Caretenders

The agency failed to obtain signatures of the physician or allowed practitioner in order to administer services and treatments for 1 of 2 active patients.

The agency failed to ensure an order for Registered Nurse (RN) evaluation was completed in a timely manner for 1 of 5 active patient records reviewed (Patient #5) and 1 of 1 discharged patient records reviewed (Patient #3).

The agency failed to ensure that patient comprehensive assessments were completed by the appropriate skilled professional for 1 of 1 therapy patient records reviewed (Patient #4).

The agency failed to ensure an update of the comprehensive assessment was completed within the last 5 days of every 60 days beginning with the start-of-care date for 3 of 5 active patient records reviewed (Patient #4, #6, #7).

The agency failed to revise the Plan of Care (POC) to reflect medications the patients were currently taking for 5 of 7 home visits/ (Patient's #1, #2, #4, #5, & #6) Findings include: 1. A revised policy dated 12/01/2021 titled “Plan of Care” was provided on 01/11/2024 at 1:24 PM by the…

The agency failed to ensure a current plan of care was provided to the patient for 6 of 7 home visits (Patients #1, #2, #3, #4, #5, #6).

The agency failed to ensure standard infection control precautions were followed during an agency tour for 1 of 1 Home Health Agency.

The Administrator failed to ensure influenza vaccines were stored in a designated refrigerator with maintained and regulated temperature for 1 of 1 Home Health Agency.

The agency failed to provide a current medication schedule to the patient including medication name, dosage, and frequency for 5 of 7 home visits (Patient #1, #2, #4, #5, #6).

The Administrator failed to ensure that staff followed standard precautions and guidelines for urine specimen storage for 1 of 1 Home Health Agency.

The agency failed to evidence all policies had been approved or adopted by the Governing Body for 1 of 1 home health agency's reviewed.

The agency failed to provide patients with a written medication list for 4 of 7 home visit observations.

The agency failed to provide written information describing the services the patient would be receiving as ordered on the plan of care on 5 of 7 admission packets reviewed.

The administrator failed to maintain responsibility for all day to day operations of the home health agency and failed to ensure all policies were specific to the home health agency for 1 of 1 agency.

The agency failed to ensure the plan of care included all supplies and equipment required for 2 (#6 and 8) and failed to ensure the plan of care accurately identified a patient's wound for treatment in 1 (#7) out of 5 records of patients with wounds in a sample of 13. Findings Include: 1. The…

The agency failed to ensure a physician order was written in 1 (#4) of 13 records reviewed.

The agency failed to follow their policy and ensure the ongoing nursing assessments accurately reflected the status of the patient's wounds in 3 (#1,3 and 7) of 5 records reviewed for patients with wounds in a sample of 13. Findings Include: 1. An undated agency policy titled Wound Management…

The agency failed to ensure the registered nurse completed home health aide supervisory visits at least every 14 days in 1(#12) of 2 skilled patients who received home health aide services in a sample of 13. Findings Include: 1. The clinical record for patient #12, start of care 11/27/17 was…

The agency failed to ensure all assessments in the clinical record were clear and accurate in 1 (#7) of 5 records reviewed of patient with wounds in a sample of 13. Findings Include: 1. The clinical record for patient #7, start of care 8/8/17, was reviewed 2/12/18. The record included a plan of…