Hcr / Hcr Home Care Chha (Rochester)

The agency failed to ensure the comprehensive assessment was updated and revised to reflect changes in the patient's health status.

The agency failed to ensure the patient received a copy of the patient's complete clinical record (hard copy or electronic form) upon request at the next home visit or within four (4) business days (whichever comes first).

The agency failed to ensure a comprehensive assessment was completed within the last five (5) days of the sixty (60) day certification period.

The agency failed to ensure services and treatments are administered in accordance with physician orders.

The agency failed to ensure for two (2) of two (2) recertified patients (Patient #'s 1 and 2) that staff are reviewing and revising the individualized plan of care at least every sixty (60) days.

The agency failed to ensure revised plans of care reflect the patient's needs.

The agency failed to follow current clinical practice guidelines and agency policy and procedure.

The agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) were transmitted to the State/Centers for Medicare and Medicaid Services within thirty (30) days of completion.

The agency failed to obtain either the patient's or the patient's legal representative's signature confirming the patient received a copy of the patient rights and responsibilities at start of care (SOC).

The agency failed to obtain patient consent for wound photography.

Failure to complete the NOMNC form with the patient prior to discharge has the potential to result in negative patient outcomes.

The agency failed to ensure the Registered Nurse (RN) completed an initial assessment of the patient within forty-eight (48) hours of referral, the patient’s return home, or on the physician-ordered start of care date.

The agency failed to complete a comprehensive medication reconciliation as evidenced by the following: Review of the HCR Home Care “Medication Reconciliation Protocol dated 1.2022 revealed “Medication reconciliation is required at every in-home patient visit.

The agency failed to determine the patient’s primary caregiver(s) willingness and ability to provide care and availability and schedules.

Staff interviews for one (1) of seventeen (17) patients (Patient #: 1) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients.

The agency failed to ensure services and treatments are administered in accordance with physician orders.

The agency staff failed to promptly alert the physician to any changes in the patient's condition that suggests the need to alter the plan of care (POC).

The agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care (POC).

The agency failed to prepare and document complete clinical progress notes.

The agency failed to document a complete agency discharge summary, discipline discharge (Outcome and Assessment Information Set discharge assessment), and failed to communicate the discharge from services and the agency with the physician, and all other disciplines involved in the plan of care.

13 and 17) the agency failed to provide services in accordance with physician orders, and agency policy.

For two (2) of seventeen (17) records (Patient #'s: 2 and 10) the agency failed ensure the Registered Nurse conducted an initial assessment visit of the patient within 24 hours of referral, the patient's return home, or on the physician-ordered start of care date, per agency policy.

16) the agency failed to ensure the comprehensive assessment was completed within 5 calendar days after the start of care (SOC).

The agency failed to ensure a review of all medications was completed, and the physician was notified of any medication discrepancies, side effects, problems or reactions, per agency policy.

Staff interview for one (1) of seventeen (17) patients (Patient # 4) the agency failed to ensure comprehensive assessments are updated and revised within forty-eight (48) hours of the patient's return to the home from a hospital admission of 24 hours or more.

The agency failed to ensure the Plan of Care (POC) was individualized and comprehensive.

The agency failed to ensure drugs and treatments are administered in accordance with physician orders.

Staff interview for one (1) of seventeen (17) patients (Patient # 12) the agency failed to coordinate care delivery to meet the patient's needs for Occupational Therapy (OT).

The agency failed to ensure ongoing interdisciplinary assessments and communication for patients receiving nursing and social work services.

The agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes.

9 and 16) the agency failed to follow agency policies and procedures, current clinical practice guidelines, and accepted professional standards when providing services.