Deaconess Home Health, LLC

The agency failed to ensure patient’s clinical records were made available to a patient within 4 business days of request for 1 of 1 active patient on the medical record request log (Patient #12).

The agency failed to provide the name and contact information for the agency's Clinical Manager for 9 of 9 home visits conducted (Patients #1, #2, #3, #4, #5, #7, #8, #9, and #25).

The agency failed to have a signed POC or a verbal POC order from the primary physician before providing services and treatments to patients for 2 of 3 closed record reviews.

The agency failed to develop and maintain an emergency plan for each hazard identified in the all-hazard risk assessment, outlined in the agencies emergency preparedness policy for 1 of 1 emergency preparedness plans reviewed.

The agency failed to ensure a copy of written instructions for emergency preparedness, written instruction sheet on safety, and explanation of service coverage was provided to patients for 5 of 7 home visit observations.

The agency failed to ensure standard infection control precautions were followed for 3 of 7 home visit observations.

The agency failed to resolve 4 of 4 complaints made in regard to not answering the telephone.

The agency failed to ensure all medication, treatments, mental status, and labs were listed on the current plan of care for 9 of 18 active record reviews (Patients #4, #5, #6, #7, #9, #14, #15, #16, #17); and failed to ensure all entities providing care were listed on the current plan of care for…

The agency failed to obtain physician orders for services being provided for patient care for 2 of 24 records reviewed.

The agency failed to maintain Home Health Aid (HHA) competency documentation to ensure employee meets qualifications required for job performance for 1 of 7 personnel file review.

The agency failed to ensure the home health aide reported skin integrity issues to the nurse, failed to follow the aide plan of care, and failed to follow agency policy on bag technique for 1 of 2 home health aide observations.

The agency failed to ensure a relationship between the Administrator and the Governing Body was maintained; failed to ensure the administrative functions were not delegated to an outside entity; and, failed to ensure the organizational structure and lines of authority were clearly identified (See…

The agency failed to follow physician orders for 1 of 2 wound care observations.

The agency failed to ensure standard infection control precautions were followed for 2 of 2 wound care observations.

The agency failed to assume responsibility on updating the aide plan of care for 1 of 2 home health aide visits.

The Governing Body failed to adopt policies and procedures specific to the home health agency and not that of another entity; and failed to ensure Governing Body meeting minutes reflected the home health agency and not another entity.

The agency failed to provide oversight and ensure patient needs were continually assessed for 1 of 2 home visits with wound care.

The agency failed to ensure accurate documentation was recorded in the clinical record for 1 of 7 home visit observations.

The agency failed to ensure patients were provided the current Administrator's name, phone number, and address in order to report complaints.

The agency failed to ensure all services in the plan of care were provided for 1 of 2 home visit observations with wound care (Patient 1); and 3 of 3 patients on teaching/reinforcement of managing hypertension (Patient 1, 5, 11); and failed to provide a home exercise program for 1 of 2 therapy home…

The agency failed to ensure the physician was noted regarding condition changes for 1 of 2 home visit observations with wound care.

The agency failed to update the aide plan of care for 1 of 2 home health aide visits.

The agency failed to ensure all services were documented in the clinical record for 1 of 12 active records reviewed.

The agency failed to incorporate a gait belt while walking an unsteady patient for 1 of 1 home visit patients receiving physical therapy services.

The Administrator failed to be responsible for all day-to-day operations of the home health agency.

The agency failed to ensure patient needs were continually assessed for 1 of 2 home visits with wound care.

The agency failed to ensure services were provided under current clinical practice and accepted standard of practice regarding infection control for 2 of 2 home visit observations.

The agency failed to document all responses to interventions provided by the agency for 3 of 3 record reviews with interventions on hypertension.