 sampled records reviewed and; failed to assess baseline blood glucose/sugar…

The Agency failed to ensure the Plan of Care included all appropriate interventions, reportable parameters, prescribed medications and measurable goals for 9 (MR #'s 5, 1, 2, 3, 6, 7, 8, 9 and 10) of 10 sampled records reviewed, resulting in patient's not receiving care and services specific to…

The Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the Home Health Aides regarding client needs, and safety precautions, prior to the provision of care in 3 (MR#'s 1, 2 and 3) of 5 records in which Home Health Aide services were ordered, from a total of…

The agency failed to inform the patient in advance of the disciplines that will furnish care in 1 record reviewed (MR# 9) from a total sample of 10 records reviewed, resulting in the patient not having knowledge of the plan for treatment and potential unmet care needs.

The Agency failed to ensure the Initial Comprehensive Assessment was complete and accurately reflected the patient's health status at the time of admission for 6 (MR #'s 5, 6, 7, 8, 9 and 10) records, from a total of 10 sampled records reviewed and; failed to assess baseline blood glucose/sugar…

The Agency failed to ensure the patient's Activities of Daily Living needs were adequately met in the patient's home in 1 (MR# 3) of 5 records in which the patient required assistance with self-care, resulting in the potential for psychological decline, poor hygiene, caregiver burden, and unmet…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review, failed to ensure the Physician was notified of potential drug interactions as appropriate in 10 (MR's # 1, 2, 3…

The Agency failed to ensure the Plan of Care included all appropriate interventions, reportable parameters, prescribed medications and measurable goals to meet the needs of the patients, for 9 (MR #'s 5, 1, 2, 3, 6, 7, 8, 9 and 10) of 10 sampled records reviewed, resulting in patient's not…

The agency failed to ensure the Registered Nurse performed re-assessments of the patient's health status and needs in 1 (MR #5) of 1 record of a patient with a new diagnosis of Diabetes Mellitus, from a total of 10 sampled records reviewed, resulting in the potential for unidentified health…

The agency failed to ensure clinical notes were accurate for 1 of 10 (MR# 8) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The Agency failed to ensure the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician within the required time, in 4 (MR#s 1, 5, 6, 7), of 4 records…

The Registered Nurse (RN) failed to prepare clearly written patient care instructions and include safety precautions on the aide's care plan, in 3 of 3 records in which Home Health Aide (HHa) services were provided (MR#s 4, 9 and 10) resulting in the potential for the provision of unsafe care and…

The agency failed to ensure the contracts (Contract #1 and #2) included all the regulatory language specified in paragraph (f) of this section and with the requirements of section 1861(w) of the Act (42 U.S.C 1395x(w)), resulting in the potential to adversely affect the finances of all patients…

The agency failed to ensure the comprehensive assessment included a review of the patient's current medications to determine major drug interactions, failed to document the findings of the drug regimen review, and failed to ensure the physician was notified of potential drug interactions/adverse…

The registered nurse failed to ensure the plan of care included safety precautions, reportable parameters, and specific individualized interventions based on the patients initial assessment, and objectively measurable goals and outcomes in 6 of 10 records reviewed (MR#s 1, 2, 3, 4, 5, and 10)…

The Registered Nurse (RN) failed to provide nursing services as ordered by the physician and according to the plan of care for 3 of 10 records reviewed with nursing services (M.R.# 3, 7 and 8) resulting in the potential for unmet care needs.

The agency (HHA) failed to maintain documentation of competency evaluations in 1 of 1 Home Health Aides (HHa #1) whose personnel file was reviewed, resulting in the potential for the rendering of substandard care and unmet care needs.

The agency failed to ensure that 1 of 2 contracts (Contract #1) included the provision that the Home Health Agency (HHA) must maintain overall responsibility for the services provided under contract.

The Home Health Agency (HHA) failed to ensure the discharge and transfer summaries were complete and provided the patient's current health status at the time of discharge/transfer, status of problems identified throughout the course of care, and a summary of care or services provided and sent to…