All Americans Home Health Care

The Agency failed to ensure the plan of care included objectively measurable goals specific to the individualized needs of the patient in 4 (MR's # 1, 2, 5, 7) records, from a total of 7 sampled records reviewed, resulting the potential for poor patient outcomes and unmet care needs.

The agency failed to ensure a detailed discharge summary was included in the record for 2 of 2 (P-1, P-6) discharge records reviewed, from a total sample of 7 records reviewed, resulting in a lack of information to ensure continuity of care.

The Registered Nurse (RN) failed to include safety precautions on the aide's care plan, in 1 of 2 records reviewed in which Home Health Aide (HHa) services were provided (MR#7) resulting in the potential for the provision of unsafe care.

The agency failed to inform the patient in advance of the disciplines that will furnish care in 1 records reviewed (MR# 3) from a total sample of 7 records reviewed, resulting in the patient not having knowledge of the plan for treatment and potential unmet care needs.

The agency failed to provide all services as ordered in the Plan of Care in 1 of 7 (MR#2) records reviewed, resulting in the patient not receiving all services to assist in improving the health status of the patient.

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments…

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 as required, and failed to ensure the physician was notified of potential severe drug interactions and…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 7 of 7 records reviewed (M.R.#s 1, 2, 3, 4, 5, 6, and 7), and failed to ensure reportable parameters were included on the POC, resulting in the potential for a plan of care not meeting the patient's…

The agency failed to ensure services were provided only as ordered by the physician in 1 of 7 (MR# 3) records reviewed, resulting in the potential for the provision of inappropriate care and services Findings include: MR#3: The Start of Care (SOC) was dated 3/30/22. The Plan of Care (POC)…

The agency failed to prepare and provide the patient and the caregiver written information regarding the patient's medication regimen via the medication profile in 1 0f 7 records reviewed (MR#2).

The agency failed to ensure clinical notes were accurate for 1 of 7 (MR# 3) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The Agency failed to ensure the transfer summaries were complete, detailed, and provided the patient's current health status at the time of transfer, forwarded to the physician and receiving facility, and included the name of the facility in which the patient was transferred in 2 (MR#1 and 7) of 2…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 5 of 7 records reviewed (M.R.#s 1, 2, 4, 5 and 7), resulting in the potential for a plan of care not meeting the patient's needs.

The agency failed to ensure skilled professional services were provided as ordered by the physician for 3 of 7 records reviewed (MR#s 1, 4 and 7), resulting in the potential for poor outcomes for these patients.

The agency failed to ensure the registered nurse prepared written patient care instructions for the home health aide (HHa), that included specific safety precautions for 2 of 2 patients (M.R.#1 and 4) in which HHa services were provided, from a total of 7 records reviewed, resulting in the…