Gibraltar Home Health Services LLC

Therapeutic services and aide services directly to patients in their homes.) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to ensure a Registered Nurse completed a comprehensive assessment for three of ten sampled patients…

This CONDITION is NOT MET as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an organization that provides skilled nursing, therapeutic services and aide services directly to patients in their homes.) failed to ensure the Condition of Participation regarding Care…

Therapeutic services and aide services directly to patients in their homes.) failed to ensure the Condition of Participation regarding Clinical Records was met as follows: 1.The HHA failed to ensure the Skilled Nurse (SN) followed the plan of care for four of ten sampled selected patients (Patient…

1.Based on interview and record review, the Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure clinical records were written and authenticated (verifying accuracy, authorship, and validity of documentation)…

Therapeutic services and aide services directly to patients in their homes.) failed to ensure a Registered Nurse updated the comprehensive assessment for the recertification period for three of ten sampled patients (Patient 6, Patient 7, and Patient 8).

The Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure that he plan of care (POC) was implemented and followed for Patient 1 by failing to: Ensure implementation of Patient 1's POC for right food wound care…

The Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure clinical records were written and authenticated (verifying accuracy, authorship, and validity of documentation) by the author of the note for 6 of 10…

Therapeutic services and aide services directly to patients in their homes) failed to ensure patient care records were safeguarded against unauthorized use for four of ten sampled patients (Patient 6, Patient 7, Patient 9, and Patient 10).

Therapeutic services and aide services directly to patients in their homes.) failed to ensure a Registered Nurse completed a comprehensive assessment for three of ten sampled patients (Patient 6, Patient 9, and Patient 10).

The HHA failed to ensure the comprehensive assessment included all required elements for four of ten sampled Patients (Patient 1, Patient 3, Patient 5, and Patient 6).

Therapeutic services and aide services directly to patients in their homes.) failed to ensure that all medications and treatments were reviewed and documented for four of ten sampled patients (Patient 1, Patient 2, Patient 6 and Patient 7).

The HHA failed to ensure the comprehensive assessment was updated upon discharge for five of ten sampled patients (Patient 4, Patient 5, Patient 8, Patient 9, and Patient 10).

Therapeutic services and aide services directly to patients in their homes.) failed to include information required in the care plan for five of ten sampled patients (Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9).

Therapeutic services and aide services directly to patients in their homes) failed to ensure that one of ten sampled patients (Patient 1), received treatment in accordance with physician orders.

Therapeutic services and aide services directly to patients in their homes) failed to ensure that verbal physician orders were received and accepted by licensed staff for two of ten samples patients (Patient 4 and Patient 5).

Therapeutic services and aide services directly to patients in their homes) failed to ensure one of ten sample patients (Patient 9) plans of care were reviewed and approved by a physician.

Therapeutic services and aide services directly to patients in their homes.) failed to ensure the physician was notified of one of ten sampled patients change of condition which resulted in hospitalization resulting in a 3rd toe amputation.

Therapeutic services and aide services directly to patients in their homes) failed to ensure the Skilled Nurse (SN) followed the plan of care for four of ten sampled selected patients (Patient 3, Patient 4, Patient 5, and Patient 7).

Therapeutic services and aide services directly to patients in their homes) failed to perform supervisory visits for License Vocational Nurse (LVN) services for one of ten sampled patients (Patient 5).

Therapeutic services and aide services directly to patients in their homes) failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for three of ten sampled patients (Patient 4, Patient 5, and Patient 10).

The home health agency (HHA) failed to ensure the Condition of Participation for Comprehensive Patient Assessment was met as follows: The Home Health Agency (HHA) failed to conduct an accurate comprehensive assessment that reflected the patient’s current health status.

The hospice agency failed to ensure that the Condition of Participation regarding Care Planning, coordination and quality of care was met as follows: 1) The hospice agency failed to follow the plan of care (POC) to two of four sampled patients (Patient 3 and 4).

The home health agency (HHA) failed to: 1) Ensure the nutrition requirements was assessed accurately to reflect the current diet required for one of four sampled patients (Patient 1).

The home health agency (HHA) failed to follow the plan of care (POC) for two of seven sampled patients (Patient 3 and 4).

The home health agency (HHA) failed to: 1) Document Patient 1's name correctly on the Skilled Nursing (SN) Clinical Note for one of four sampled patients (Patient 1). 2) Sign the Comprehensive Adult Assessment for two of four sampled patients (Patient 2 and 3) 3) Sign the SN Clinical Notes for…

The Home Health Agency (HHA) failed to review and document all the medications changes for one of four sampled patients (Patients 3).

The home health agency (HHA) failed to obtain and follow a physician's order for the wound treatment of three of four sampled patients (Patient 1, 2 and 4).

The home health agency (HHA) failed to employ qualified personnel by failing to ensure Licensed Vocational Nurse (LVN 1 and LVN 2) had a current competency review and LVN 2 had a performance evaluation on file.

The Condition is not met as evidenced by: The HHA failed to ensure the Condition of Participation: CFR 484.75 Skilled Professional Services was met when: a.

The Condition is not met as evidenced by: The facility failed to ensure the Condition of Participation: CFR 484.105 Organization and Administration of Services was met when an unlicensed staff, Staff 1, provided skilled nursing care for approximately 2 years and 11 months.

The HHA failed to provide services that were ordered by the physician as indicated in the plan of care for one of seven sampled patients (Patient 6).

The HHA failed to ensure Staff 1 was a qualified licensed nurse prior to assigning her to provide skilled nursing care for one of seven sampled patients (Patient 6) for approximately 2 years and 11 months.