Cherokee Regional Home Health

The home health agency failed to ensure all clinical documentation was completed in a timely manner for 4 of 7 sampled patients (Patients #3, #5, #6 and #7).

The home health agency failed to ensure the drug regimen review identified ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for 6 of 7 sampled patients (Patients #1, #2, #3, #5, #6 and #7) . Failure to…

The agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements included following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks…

The agency failed to ensure completion of documentation for routine visit notes were completed within the agency's administrative expectations and/or failed to ensure all documents were authenticated by the author by signature, credentials, date and time of signature for 7 of 7 sampled patients…

The agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 2 of 4 sampled patients requiring a recertification assessment (Patients #4 and #5) and failed to ensure accurate…

The agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #4).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including current physician orders, all supplies/equipment used by the patient to meet individualized needs and accurate, complete medication orders for 6 of 7 sampled patients (Patients #1, #2, #3…

The agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 4 sampled patients with wounds (Patient #2).

The agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address).

The agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 4 of 7 sampled patients (Patients #1, #2, #3 and #4).

The agency failed to ensure a registered nurse completed home health aide supervision at least every 60 days while observing the home health aide present and providing direct patient care for 1 of 1 sampled patients who received hands on personal care services with no skilled service provision.

The agency failed to maintain documentation showing transfer summaries were sent to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to maintain documentation showing discharge summaries were sent to the…

3. Patient #1 had a start of care date of 6/16/18. The clinical record included documentation of a Start of Care Comprehensive Assessment, dated 6/16/18, and two Recertification Comprehensive Assessments, dated 8/13 and 10/12/18. The assessments lacked documentation the nurse reviewed developed or…

The agency failed to ensure all contracted therapists received training in the agency's emergency preparedness policies and procedures.

The agency failed to assure clinicians followed agency policies and procedures when providing wound care to agency patients for 2 of 2 sampled patients who required wound assessments after the initial comprehensive assessment (Patients #1 and #4).

The agency failed to ensure 2 of 3 sampled home health aides (Staff F and G), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 3 sampled patients (Patient #1); had documented evidence of competency by a registered nurse in the assigned task…

The agency failed to ensure accurate and thorough completion of all pertinent components of comprehensive assessments for 4 of 7 sampled patients (Patients #1, #2, #5 and #7).

The agency failed to complete a drug regimen review, including all required components, with each comprehensive assessment for 5 of 7 sampled patients (Patients #1, #2, #3, #4 and #7).

The agency failed to ensure timely completion of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 1 of 3 sampled patients requiring a recertification assessment (Patient #1).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all physician orders, supplies and equipment used by the patient to meet his/her needs and an accurate list of the patient's current medications for 4 of 10 sampled patients (Patients #1…

The agency failed to update the Plan of Care with all new physician orders for 4 of 5 sampled patients admitted after 1/12/18 with interim orders.

The agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 3 of 7 sampled patients (Patients #4, #5 and #6).

The agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions for 3 of 7 sampled patients (Patient #1, #4 and #7).

The agency failed to complete and send a transfer summary to the physician or other health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of knowledge of the occurrence of the transfer for 1 of 1 sampled patients (Patient #5).