Horizon Home Health Magic Valley

The HHA failed to follow its own established policy for investigating and responding to a serious adverse event for 1 of 1 sampled patient who experienced an unexpected death (Patient #1).

The agency failed to capture a patient infection in 1 of 10 Patients (Patient #9) whose records were reviewed.

1 of 10 patients (Patient #7) whose records were reviewed, did not receive all services requested on their plan of care.

The agency failed to ensure the POCs included all interventions, measurable outcomes, medications, and goals for 2 of 11 patients (Patient #1 and #5) whose records were reviewed.

The facility failed to ensure all staff had current clinical competencies for 1 of 3 nurses (Staff A) whose personnel files were reviewed.

The agency failed to ensure SOC comprehensive assessments accurately reflected the patient’s status for 1 of 10 patients (Patient #1) whose records were reviewed.

The facility failed to ensure medication lists were reviewed for accuracy for 1 of 3 patients (Patient #7) whose home visits were observed by surveyors.

The facility failed to ensure the POC included all relevant diagnoses for 1 of 10 patients (Patient #7) whose records were reviewed.

The agency failed to ensure each patient received services written in their POC, that POCs were complete, that verbal orders were recorded in the POC, that agency staff promptly alerted relevant physicians to significant changes in patients' conditions or needs, that POCs were updated to reflect…

The agency failed to ensure skilled professional services assured ongoing interdisciplinary assessment, development of a POC in partnership with the patient/caregiver, necessary counseling, accurate clinical notes, and communication with all physicians.

The agency failed to ensure encoded OASIS data accurately reflected patients' status at the time of assessment for 2 of 10 patients (#1 and #10) whose OASIS assessments were reviewed.

The agency failed to ensure each patient received services written in their POCs for 2 of 10 patients (#1 and #5) whose records were reviewed.

The agency failed to ensure sentinel events were fully investigated for 1 of 1 patient (Patient #11) who had a documented sentinel event, and that adverse patient events were tracked and analyzed for 1 of 2 patients (Patient #6) who had documented ER visits and whose records were reviewed.

The agency failed to ensure their surveillance screening for COVID-19 was completed on all patient visits for 1 of 2 patients (Patient #10) who received aide services and whose records were reviewed.

The agency failed to ensure the skills of 1 of 1 CNA who was hired in 2020, were evaluated by qualified staff.

The agency failed to ensure assessments were comprehensive for 4 of 10 patients (#1, #5, #6, and #10) whose SOC assessments were reviewed.

The agency failed to ensure medications were reconciled at the time of admission for 2 of 10 patients (#1 and #4) whose home health records, including SOC assessments, were reviewed.

The agency failed to ensure POCs were complete for 9 of 10 patients (#1, #2, #3, #4, #5, #6, #7, #9, and #10) whose records were reviewed.

The agency failed to ensure verbal orders were recorded in the POC for 2 of 10 patients (#1 and #5) whose records were reviewed.

The agency failed to ensure agency staff promptly alerted relevant physicians to significant changes in patients' conditions or needs for 3 of 10 patients (#2, #6, and #9) whose records were reviewed.

The agency failed to ensure POCs were updated to reflect current information for 5 of 10 patients (#1, #3, #5, #6, and #9) whose records were reviewed.

The agency failed to ensure coordinated care delivery for 4 of 10 patients (#1, #5, #7, and #10) whose records were reviewed.

The agency failed to ensure ongoing interdisciplinary assessment of 7 of 10 patients (#1, #4, #5, #6, #7, #9, and #10) whose records were reviewed.

The agency failed to ensure POCs were developed and updated in partnership with the patient and caregiver for 3 of 10 patients (#1, #3, and #4) whose records were reviewed.

The agency failed to ensure necessary counseling was provided to 3 of 10 patients (#2, #6, and #11) whose records were reviewed.

The agency failed to ensure clinical notes were prepared, consistent, and accurate, for 4 of 10 patients (#2, #4, #5, and #7) whose records were reviewed.

The agency failed to ensure communication with all physicians involved in the plan of care for 1 of 2 patients (Patient #4) who were referred to the agency by a wound care clinic and whose records were reviewed.

The agency failed to ensure LPN supervision occurred in accordance with agency policy and to ensure patient safety for 3 of 5 patients (#1, #7, and #11) who received SN services from an LPN and whose records were reviewed.

The clinical manager failed to ensure patient needs were continually assessed for 7 of 10 patients (#1, #4, #5, #6, #7, #9 and #10) whose records were reviewed.

The agency's clinical manager failed to ensure each patient received services written in their POCs, that POCs were complete, and that POCs were updated to reflect current information for 9 of 10 patients (#1, #2, #3, #4, #5, #6, #7, #9, and #10) whose records were reviewed.

The agency failed to ensure complaint resolutions were provided to 1 of 3 patients (Patient #3) who had a documented complaint and whose records were reviewed.

The agency failed to ensure HHA staff reported potential abuse and neglect to appropriate authorities in accordance with State law for 1 of 1 patient (Patient #3) who had documented potential abuse and neglect and whose record was reviewed.