Community Home Care Services

The agency failed to ensure 5 out of 5 annual Emergency Preparedness (EP) testing drills reviewed included all documentation including staff participation and event specific information regarding details of the exercise, resulting in the potential for an unprepared staff response during an…

The agency failed to ensure missed visits altering the plan of care frequency were communicated with the doctor per agency policy in 3 (Patient #2, 3, 4) of 10 records reviewed, resulting in the potential for unmet patient care needs and poor patient outcomes.

The agency failed to ensure the home health aide followed accepted standards of practice in infection control according to agency policy in 1 (P-1) of 1 observation in which a joint survey home visit was conducted with a home health aide, potentially resulting in transmission of infectious disease…

The agency failed to ensure that 2 (P-8, P-9) of 10 overall patient planning of care records reviewed included informing the patient/caregiver in advance of potential payment charges, resulting in a lack of inclusion in planning, lack of informed consent, and unmet care needs.

The agency failed to notify the physician/practitioner the initial assessment to determine immediate care needs and home care eligibility would not be performed within 48 hours of referral in 1 (Patient #3) of 10 records reviewed, resulting in the potential for unidentified patient care needs.

The agency failed to ensure the comprehensive assessment included identification of duplicate drug therapy for 3 (P-1, P-9, P-10) of 10 records reviewed resulting in the potential for an undetected harmful medication related poor outcome for this patient.

The agency failed to ensure that orders for frequency and duration of visits were included on the Plan of Care in 2 of 7 records reviewed (Patient #5, 7); and the agency failed to ensure the goals on the Plans of Care were objectively measurable to determine the patient's progress towards obtaining…

The agency failed to promptly notify the Physician concerning a vital sign outside of the specified reportable parameters for 1 (P-10) of 10 records reviewed, resulting in a potential poor clinical outcome.

The agency failed to ensure the home health aide provided only the services which were included in the Plan of Care in 1 (P-1) of 1 observation for which a joint home visit was conducted with the home health aide, resulting in unsafe care and the potential for a poor patient outcome.

The agency failed to ensure the home health aide provided only a passive role in assisting the patient with a medication in 1 (P-1) of 1 observation for which a joint home visit was conducted with the home health aide, potentially resulting in unintended consequences of a medication…

The agency failed to ensure the clinical record contained all interventions, treatments, services, and responses to treatment in 2 (Patient #3, 4) of 10 records reviewed, resulting in an incomplete medical record.

The agency failed to complete a transfer and/or discharge summary that included all pertinent information and was sent to the physician in 3 of 3 transferred/discharged records reviewed (P-6, P-7, P-10), resulting in no information regarding the goals accomplished during the course of care, and the…

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 2 (MR's #10, 12) of 13 sampled records reviewed, resulting in a poor outcome and patients not…

The Agency failed to ensure Skilled Nursing utilized Infection Control Standards of Practice during the provision of wound care observed during a home visit (MR #3) (See G 682); and failed to ensure contingency plans were in place to help mitigate the spread of COVID-19 due to unvaccinated staff…

The Registered Nurse failed to utilize professional standards of practice during the patient assessment, the provision of wound care and accurate documentation for 1 (MR #3) of 2 patients observed during a home visit, from a total of 13 sampled records reviewed, resulting in the potential for…

The Agency failed to ensure an Emergency Preparedness Plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, that included identification of the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor…

The Agency failed to provide documentation for the required Tabletop, Community/Facility based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan since its initiation in 2009, resulting in the potential to affect staff and all patients…

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, and ascertained the patient's immediate care needs in 2 of 13 records reviewed (MR's #8, 12) out of…

The Registered Nurse failed to utilize Infection Control Standards of Practice during the provision of wound care for 1 (MR #3) of 1 patient observed during a home visit who received wound care services, from a total of 13 sampled records reviewed resulting the potential for the development and…

The Agency failed to ensure unvaccinated staff had implemented additional infection control measures as required, resulting in the potential for the development and spread of the COVID-19 infection for all 125 patients currently serviced by this Agency.

The Registered Nurse failed to utilize professional standards of practice during the patient assessment, the provision of wound care and accurate documentation for 1 (MR #3) of 2 patients observed during a home visit, from a total of 13 sampled records reviewed, resulting in the potential for…

The Agency failed to ensure the Registered Nurse prepared clear written patient care instructions for the Home Health Aide regarding client needs, prior to providing care in 4 (MR's #5, 7, 8, 12) of 5 records in which Home Health Aide services were provided, from a total of 13 sampled records…

The Agency failed to ensure that 4 (MR's #3, 4, 8, and 9) of 5 patient's observed during home visits, from a total of 13 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, from…

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 2 (MR's #10, 12) of 13 sampled records reviewed, resulting in a poor outcome and patients not…

The Agency failed to ensure the Registered Nurse promptly notified the Physician of 2 (MR's #5, 10) of 2 patients who experienced an elevated blood sugar outside of the reportable parameters, from a total of 13 sampled records reviewed, resulting in the potential unidentified, untreated health…

The Agency's skilled professional services failed to coordinate care to ensure communication with patient care team members was effective for facilitating care as ordered by the physician for 1 (MR #13) of 1 records with reviewed with recent multiple falls, resulting in unmet care needs and an…

The Agency failed to provide 2 (MR's #3, 4) of 2 patients observed during a home visit, with a Medication Profile that included the names, dosages, frequencies, indications for use and side effects of the patient's prescribed medications, in plain language, from a total of 13 sampled records…

The Registered Nurse failed to accurately assess the patients upon admission and throughout the course of care in 2 (MR’s #3, 5) of 2 records reviewed of patients who required ongoing monitoring of weights and edema, from a total of 13 sampled records reviewed, resulting in the potential for…

The Occupational Therapist and Physical Therapist failed to conduct an accurate and complete evaluation of the patient's range of motion status in order to assist the Physician with developing a plan of care in 2 (MR's #4, 2) of 2 records of patients who required Therapy services, from a total of…

The Agency failed to ensure Skilled Nursing services were provided as ordered for 1 (MR #6) of 1 record of a patient who required Skilled Nursing services, and failed to ensure the Skilled Nurse followed the plan of care for 1 (MR #5) 1 patient who required monitoring for fluid overload, from a…

The Agency failed to ensure the RN (registered nurse) supervised the care provided by the LPN (licensed practical nurse) in 2 of 8 records reviewed in which LPN services were provided (MR#'s 12 and 13), from a total sample of 13 records reviewed, resulting in a lack of clinical supervision and…

The Agency failed to ensure the PT (physical therapist) supervised the care provided by the PTA (physical therapy assistant) in 2 of 9 records reviewed in which PTA services were provided (MR#'s 9 and 13), from a total sample of 13 records reviewed, resulting in a lack of clinical supervision and…

The Agency failed to ensure the Administrator was appointed by, and reported to the Governing Body resulting in the potential for lack of oversight of the Agency's functions and unmet patient care needs.

The Agency failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions.

The Agency failed to insure a detailed discharge summary had been completed and sent to the physician within 5 business days of discharge for 2 (MR's #1, 2) of 4 records where the patient was discharged from Agency services, resulting in a lack of information to ensure continuity of care and the…

The agency failed to ensure the Emergency Preparedness Plan addressed the services the agency could provide during an emergency and succession plans, affecting 504 of 504 patients served by the agency in the past 12 months, resulting the agency not being prepared to respond effectively during an…

The agency failed to have a process to contact and collaborate with local, tribal, regional, State and Federal emergency preparedness officials to prepare an integrated emergency preparedness program.

The Facility's Emergency Preparedness (EP) plan policies and procedures failed to address a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records affecting all 504 patients served by the…

The agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, local emergency preparedness staff and other sources of assistance, affecting all 504 patients served in the last 12 months, resulting in…

The agency failed to develop and maintain an emergency preparedness communication plan that included a primary and alternate means for communicating with staff, Federal, State, tribal, regional, and local emergency preparedness officials, affecting all 504 patients admitted to the agency in the…

The agency failed to develop and maintain an emergency preparedness communication plan that included a method for sharing information and medical documentation for patients under the agency's care with other health providers to maintain the continuity of care; a means, in the event of an…

The agency failed to maintain compliance with this condition of participation.

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, and history of events leading to current home care needs in 6…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 16 records…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 7 of 22 records reviewed (M.R.#s 9, 11, 12, 13, 18, 20 and 22), and failed to be comprehensive in 2 of 22 records (MR #'s 1 and 5) resulting in the potential for a plan of care not meeting the…

The agency failed to ensure treatments were provided in accordance with a physician's order in 1 of 22 records reviewed (MR #18), which resulted in the potential for the patient to receive inappropriate treatments.

The agency failed to ensure that skilled services were administered in accordance with the physician's orders and the plan of care (POC) in 1 (MR#'s 21) of 22 sampled patient records reviewed for skilled services and failed to ensure home health aid services were provided in accordance with the…

The Agency failed to ensure Skilled Nursing notified the physician in 1 of 22 records reviewed (MR#15) regarding significant clinical findings from a total of 22 records reviewed resulting in a poor patient outcome and the potential for adverse effects for all patients serviced by this Agency.

The agency failed to notify the physician of the patients transfer in 1 of 3 transfer records reviewed (MR# 15) from a total of 22 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs.