Bluebird Home Health

The agency failed to ensure the POCs included all interventions, measurable outcomes, medications, and goals for 2 of 13 patients (Patient #6 and #7) whose records were reviewed.

The agency failed to ensure patients were informed of transfer and discharge policies, confidentiality of information, and financial liability, and were free from abuse.

The agency failed to ensure care and treatments followed the patients' POCs, POCs were individualized, included all pertinent items, and revised as needed, wound care was administered only as ordered, physicians were alerted to changes in patient conditions, and care was coordinated to meet patient…

The agency failed to ensure infection prevention for COVID-19 was well established and education was consistent and clear as to expectations for self-screening and use of PPE.

The agency failed to ensure competency evaluations were conducted and complete, aide plans of care were sufficiently developed, and aide documentation was in accordance with agency policies.

The agency failed to ensure the communication plan included contact information for staff.

The agency failed to ensure OASIS data was transmitted only as required for 1 of 2 patients (Patient #4) whose home health services were covered by private insurance and whose records were reviewed.

The agency failed to ensure encoded OASIS data accurately reflected patient status at the time the OASIS was completed for 1 of 3 patients (Patient #8) who required OASIS data transmission and whose records were reviewed.

The agency failed to ensure each patient received services written in their POCs for 2 of 7 patients (#2 and #4) whose records were reviewed.

The agency failed to ensure adverse patient events were reported, tracked and analyzed for 1 of 1 patient (Patient #8) whose record included documentation of potential exploitation and whose record was reviewed.

The agency failed to ensure infection prevention for COVID-19 was fully established.

The agency failed to ensure clarity and consistency of educational content as it related to COVID-19 precautions.

The agency failed to ensure competency evaluations included direct observation of cares provided on patients or pseudo-patients for 4 of 4 home health aides (A, B, C, and D) whose personnel records were reviewed.

The agency failed to ensure written patient care instructions were complete for 1 of 1 patient (Patient #8) who received aide services and whose aide care plan was reviewed.

The agency failed to ensure patients were provided the agency's transfer and discharge policies for 8 of 8 patients Findings include: An agency policy, "TRANSFER, REFERRAL, AND DISCHARGE CRITERIA AND PROCESS," dated 11/2018, was reviewed.

The agency failed to provide an OASIS privacy notice for 7 of 7 patients (#2 - #8) from whom OASIS data was collected and whose records were reviewed.

The agency failed to ensure allegations of exploitation, a type of abuse, were investigated and resolved to protect 1 of 1 patient (Patient #8) who verbalized allegations of abuse and whose record was reviewed.

The agency failed to ensure clinical information was confidential for 1 of 1 patient (Patient #6) whose SOC assessment was observed.

The agency failed to ensure a Medicare patient was informed in writing of specific financial responsibility for 1 of 3 patients (Patient #5) who had Medicare and whose records were reviewed.

The agency failed to ensure agency staff reported findings of potential abuse to appropriate authorities for 1 of 1 patient (Patient #8) whose record was reviewed and documented potential exploitation.

The agency failed to complete the PT portion of the comprehensive assessment within 5 calendar days of the SOC for 1 of 4 patients (Patient #8) who had orders for PT and whose records were reviewed.

The agency failed to ensure the SOC assessment was comprehensive to include a baseline assessment of edema for 1 of 2 patients (Patient #3) who had a diagnosis of CHF and whose records were reviewed.

The agency failed to ensure the comprehensive assessment identified immediate care needs as it related to social services for 1 of 1 patient (Patient #8) with a need for a social service referral and whose record was reviewed.

The agency failed to ensure medications were reconciled at the time of admission for 1 of 3 patients (Patient #5) who were observed in their home and whose records were reviewed.

The agency failed to ensure an update was conducted to the comprehensive assessment during the last 5 days of the certification period for 1 of 4 patients (Patient #1) who had more than one certification period and whose records were reviewed.

The agency failed to ensure POCs included all required elements for 3 of 7 patients (#2, #4, and #5) whose records were reviewed.

The agency failed to ensure wound treatments were administered as ordered for 2 of 4 patients (#4 and #7) who received wound care and whose records were reviewed.

The agency failed to ensure patients' individualized POCs were reviewed and revised to address changes in patient status and at a minimum of every 60 days, for 2 of 7 patients (#2 and #3) whose records were reviewed.

The agency failed to ensure an out-of-range temperature was reported to the physician for 1 of 1 patient (Patient #1) whose temperature was documented out of an acceptable range and whose medical record was reviewed.

The agency failed to ensure coordination of care delivery included the patient/caregiver to meet patient needs for 1 of 1 patients (Patient #8) whose record included documentation of potential exploitation and whose record was reviewed.

The agency failed to ensure ongoing interdisciplinary assessment of 4 of 7 patients (#2, #3, #4, and #8) whose records were reviewed.

The agency failed to ensure patient education related to CHF was provided for 1 of 2 patients (Patient #2) who had a diagnosis of CHF and whose records were reviewed.

The agency failed to ensure clinical record documentation was accurate for 1 of 7 patients (Patient #2) whose records were reviewed.

The agency failed to ensure appropriate aide documentation was completed for 1 of 1 patient (Patient #8) who received aide services and whose record was reviewed.

The agency failed to ensure a transfer summary was sent to the receiving hospital for 1 of 1 patient (Patient #4), who was transferred to the hospital and whose record was reviewed.