Atrio Home Health Lakeshore

The Agency failed to ensure the plan of care addressed the individualized needs of the patient and included all pertinent interventions with reportable parameters and objectively measurable goals for 10 of 17 (MR#'s 1, 2, 3, 4, 5, 6, 9, 15, 16) records reviewed, resulting in patients not receiving…

The Agency failed to ensure the Speech Therapist completed a detailed Discharge Summary that detailed the course of care provided, the patient's health status at the time of discharge and was forwarded to the Physician within 5 days of the date of discharge for 1 (MR #16) record, from a total of 17…

The Agency failed to establish Vaccine protocol written policies and procedures that included (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for tracking/documenting information provided by staff who have requested/been granted an…

The Agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide's performance of the required tasks with a patient…

The Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to providing care in 2 (MR#'s 7, 15) of ___ records in which Home Health Aide services were ordered, from a total of 17 sampled…

The Agency failed to ensure that 3 (MR's #13, 14, 15) of 3 patients observed during home visits, were included in the overall planning of care including the timeliness of services received; and failed to inform the patient/caregiver in advance of the days in which services would be provided…

The Agency failed to provide documented evidence of the details of the investigation and the resolution of the complaints, as per this requirement, resulting in the potential for unaddressed patient/family concerns, inability to exercise one's rights and unmet care needs.

The agency failed to ensure the comprehensive assessment included an accurate reflection of the patient’s current health, psychosocial, and functional status in 7 of 17 records reviewed (MR# 8, 10, 11, 12, 14, 15, 16) resulting in incomplete clinical information to aid in determining the needs of…

The agency failed to identify potential clinically significant medication issues and report to the physician in 1 of 17 (MR#1) records reviewed.

The Agency failed to ensure the plan of care addressed the individualized needs of the patient and included all pertinent interventions with reportable parameters and objectively measurable goals for 10 (MR#'s 1, 2, 3, 4, 5, 6, 9, 15, 16) records, from a total of 17 sampled records reviewed…

The agency failed to ensure the physician ordered treatment for wound care was administered only as ordered for 1 of 3 (MR# 9) sample records for which the patient was receiving wound care from a total of 17 records reviewed resulting in the potential for unidentified complications and unrecognized…

The Agency failed to ensure the Physician was promptly notified of the severe drug interactions that were identified in 4 (MR#'s 14, 15, 16, 17) records reviewed that were found to have severe drug interactions, and 2 (MR#s 11, 17) records with significant fluctuations in weight, from a total of 17…

The agency failed to ensure the integration of medication orders from all physicians involved in the plan of care for 1 of 4 (MR# 8) sample records reviewed for which a home visit was made with a patient residing in an assisted living facility potentially resulting in undetected overmedication and…

The agency failed to provide 2 (MR#'s 14, 15) of 3 patients observed during home visits, with a Medication Profile that included the names, dosages, frequencies and side effects of the patient's prescribed medications, in plain language, from a total of 17 sampled records reviewed, resulting in…

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet for Skilled Nurse openings, resulting in the potential for unaddressed patient concerns.

The Agency failed to ensure the Physical Therapist (PT), Occupational Therapist and Speech Therapist assisted the Physician in evaluating the patient's level of function and helped to develop the plan of care for 3 (MR#'s 15, 16, 17) records in which Therapy services were required, from a total of…

The Agency failed to ensure the clinical record was complete and included accurate documentation within Nursing visits for 1 (MR #15) record; and, failed to ensure the clinical record included approved medical abbreviations in 1 (MR #1) record, from a total of 17 sampled records reviewed, resulting…

The Agency failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge and identified the patients progress toward goals in 2 (MR#s 16, 17) of 5 records in which the patient was discharged from the Agency's services, from a total of 17…

The Agency (HHA) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, objective baseline data for future assessments, and ascertained the patient's immediate care needs in 3 of 13 sampled patient records reviewed (MR#s 1, 2…

The agency failed to ensure services were provided as ordered by the physician for 3 of 13 records reviewed (MR# 4, 8, 13), resulting in the potential for poor outcomes for the patients.

The agency failed to ensure the plan of care included objectively measurable outcomes and goals for 4 of 13 (MR# 1, 2, 3, and 4) records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress towards goals and the…

The agency failed to promptly notify the physician that the patient's weight was outside the reportable parameters in 1 of 13 records reviewed (MR#4), resulting in the potential for poor outcomes.

The home health aide failed to provide services that were consistent with home health aide training in 1 of 7 sampled records reviewed in which home health aide services were provided, resulting in the potential for poor surgical outcomes or unmet post surgical care needs.