Five Star Home Health Care

This CONDITION was not met as evidenced by: Based on staff interviews and review of patient records, review of the complaint log, task notes and selected policies and procedures it was determined the agency failed to ensure that patients were protected by Patient Rights.

The agency's emergency's preparedness policy and procedures failed to include the procedures to follow up with on-duty staff and patients.

The agency's emergency's preparedness policy and procedures failed to include a policy and procedure for the use of volunteers in an emergency or for emergency staffing needs.

The agency's emergency's preparedness policy failed to include methods for sharing medical documentation for patients with other health providers to maintain continuity of care.

The agency failed to implement a training and testing program for ten (10) of eleven (11) employees in the survey sample (employee #1-8 and 10-11).

The agency failed to ensure the agency staff followed the physicians wound care orders for one (1) of four (4) patients in the survey sample with physician orders for wound care (patient #11).

The agency's governing body failed to ensure an ongoing program for quality improvement and patient safety is defined, implemented and maintained; all improvement actions are evaluated for effectiveness, and with clear expectations including any findings of fraud or waste appropriately addressed.

The agency failed to have written evidence of furnishing Patient's Rights during the initial evaluation visit in advance of care in order to protect and promote the exercise of these rights for one (1) of seventeen patients whose records were reviewed in the survey sample (Clinical record #6).

The agency failed to ensure the patient's property/person was treated with respect.

The agency failed to document informing patients verbally and in writing regarding the disciplines to be furnishing care and or the frequency of proposed visits for three (3) of seventeen patient records reviewed in the survey sample (Patient record #'s 3, 6 and 10).

The agency failed to document informing patients verbally and in writing regarding the financial liabilities for two (2) of seventeen patient records reviewed in the survey sample (Patient record #s 3 and 6).

The agency failed to provide a Notice of Medicare Non-Coverage (NOMNC) to Medicare patients in advance of terminating care for one (1) of one (1) closed/discharge clinical records reviewed in the survey sample, for which a NOMNC was applicable.

The agency failed to acknowledge complaints and document the investigation of those complaints for one (1) of one (1) patient records reviewed in the survey sample with documented complaints.

Care was furnished inappropriately by an agency aide who administered medication that was not a task on the patient's plan of care.

The agency failed to ensure the patient was free from mistreatment, neglect and misappropriation of patient property by anyone furnishing services on behalf of the HHA (Home Health Agency) for one (1) of one (1) patients in the survey sample (Patient record #1).

The agency failed to document both the existence and the resolution of the complaint according to the agency's complaint policy and procedure for one (1) of seventeen patient records reviewed in the survey sample.

The agency failed to report without delay to the appropriate authorities in accordance with State law an incidence of physical abuse to a patient.

The agency staff failed to ensure the comprehensive assessment was completed within 5 calendar days of the initial assessment for two (2) of eight (8) skilled patients in the survey sample (patient #15 and #17).

The agency failed to ensure the patient's individualized plan of care included but not limited to a diagnosis and the site of wounds to be managed for two (2) of eight (8) skilled patients in the survey sample (patients #15 and #17).

The agency failed to document a patient's discharge summary and or send a discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit for five (5) of five (5) closed/discharged clinical records.