Ascension at Home

The agency failed to have a signed plan of care (POC) or a verbal POC order from the primary physician before providing services and treatments to patients for 5 of 5 patient record reviews with the potential to affect all patients on service.

The agency failed to maintain an updated individualized plan of care (POC) for 4 of 5 patient record reviews.

The agency failed to communicate information on the plan of care (POC) to the primary physician, resulting in patient care being provided without a physician order for 5 of 5 patient record reviews with the potential to affect all patients on service.

The agency failed to maintain patient information within the electronic medical record (EMR) system for 1 of 4 active records reviewed.

The agency failed to provide patients with a written plan of care for 6 of 7 home visit observations.

The agency failed to ensure staff performed hand hygiene and followed standard precautions of infection control for 1 of 1 home health aide observation (Patient 4); and for 1 of 1 RN (Registered Nurse) observation.

The agency failed to appropriately assess a patient for 1 of 2 patient's receiving occupational therapy services.

The agency failed to list all durable medical equipment on the plan of care for 3 of 7 home visit observations.

The agency failed to ensure patient medication schedule and instructions were provided to the patient for 6 of 7 home visit observations.

The agency failed to ensure the clinical notes contained adequate information for 4 of 4 patient records reviewed with blood thinning medications.

The agency failed to document the interventions provided and the patient's response to interventions in 2 of 4 clinical record's reviewed for patient's with wounds.