Homecare of East Alabama Medical Center

The agency failed to ensure staff: A.

The agency failed to ensure: A.

The agency failed to ensure conformance with physician orders for laboratory (lab) and as needed (prn) visits.

The agency failed to ensure staff: 1. Followed their policy and procedure for bed bath and perineal care.

The agency failed to ensure agency staff completed clinical notes per policy.

The agency failed to ensure staff reconciled medications in 4 of 7 Home Visits (HV) conducted, including HV # 1, HV # 2, HV # 6, HV # 4, and had the potential to negatively affect all patients receiving services by this agency.

The agency failed to ensure an individualized Plan of Care (POC) was developed to meet the needs of a patient with a Mediport (Implanted Venous Access).

The agency staff failed to notify the physician timely with changes in the patient's condition and/or Plan of Care including: 1. Assessment of a new wound.

The agency staff failed to document an assessment of a new wound was completed upon development of the wound.

The agency failed to ensure the patient/caregiver (pt/cg) were provided education and/or provided a return demonstration of the following: 1. Wound care per the physician's orders.

The agency failed to ensure medical record documentation was complete and accurate with all events, and treatments administered which included specific and accurate wound care provided.

The facility failed to provide documentation on the use of volunteers in an emergency per the requirements of: 42 CFR 483.73(b) (6) This deficiency had the potential to negatively affect all patients served by the agency.

The staff failed to ensure the physician was notified when therapy visits were missed and the patients plan of care was not completed as ordered.

The agency failed to ensure: 1) the visit frequency was followed by all disciplines 2) The patient's pain was reported to physician per the physician orders. 3) The patient's weight gains were reported to physician per the physician orders. 4) Vital Signs (VS) were documented according to physican…

The agency staff failed to ensure all reportable patient care incidents were documented in the agency incident report system, analyzed, and all required reportable incidents were available to track/trend for patient care improvement activities.

The agency staff failed to ensure all HHA staff received 12 hours annual training for 2017. This affected 1 of 3 HHA staff and had the potential to affect all patients who received personal care services.

The agency staff failed to follow agency policy, complete and document all complaint investigation, analysis and follow-up with the patient and/or complainant . This had the potential to affect all patients cared for by the agency.

The agency failed to ensure medications were reviewed and reconciled in 3 of 17 records reviewed.

The agency failed to ensure staff documented all physician orders and entered them into the patient medical record.

Staff failed to notify the physician of change, in the patient's condition which included the following: 1) Deterioration in skin integument and wound status 2) Development of edema. 3) The patient's pain was reported to physician This affected 5 of 17 records reviewed and did affect Home Visit…

The staff failed to ensure changes in the patient's plan of care and treatment were confirmed with a physician and documented in the medical record.

The agency failed to ensure: a) Medication education was performed on changed high risk medications b) The patient or caregiver performed a return demonstration to ensure competency for insulin administration and glucometer use.

The agency failed to ensure wounds were assessed per agency policy.

The agency failed to ensure the Physical Therapist (PT) developed and updated the Aide Plan of Care to meet the needs of the patient.

The agency staff failed to follow the physician's plan of care that included: 1) Care of a Peripherally Inserted Cutaneous Catheter (PICC).

The agency failed to ensure staff completed and documented PICC (peripherally inserted cutaneous catheter ) assess site assessment.