Bethesda Home Health

The home health provider failed to: - Ensure that each patient received an individualized plan of care that includes all elements (Refer to G574); - Ensure that all orders were transcribed and added to the patient’s medical record (Refer to G584); - Ensure that the physician was alerted to changes…

The home health provider failed to ensure that one of four employee files reviewed contained emergency preparedness training on orientation (E-2).

The home health provider failed to ensure that one of four employee files reviewed contained infection control training on orientation (E-2).

The home health provider failed to ensure the initial assessment visit was held within 48 hours of the referral or within 48 hours of the patient’s return home in two of five records reviewed (Records/Patients #3 and #4) and failed to ensure a registered nurse (RN) conducted the initial assessment…

The home health provider failed to conduct an accurate review of all medications taken by the patient in, but not limited to, three of five records reviewed (Records/Patients #1, #2, and #3).

The home health provider failed to provide an individualized plan of care that included, all pertinent diagnosis, all medications and treatments, and patient specific interventions and goals in three of five records reviewed (Records/Patients #2, #4 and #5).

The home health provider failed to ensure physician orders received verbally or by telephone were signed, dated, timed and documented in the clinical record and that verbal orders were authenticated and dated by the physician in two of five records reviewed (Records/Patients #3 and #5).

The home health provider failed to notify the physician of a 21 pound weight loss from 08/26/2023 to 09/13/2023, on a patient with a diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and also was on a diuretic (used to remove excess fluid) and an…

The home health provider failed to ensure that a visit schedule was available to the patient and caregiver in one of three home visits conducted (Record/Patient #2).

The home health provider failed to ensure that the plan of care (POC) was followed in one of five full records reviewed (Record/Patient #2).

The provider may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey.

The home health provider failed to ensure that one out of four employee files contained the family care safety registry (FCSR) check as required and that one out of four employee files contained the employee disqualification list (EDL) check as required (E-1 and E-3).

The agency failed to meet the requirements of 484.58 Condition of Participation: Discharge Planning, when the agency: - Failed to implement an effective discharge planning process (G562); and - Failed to document/send all necessary medical information to the receiving facility or health care…

The agency failed to meet the requirements for 484.60-Condition of Participation: Care Planning, coordination of services, and quality of care, when the agency failed to: - Provide an individualized plan of care that included all required elements (G574); - Promptly alert the relevant physician of…

The agency failed to implement an effective discharge planning process in one (Record/Patient #1) of two closed records reviewed.

The agency failed to send: - All necessary medical information pertaining to the patients' current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility in three (Record/Patient #3, #4 and #6) of three records reviewed that had a…

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the quality of assessment and performance improvement (QAPI) program.

The agency failed to ensure each patient received written information related to the contact information for the home health agency administrator in order to receive complaints in two (Record/Patient #4 and #5) of three applicable home visit records.

The agency failed to provide proper written notice in advance of the agency reducing skilled nursing visits, for one (Record/Patient #1) of five records reviewed.

The agency failed to document the existence of a complaint and resolution of complaint, for one (Record/Patient #1) of five records reviewed.

The agency failed to ensure an accurate medication reconciliation was completed in, but not limited to, two (Records/Patients #4 and #5) of three home visits performed.

The agency failed to ensure that each patients' written individualized care plan included all the required elements in, but not limited to, one (Record/Patient #3) of five records reviewed.

The agency failed to alert the physician to changes in the patient's condition or needs that may suggest that the plan of care (POC) should be altered in, but not limited to, two (Record/Patient #1 and #3) of six records reviewed.

The agency failed to assure communication with all physicians involved in the plan of care in one (Record/Patient #1) of six records reviewed.

The agency failed to ensure each patient received written information related to visit schedule/instructions, in two (Record #4, and #5) of three applicable home visits.

The agency failed to ensure: - A completed transfer summary was sent within two business days of an unplanned transfer in two (Record/Patient #4 and #6) of two records reviewed; and - A completed discharge summary was sent to the primary care practitioner or other health care professional who will…

The agency failed to conduct a full scale exercise (either community - based or individual, facility - based) to test its emergency preparedness plan.

The agency failed to ensure that all nursing, and physical therapy clinicians performed and documented ongoing interdisciplinary assessment in but not limited to two (Records/Patients #4 and #5) of six records reviewed.

The agency failed to assess/document information regarding the patient's advance directive status in but not limited to two (Records/Patients #4 and #5) of six records reviewed for this standard.