Cimarron Home Care LLC

The agency failed to ensure services and treatments were provided in accordance with physician's orders for 1 of 1 patient records receiving Home Health Aide (HHA) services (Patient #2).

The agency failed to ensure each patient received home health services in accordance with a written plan of care established and periodically reviewed by a physician for 4 of 7 patient records reviewed (Patients #1, #2, #3 and #6).

The agency failed to ensure services and treatments were provided in conformance with physician orders for 2 of 2 patients where occupational therapy (OT) services were ordered on the referral for home health services (Patients #1 and #7).

The agency failed to ensure maintenance of the clinical record which contained past and current information for every patient accepted by the home health agency and receiving home health services including accuracy, adherence to current clinical record documentation standards of practice and…

The agency failed to provide the complete clinical record for 1 of 7 patient records reviewed (Patient #3) and failed to ensure records were maintained and available for review for all patients admitted by the agency or to the State Agency (SA) prior to 4/1/18. AGENCY POLICY According to agency…

The agency failed to ensure all patient medications were reviewed and reconciled for potential interactions, significant side effects, duplications, discrepancies, noncompliance, ineffective therapy or adverse effects for 1 of 7 patient records reviewed (Patient #3).

The agency failed to ensure wound care services and treatments were administered by agency staff only as ordered by a physician for 3 of 4 patient records reviewed who received services for wound care (Patient #2, #4 and #5).

The agency failed to ensure verbal orders were signed and dated with the date of receipt by the registered nurse (RN) responsible for furnishing or supervising the ordered services for 5 of 7 patients reviewed (Patients #1, #2, #4, #5 and #7).

The agency failed to ensure ongoing interdisciplinary assessment occurred to re-evaluate the medical needs as a routine practice, to appropriately reassess the status, needs and overall well being of patients under their care when the patients experienced changes in condition for 1 of 7 patients…