Henderson County Health Depart

For 1 of 5 patient's (Pt.#6) receiving therapy services, the Facility failed to provide a Physical Therapy (PT) and Occupational Therapy evaluation as ordered by the physician in a timely manner.

For 1 of 7 (Pt #7) patients records reviewed, the Agency failed to ensure the physician was notified of changes in the patients condition.

In 1 of 7 (Pt #4) patient records reviewed, the Agency failed to ensure patients clinical notes were completed and incorporated into the clinical record in accordance with the agency's policy.

In 1 of 4 (Pt #4) patient record reviewed, who received Home Health Aide (HHA) services greater than 14 days, the Agency failed to ensure HHA supervision was conducted at least every 14 days.

For 1 of 1 (Pt# 4) patient transfer of care record reviewed. that the Agency failed to complete the transfer of care within 2 days after inpatient admission to the Hospital.

In 3 of 3 (Pt #5, Pt #6, Pt #7) patients records reviewed who required monthly weights, the Agency failed to ensure staff provided care per physician order.

For 1 of 5 (Pt #3) home visit with a record review and 1 of 7 (Pt #4) patient records reviewed, the Agency failed to ensure patients were appropriately screened for signs/symptoms or exposure to COVID-19 per policy.

For 1 of 5 (Pt #4) patients who received care by a Home Health Aide (HHA), the Agency failed to ensure a written Plan of Care (POC) for the HHA was prepared by a Registered Nurse (RN).

For 1 of 2 (Pt #4) patient records reviewed, the Agency failed to ensure patient care orders were included on the Plan of Care (POC).

For 2 of 2 (Pt #4, Pt #6) patients records reviewed, the Agency failed to ensure the physician was notified of changes in the patients condition.

For 1 of 1 (Pt #6) patient records reviewed with a change in condition, the Agency failed to revise the Plan of Care (POC) with appropriate interventions and goals as a result of the change in patients condition.

For 2 of 2 (Pt #4, Pt #6) patient records reviewed, the Agency failed to ensure the Licensed Practical Nurse (LPN) was supervised by the Registered Nurse (RN) per policy.

For 2 of 5 (Pt #4, Pt #5) patients who received care by a Home Health Aide (HHA), the Agency failed to ensure the HHA provided services as ordered on the Plan of Care (POC).

For 5 of 5 (Pt #1, Pt #3, Pt #4, Pt #5, Pt #6) patients records reviewed, the Agency failed to ensure documentation was incorporated into the record.

For 2 of 2 (Pt #3, Pt #7) patients records reviewed who were discharged, the Agency failed to ensure a discharge summary was completed and provided to the primary care provider within 5 business days.