Aim Home Health LLC

G574 - Standard: The Plan of Care must Include - The agency failed to ensure each patient's plan of care covered all pertinent diagnoses and treatments, types of services, supplies and equipment required, nutritional requirements, all medications and treatments and patient-specific interventions…

According to interview and record review, the agency failed, as a routine practice, to appropriately reassess the status, needs and overall well being of patients under their care when the patients experienced falls with injury, surgical procedures, falls that resulted in hospitalization and/or…

The agency failed to ensure the registered nurse (RN) or other appropriate skilled professional prepared patient-specific written care instructions for the certified nurse aide (CNA) for 9 of 25 patients reviewed who received CNA services (Patients #2, #4, #8, #9, #24, #28, #29, #35 and #36).

Specifically, interview and record review showed Patient #16, along with her family, was moved to a motel and the agency abruptly discharged the patient and failed to assist the patient even though she had ongoing physical and occupational therapy needs.

The agency failed to coordinate care and document due diligence with regard to ensuring continuity of care upon the discharge of Patient #16. Cross Reference G466 Make Efforts to Resolve the Problem (s) Findings include: Interview and record review showed Patient #16, along with her family, was…

The agency failed to ensure the comprehensive assessment accurately reflected each individual patient's status and included their medical, nursing, rehabilitative, social/behavioral and discharge planning needs for 5 of 36 patients reviewed (Patients #8, #9, #24, #29 and #35).

The agency failed to ensure each patient's Plan of Care covered all pertinent diagnoses and treatments, types of services, supplies and equipment required, nutritional requirements, all medications and treatments and patient-specific interventions and education for 3 of 36 patient records reviewed…

The agency failed to ensure the physician was notified of a change in condition for 7 of 36 patients reviewed with a change in condition (Patients #6, #15, #21, #23, #24, #29 and #32).

The agency failed to coordinate care delivery with external care providers and involve the patient, representative and caregiver in the coordination of care activities in order to meet the needs of the patient for 5 of 36 patients reviewed (Patient's #3, #24, #29, #35 and #36).

The agency failed to ensure ongoing interdisciplinary assessment occurred to re-evaluate the medical needs for 9 of 36 patients reviewed (Patients #3, #6, #9, #17, #20, #21, #22, #28 and #29).

The agency failed to ensure certified nursing aides (CNAs) provided services as ordered by the physician, included in the plan of care, permitted to be performed under state law and were consistent with home health aide training for 3 of 25 patients reviewed receiving CNA services (Patients #8, #28…

The agency failed to ensure the certified nurse aide (CNA) reported changes in the patient's condition to a registered nurse or other appropriate skilled professional and completed appropriate documentation for 3 of 25 patient records reviewed who received CNA services (Patients #17, #23 and #28).

The agency's supervision of the certified nurse aides (CNA) failed to ensure the CNAs furnished care in a safe and effective manner including ensuring their competency with assigned tasks along with their adherence to the CNA care plan and reporting changes in the patient's condition as required…