Community Health Center of Branch County

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 2 of 2…

The Agency failed to adequately assess and monitor the needs of 1 (MR #1) of 1 patient observed during a Physical Therapy home visit, and 2 (MR#'s 5 and 6) of 2 records reviewed with therapy only cases, from a total sample of 7 sampled records reviewed, resulting in the potential for poor patient…

The Agency failed to ensure the Governing Body had reviewed and approved policies and procedures specific to the Home Health Agency, resulting in a lack of clear guidance concerning the Agency's expectations concerning the provision of home health care services, which has the potential to…

The Agency failed to ensure patients were informed in advance of the disciplines that will furnish care and the proposed visit frequency in 3 of 3 (MR#'s 1, 2, and 3) records reviewed with home visits, out of a total sample of 7 records, resulting in these patients not having knowledge regarding…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, severe drug to drug interactions, and duplicate drug therapies in 1 record (MR# 4) from a total of 7 sampled records reviewed, resulting in the potential for harmful…

The Agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 3 (MR#'s 3, 5 and 6) of 7 sampled records reviewed, resulting in patients not receiving care…

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure the patient's family or guardian was notified of their right to exercise the patient's rights in one of two records reviewed in which the patient had diagnoses of dementia or a cognitive impairment and signed their own consents (MR#9) of a total sample of 13 records…

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments…

The agency failed to ensure skilled professional services were provided as ordered by the physician for 1 of 13 records reviewed (MR# 9), resulting in the potential for poor outcomes for these patients.

The agency failed to ensure the registered nurse prepared clear written patient care instructions for the home health aide regarding patient needs prior to providing care for 1 of 5 patients (MR# 12) in which home health aide services were provided, resulting in the potential for the provision of…

The Agency (HHA) failed to inform the patient, in advance, of the disciplines that will furnish care, and the proposed visit frequency in one of a total of thirteen sampled records reviewed (MR# 1), resulting in the patient not having knowledge or a say in the plan for treatment.

The agency failed to inform the patient/caregiver before care was initiated of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient in two of thirteen sampled records…

The Agency failed to ensure the comprehensive assessment included a review of all medications in the patient's home in 1 record (MR #5), from a total of 13 sampled records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this Agency.

The agency failed to ensure the plan of care (POC) was patient specific and individualized to the patient's identified needs, covered all pertinent interventions, reportable parameters, safety measures, supplies, and functional limitations in 4 of 13 sampled records reviewed (MR#s 1, 2, 6, and 11)…

The agency failed to ensure the physician was notified of changes in the patient's condition in 1 of 1 records reviewed (MR#1) in which the patient was diagnosed with end stage renal disease requiring dialysis and treatment for cellulitis, resulting in the agency not following the "Physician…

The Agency failed to coordinate care to meet the needs of the patient for 1 of 13 (MR# 6) sampled patients, resulting in the potential for unmet care needs for all patients admitted.

The Agency failed to notify the physician of significant changes in the patient's condition for 1 of 13 (MR# 6) sampled patients, resulting in the potential for unmet care needs for all patients admitted.

The agency failed to ensure the home health aide provided care in accordance with the plan of care for 3 of 5 (MR# 10, 12, and 13) patients in which aide services were provided, resulting in the aide failing to provide the service frequency ordered in the plan of care.

The agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes in 7 of a total of 13 sampled records reviewed (MR#s: 1, 2, 3, 4, 5, 6, and 9), resulting in difficulty determining the patient's progress toward the achievement of goals.

The agency failed to notify the physician of the patients discharge in 4 of 4 discharged records reviewed (MR# 3, 4, 9, and 10) and 2 of 2 transfer records (MR# 5 and 7) from a total of 13 records reviewed.