Bethany Cares Inc D/B/a

The home health agency failed to ensure all Registered Nurses (RNs) followed agency policy specific to frequency of wound measurement for 1 of 1 records reviewed of a patient with an active wound (Registered Nurse #6).

The home health agency failed to ensure all Registered Nurses (RNs) followed agency policy specific to frequency of wound measurement for 1 of 1 records reviewed of a patient with an active wound (Patient #11).

The home health agency failed to ensure the agency did not provide a home health aide training and competency evaluation program while precluded from offering such programs for 1 of 1 home health agency.

The agency failed to notify the patient’s provider, per agency policy, of a change in wound status, abnormal urinary symptoms, and abnormal bowel movement color and consistency (See G590) and failed to ensure staff coordinated care with the patient’s primary caregiver regarding missing a supply of…

The home health agency failed to maintain an emergency preparedness plan which included a facility-based and community-based risk assessment completed biennially, which had the potential to affect all agency patients and employees.

The home health agency failed to ensure all staff followed standard precautions and infection control policies and procedures for 3 of 3 home visit observations (Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #2, Home Health Aide (HHA) #3).

The home health agency failed to ensure the aide care plan was detailed and specific to the individual patient for 4 of 4 records reviewed of patients receiving home health aide services (Patients #1, 3, 4 and 6).

The home health agency failed to follow its policy of documenting its communication with the responsible physician regarding the need to discharge a patient for noncompliance with the plan of care, the measures the agency took to investigate the patient’s refusal of services, and the interventions…

The agency failed to notify the patient’s provider according to agency policy of a change in wound status, abnormal urinary symptoms, and abnormal bowel movement color and consistency, for 1 of 1 clinical records reviewed which evidenced a change in patient condition (Patient #4).

The home health agency failed to ensure staff coordinated care with the patient’s primary caregiver regarding missing a supply of an emergency seizure medication for 1 of 1 nurse visit observations with a patient with emergency seizure medications (Patient #2).

The home health agency failed to ensure the home health aide completed appropriate documentation of care in compliance with the home health agency’s policies and procedures for 1 of 4 active patients who received home health aide services (Patient #1.) Findings include: 1. Review of Policy C-140…

The agency failed to ensure infection control precautions were maintained for 2 of 2 patients with home visit observations (#1, 3).

The agency failed to ensure COVID infection control precautions were followed for 2 of 2 patient home visit observations (#1, 3).

The agency failed to ensure patients had the right to receive services outlined in the plan of care if they had a bed bug infestation.

The agency failed to ensure confidentiality of clinical records.

The agency's Registered Nurse (RN) failed to ensure the comprehensive assessment contained an accurate assessment of the patient's functional status for 1 of 2 records with home visits (#1).

The agency failed to ensure comprehensive assessments contained strengths identified by the patient for 3 of 4 active skilled nursing patient records reviewed (#1, 2, 5).

The agency failed ensure comprehensive assessments contained the patient's primary caregiver's availability, willingness, and schedule they're able to provide care for 3 of 4 active skilled nursing patient records reviewed (#1, 2, 5).

The agency failed to ensure accurate and complete information was on the plan of care for 1 of 4 active skilled nursing records reviewed (#5).

The home health agency failed to ensure the patients were not neglected by accurately completing an environmental safety assessment to identify any and all safety concerns that could lead to an adverse event or psychological harm; the administrative staff failed to ensure proper use of a hoyer lift…

The agency failed to meet the needs of the patient, ensure the plan of care contained all required information.

The agency failed to ensure a thorough quality assessment and performance improvement (QAPI) plan was developed, implemented, evaluated, and approved by the governing body.

The home health agency failed to ensure home health aides (HHA) were oriented and were competencied on the proper use of hoyer lifts for 7 of 7 interviewed HHA's (B, D H, P, R, S, U) and were trained on patient specific hoyer lifts via manufacturer's instructions for use for patients they cared for…

The agency failed to ensure their quality assessment performance improvement (QAPI) program measured, analyzed, and tracked adverse events, falls, or any other performance data and failed to show measurable improvement in those areas.

The agency failed to utilize quality indicators such as outcome and assessment information set (OASIS), or other data collection to monitor the effectiveness of care or identify opportunities for improvement, and failed to ensure the frequency and detail of the data collection was approved by the…

The agency failed to ensure all staff followed infection control policies and standard precautions for 3 of 4 home visits observed (# 1, 2, 6).

The agency failed to ensure all home health aides (HHA) successfully completed an entire competency program by verifying skills on a patient or pseudo-patient for 2 of 2 interviewed HHA's regarding competency check off's (B, F).

The governing body failed to assume full legal authority and responsibility for the agency's fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.

The agency failed to ensure that all entries into the record were appropriately authenticated with clear and accurate content for 5 of 5 home health aides interviewed (B, H, P, R, S) and 2 of 12 clinical records within the electronic medical record (# 3, 15).

The agency failed to make efforts to resolve problems with the caregiver prior to discharging the patient for 1 of 3 discharged records reviewed (#3).

The registered nurse (RN) failed to ensure the comprehensive assessment contained individual patient strengths, goals and preferences for 12 of 12 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 16).

The registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications, drug interactions were identified, and medication lists were accurately maintained for 5 of 12 records reviewed (#1, 2, 6, 7, 15) Findings include: 1. An undated agency policy…

The registered nurse (RN) failed to identify availability of caregiver assistance for 9 of 9 records reviewed with primary caregivers (#1, 3 ,4, 5, 6, 7, 8, 9, 15).

The agency failed to ensure the plan of care (POC) included all measurable goals based on the needs of the comprehensive assessment, all nutrition/fluid orders, durable medical equipment (DME), frequency and duration of all disciplines, treatment orders, diagnoses, and all functional limitations…

The agency failed to ensure performance improvement plans were initiated and implemented prior to the notification by the surveyor of safety and concern, and failed to measure and track performance improvements previously identified.

The registered nurse (RN) failed to assess the patient after a fall for 1 of 1 patients reviewed for falls (#3).

The registered nurse (RN) failed to follow the plan of care (POC) for 2 of 3 records reviewed with skilled nursing services only (#6, 9).

The home health aide (HHA) failed to follow the plan of care and completed tasks beyond their scope of practice for 5 of 9 records reviewed with HHA services (#2, 5, 10, 16).

The agency failed to ensure written agreements were in place with other agency's providing care in the home for 6 of 6 records reviewed with shared patients (#9, 11, 18, 19, 20, 21).

The agency failed to ensure all shared patients had one primary home health agency (HHA)identified for 6 of 6 records reviewed with shared patients (#9, 11, 18, 19, 20, 21).

The Registered Nurse (RN) failed to perform a suprapubic catheter insertion utilizing aseptic technique and failed to follow physician orders related to catheter insertion for 1 of 1 suprapubic catheter insertions observed (#2).

The agency failed to ensure the comprehensive assessments/OASIS data accurately reflected the patient's status at the time of the assessment for 1 of 12 patients whose clinical record was reviewed (Patient #7.) The findings included: 1. Review of a policy, "Comprehensive Client Assessment,"…

The agency failed to follow their policy to recognize, take immediate action, and thoroughly investigate complaints of narcotic theft and when the same registered nurse demonstrated impairment during working hours.

The agency administrator failed to have a system in place to establish a data collection process to include an established methodology to measure, analyze and track quality indicators and be able to show measurable improvement in those indicators to improve patient health outcomes, patient safety…

The agency failed to establish a data collection process to include adverse patient events, their causes, and implement preventative measures for improvement.

The agency governing body failed to establish an effective quality improvement program where quality of care and patient safety are defined and evaluated for effectiveness.

The agency failed to establish a system for identifying and tracking infectious and communicable diseases, failed to have a system in place to investigate any identified infectious and communicable diseases, and failed to have a system in place for the prevention and control of any identified…

The agency failed to follow their policy and failed to provide community resources to aide a guardian with locating another home health agency for an appropriate transfer of care and failed to provide adequate discharge notice, in 1 of 7 discharged charts reviewed.

The agency failed to investigate and appropriate resolve a grievance in regards to a family concern of properly oriented staff providing care and inability to provide a notice of an advanced schedule in 1 out of 3 complaints reviewed of patient complaints of quality of care in a sample of 15.…

The agency failed to ensure a registered nurse performed an initial assessment of patient to determine the patients' immediate care and support needs for 2 of 12 patients (Patients #7 and 15).

The agency failed to ensure the comprehensive assessment was not performed prior to the establishment of a start of care for 2 of 12 patients whose clinical records were reviewed (Patient #7 and 15).

The agency failed to ensure a comprehensive assessment/OASIS was performed and retained in the clinical record for 1 of 7 discharged patients (Patient #7).

The agency failed to ensure the plan of care contained all the medications the patient was taking for 1 of 12 patients (Patient #7); failed to ensure the secondary diagnoses were correct for 1 of 12 patients (Patient #7); failed to ensure all nutritional requirements were on the plan of care for 1…

Agency registered nurses failed to provide services that are ordered by the physician as indicated on the plan of care for 1 of 12 patient records reviewed.

The agency failed to ensure the registered nurse notified the attending physician of a patient's hypo/hyperglycemic episodes and failed to notify the attending physician of a patient's emergency room visit for 2 of 12 patients with a change in condition (Patient #3 and 7) and failed to ensure…

The agency failed to ensure clinicians providing services and on call staff coordinated with each other in relation to a patient having hypo / hyperglycemic episodes in 1 out of 12 records reviewed.

The agency failed to ensure nurses performed ongoing assessments of 2 of 12 patients (Patient #3 and 7).

The registered nurses failed to provide services that are ordered by the physician as indicated on the plan of care for 1 of 12 patient records reviewed.

The licensed practical nurses failed to ensure prepared clinical notes were complete for 1 of 12 patients' records reviewed (Patient #7).

The agency failed to ensure the registered nurse notified the attending physician of a patient's hypo/hyperglycemic episodes and failed to notify the attending physician of a patient's emergency room visit for 2 of 12 patients with a change in condition (Patient #3 and 7) and failed to ensure…

The clinical manager failed to assure communication, documentation and appropriate interventions occurred between nurses, home health aides and after hours on-call staff regarding patient emergencies or urgent needs for 1 of 12 clinical records reviewed.

The clinical manager failed to put a system in place to maintain records of all incoming referrals and provide oversight of the status of the patients referral evaluation for admission in 1 of 1 agency.

The clinical manager failed to ensure nurses performed ongoing assessments of 2 of 12 patients (Patient #3 and 7).

The agency failed to follow policy and ensure a sixty day (60) summary contained accurate information in a certification period in 1 out of 12 records reviewed.

The agency failed to ensure a discharge summary was documented in the clinical record, as required by agency policy, for 1 of 7 discharged patients whose clinical record was reviewed (Patient #7).