Cj's Abundant Care

The home health agency failed to ensure OASIS transmissions were sent on time for 1 of 1 agency.

The home health agency failed to ensure patients were provided with the Administrator’s contact information, including name, in order to receive complaints for 1 of 1 agency.

The home health agency failed to ensure all staff followed standard precautions and agency infection prevention policies and procedures for 3 of 3 home visit observations conducted (Patients #1, 2).

The home health agency failed to ensure the plan of care contained all pertinent diagnoses and patient-specific and measurable goals for 5 of 5 active records reviewed (Patients #1, 2, 3, 4, 5).

The Registered Nurse (RN) failed to conduct a complete and thorough physical assessment for 1 of 1 home visit observations of a skilled nurse visit (Patient #2) and 3 of 5 active records reviewed (Patients #1, 2, 5).

The agency failed to ensure the plan of care (POC ) contained specific supplies and treatment instructions for 1 of 7 records reviewed.

The agency failed to ensure the plan of care had been updated to include the current visit frequency for skilled nursing (SN) in 1 of 7 records reviewed.

The skilled nurse (SN) failed to ensure they followed the frequency in the plan of care for 1 of 7 patients reviewed.

The skilled nurse (SN) failed to ensure visit notes evidence descriptions or documentation of which medications were given and failed to describe any technique for injections or where the injections were given in 1 of 2 discharged patients in a sample of 7 records reviewed.

The agency failed to ensure clinical records complete and contained all skilled nursing visit notes in 1 of 2 discharged patients in a sample of 7 records reviewed.

The agency failed to ensure clinical records contained documentation of medication administration in 1 of 2 discharged patients in a sample of 7 records reviewed.