Caretenders

The home health agency failed to ensure a comprehensive assessment was completed in 2 of 2 active clinical records reviewed where a decline in the patient’s health status occurred (Patient #1, 3).

The home health agency failed to ensure care was coordinated in 1 of 7 active clinical records reviewed.

The home health agency failed to ensure skilled professionals provided services as ordered in the plan of care in 3 of 5 clinical records reviewed.

The home health agency failed to ensure skilled professionals accurately prepared clinical notes and assessments in 5 of 10 clinical records reviewed (Patient #2, 5, 6, 7, 8).

The home health agency failed to: ensure the initial assessment visit was held within 48 hours of referral, the patient’s return home, or on the physician ordered start of care date (see tag G514); ensure the comprehensive assessments included the patient’s current health, psychosocial, functional…

The home health agency failed to: ensure patients received the home health services which were written in an individualized plan of care (see tag G572); ensure the plan of care included: all pertinent diagnoses, the patients’ mental/psychosocial, and cognitive status, the types of services…

The home health agency failed to ensure patients received an individualized emergency preparedness plan as part of the comprehensive assessment in 5 of 7 home visits conducted.

A document dated and signed by Person #28 on 9/29/22, titled “Referral Order” evidenced the agency received a referral for homecare services on 9/29/22. The document failed to evidence the physician ordered a specific start of care date.

The home health agency failed to ensure the comprehensive assessment was updated in 4 of 4 clinical records reviewed where a major decline in the patient’s health status occurred (#9, 13, 14, 16).

The agency failed to ensure the patient received all services included in the plan of care, the plan of care was individualized, and/or the patient received all services ordered by the referring physician for 15 of 17 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 14, 15, 16, 17).

The home health agency failed to review and revise the plan of care in 3 of 7 home visits conducted.

The home health agency failed to ensure the registered nurse completed the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician ordered start of care date in 7 of 17 clinical records reviewed.

The home health agency failed to ensure the comprehensive assessment included a review of all medications the patient was using to identify potential adverse effects, including ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy, and/or…

The home health agency failed to ensure a comprehensive assessment occurred within 48 hours, for 1 of 1 clinical record reviewed with a patient who returned home from a hospital admission of 24 hours or more during the certification period (#16).

The home health agency failed to ensure the plan of care included: all pertinent diagnoses, the patients’ mental/psychosocial, and cognitive status, the types of services, supplies and equipment required, the frequency and duration of visits to be made, nutritional requirements, all medications and…

The home health agency failed to ensure treatments were administered only as ordered by the physician in 1 of 7 home visits conducted.

The home health agency failed to promptly alert the relevant physician to any changes in the patients’ conditions or needs which suggested outcomes were not being achieved and/or the plan of care should have been altered in 10 of 17 clinical records reviewed.

The home health agency failed to coordinate care delivery to meet the patient’s needs in 5 of 17 clinical records reviewed.

The home health agency failed to provide patients with written schedules in 3 of 7 home visits conducted.

The home health agency failed to ensure patients received written medication instructions which included the medication name, dosage, and frequency of medications in 6 of 7 home visits conducted.

The home health agency failed to ensure patients received in writing any treatments to be administered by home health agency personnel or personnel acting on behalf of the home health agency in 2 of 7 home visits observed (#4, 12).

The home health agency failed to ensure the performance improvement activities led to an immediate correction of any identified problems which directly or potentially threatened the health and safety of patients.

The home health agency failed to ensure skilled professionals accurately prepared clinical notes and assessments in 11 of 17 clinical records reviewed (#1, 2, 3, 5, 7, 8, 9, 13, 14, 15, 16).

The home health agency failed to ensure skilled professionals communicated with all physicians involved in the plan of care in 1 of 5 discharged clinical records reviewed.