Carefirst Rehab LLC

The agency failed to ensure home health aides had written patient care instructions prepared by a registered nurse or other appropriate skilled professional for 1 of 3 patients with home health aides, records reviewed (Patient #13).

The agency failed to ensure patients were advised in writing of the charges for services the individual may have to pay before care is initiated for 8 of 17 patient records reviewed (Patient #1, #4, #5, #6, #7, #13, #15, #17).

The agency failed to ensure the initial assessment visit was completed within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician ordered start of care date for 8 of 11 skilled nursing records reviewed (Patients #3, #5, #7, #8, #13, #14, #15, and #17).

The agency failed to ensure the initial assessment visit was completed within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician ordered start of care date for 2 of 6 therapy only records reviewed (Patients #4 and #9).

The agency failed to ensure an update of the comprehensive assessment was completed within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician ordered resumption date for 1 of 5 discharged patient…

The agency failed to ensure a registered nurse completed a supervisory assessment of the aide services being provided no less frequently than every 14 days for 1 of 3 patients with home health aides, records reviewed (Patient #15).

The agency failed to ensure patients were provided written notice of transfer and discharge policies for 14 of 14 records reviewed with the potential to affect all 141 active patients.

The agency failed to review and update all patient medications every 60 days and failed to have documentation in the clinical record addressing any potential adverse reactions for 14 of 14 clinical records reviewed.

The agency failed to ensure all patient care orders were included in the plan of care for 3 of 5 home visits folders reviewed.

The agency failed to promptly alert the physician of changes in the patient's condition for 2 of 2 clinical records reviewed of patients with histories of UTIs (Urinary Tract Infection).

The agency failed to provide medication instructions in plain language for 5 of 5 home visit clinical records reviewed.

The skilled nurse failed to ensure all clinical notes were accurate and depicted an accurate assessment of the patient for 1 of 5 closed records reviewed.

The agency failed to document all interventions and patient responses to those interventions for 3 of 4 complex patient clinical records reviewed.

The agency failed to send a detailed discharge summary to the primary care practitioner including admission and discharge dates, types of services and frequencies, medications patient is on at discharge, outcomes in meeting goals, and post-discharge instructions for 5 of 5 closed records reviewed.

The agency failed to evidence implementation of their policy for use of volunteers and collaboration efforts with State and Federal designated health care professionals for 1 of 1 agency.

The home health agency failed to identify the potential duplicative drug therapy and ensure the accuracy of all medications in a timely and prompt manner for 1 (Patient #8) of 7 active clinical records of a total sample of 10 records The findings include: Review of an undated agency policy titled…

The home health agency failed to ensure the physician was promptly alerted to a change in the patient's condition as outlined in the plan of care in 1 (patient #3) of 7 active clinical records in a total sample of 10 clinical records.

The home health agency failed to ensure the plan of care was revised to include current medication and patient specific interventions in 1 (Patient # 3) of 7 active clinical records of a total sample of 10 patient records.