Beartooth Billings Clinic Home Care

The agency failed to report an allegation of abuse and neglect for 1 (#1) of 3 sampled patients.

The agency failed to promptly notify the physician of changes in condition for 1 (#1) of 3 sampled patients.

The agency failed to ensure physician orders were obtained and followed for wound care for 1 (#1) of 3 sampled patients.

The agency failed to follow clinical practice guidelines for caring for a pressure wound for 1 (#1) of 3 sampled patients.

The agency failed to be in substantial compliance of the condition to establish a comprehensive emergency preparedness program with all of the required elements in writing.

Findings include: The agency failed to ensure staff followed acceptable standards of practice for maintaining a clean field, performing hand hygiene, and donning gloves when preparing medications in the home setting (See 682); The agency failed to ensure a process was developed to observe and…

Findings include: The agency failed to ensure the development of an updated Plan of Care for SLP therapy visits to include treatment orders, interventions, and goals (See G708); The agency failed to ensure all SLP therapy visits were provided as ordered by the physician (See G710); The agency…

Findings include: The agency failed to ensure a Home Health Aide (HHA) had maintained an active home health aide endorsement of certification from the state agency for completing a training and competency evaluation program specific to the agency and patient needs (See G754); and The agency failed…

The agency was found to not be in substantial compliance with the Condition of Participation for Organization and Administration of Services; findings include: The agency failed to ensure an authorized pre-designated individual, who is responsible for fulfilling the role of the administrator in…

The agency failed to create and maintain an emergency preparedness plan, review, and update with all of the required components.

The agency failed to complete an emergency preparedness risk assessment specific to the agency’s needs.

The agency failed to address the patient population, persons at risk, the services the agency could provide in an emergency, and continuity of agency operations in an emergency.

The agency failed to include a process for collaborating with emergency preparedness officials to maintain an integrated response in an emergency.

The agency failed to develop, implement, and review policies specific to the agency’s risk assessment and emergency preparedness needs.

The agency failed to ensure each patients emergency preparedness needs were captured on their comprehensive assessment and implemented into their clinical record.

The agency failed to develop and implement policies and procedures to communicate with authorities for homebound patients needs in the event of an emergency.

The agency failed to develop policies and procedures to follow up with staff and patients in an emergency and notify officials of staff and patients the agency was unable to contact.

The agency failed to develop and implement emergency preparedness policies and procedures to secure and maintain medical documentation, to preserve patient information, protect confidentiality, and maintain availability in an emergency.

The agency failed to develop and implement policies and procedures for the use of volunteers and other staffing strategies in the event of an emergency.

The agency failed to establish an agency emergency preparedness communication plan for staff and patients.

The agency failed to develop and maintain an emergency preparedness plan including the name and contacts of staff, patients, services under contract, patient’s physicians, volunteers, and other agencies.

The agency failed to maintain a communication plan with the contact information for local authorities and other sources of assistance in an emergency.

The agency failed to develop an emergency preparedness communication plan with primary and alternate means of communication with staff and emergency officials.

The agency failed to develop a communication plan including the way patient information would be shared to other providers in an emergency when the main access to records was inaccessible.

The agency failed to develop and maintain a way of providing the agency’s information on its needs and ability to provide assistance to the authorities in an emergency.

The agency failed to implement, document, review, and update an agency staff training and testing program for emergency preparedness based on the risk assessment and required program components.

The home health agency failed to provide an emergency preparedness training based on their established emergency plan, risk assessment, policy and procedures, and communication plan every two years for 2 (staff members D and G) of 7 sampled staff members.

The agency failed to conduct and document the required annual agency staff emergency preparedness testing exercises staff.

The agency failed to implement and document required agency specific risk assessment, policies, and emergency preparedness components into an integrated health system emergency preparedness program.

The agency failed to accurately code the SOC OASIS to reflect clinically significant medication issues identified during the drug regimen review as part of the comprehensive assessment for 3 (#s 1, 3, and 4) of 7 sampled patients.

The agency failed to ensure staff followed acceptable standards of practice for maintaining a clean field, performing hand hygiene, and donning gloves, when preparing medications in the home setting for 1 (#1) of 7 sampled patients.

The agency failed to ensure a process was developed to observe and evaluate services from all disciplines to identify sources of causative factors of infection specific to care and services provided in the home setting.

The agency failed to ensure staff received annual infection control education consistent with accepted standards of practice for infection prevention and treatment to be implemented in the home setting for 7 (staff members D, E, F, G, I, J, and L) of 7 sampled staff members.

The agency failed to ensure a Home Health Aide (HHA) received annual 12 hours of in-service training for 1 (staff member J) of 1 sampled HHA.

The agency failed to ensure staff received periodic training on the protection of patient clinical records in the home-setting for 2 (staff members D and F) of 7 sampled staff.

The agency failed to complete a drug regimen review to include a drug interaction review for any significant drug interactions as part of the comprehensive admission assessment for 4 (#s 1, 2, 3, and 4); and failed to notify the provider of any clinically significant drug interactions found on the…

The agency failed to ensure the development of an updated Plan of Care for SLP therapy visits to include treatment orders, interventions, and goals, for 1 (#1) of 7 sampled patients.

The agency failed to ensure all SLP therapy visits were provided as ordered by the physician for 1 (#1) of 7 sampled patients.

The agency failed to ensure staff prepared and completed documentation of clinical records for SLP therapy visits for 1 (#1) of 7 sampled patients.

The agency failed to ensure skilled professional staff participated in annual in-service trainings for 2 (staff members D and F) of 7 sampled staff members.

The agency failed to ensure a Home Health Aide (HHA) had maintained an active home health aide endorsement of certification from the state agency for completing a training and competency evaluation program specific to the agency and patient needs for 1 (staff member J) of 1 sampled HHA.

The agency failed to ensure an authorized pre-designated individual, who is responsible for fulfilling the role of the administrator in his/her absence was authorized in writing, in advance, and approved by the governing board.

The agency failed to hire direct home health nursing staff instead of utilizing supplemental contracted agency nursing staff when there was not an unexpected staffing shortage identified by the agency for home health nursing services for 1 (staff member D) of 4 sampled registered nurses.