Human Touch Home Health Care Agency Inc Pueblo

The agency failed to ensure care was provided according to each patient's individualized written plan of care and in conformance with physician orders, for 1 of 6 active patient records reviewed ordered to receive skilled nursing (SN) services (Patient #5).

The agency failed to ensure the registered nurse (RN) conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care date for 3 of 6 clinical records reviewed requiring start of care (SOC)…

The agency failed to ensure physical therapy (PT) completed their assessments no later than five calendar days after the start of care for 1 of 1 active patient records reviewed who required therapy services (Patient #5).

The agency failed to ensure services and treatments were provided in accordance with physician's orders for 2 of 7 patients receiving skilled nursing (SN) for blood glucose monitoring (Patients #5 and #9).

The agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases.

First, the review revealed the agency repeatedly failed to implement patients' Plans of Care and provide services in accordance with orders documented on the Plan of Care.

Administration failed to provide basic functional oversight of the operations of the agency.

G 1012 - Required items in clinical record - The agency failed to ensure the patient's clinical record contained current and accurate documentation of clinical notes.

The governing body and administration failed to provide basic functional oversight to the operations of the agency.

The agency failed to ensure clinical record entries were legible, clear, complete and appropriately authenticated, dated, and timed for 7 of 7 patient records reviewed (Patient #1, #2, #3, #4, #5, #6 and #7).

The agency failed to ensure all complaints made by the patient or the patient's representative investigated and resolved.

The agency failed to ensure the Registered Nurse (RN) completed an initial assessment within 48 hours of referral, return home or on the physician ordered start of care date for 2 of 7 patients reviewed (Patients #1 and #7).

The agency failed to ensure each patient's status was comprehensively reviewed the last five days of every 60 day period for 1 of 5 active patient records reviewed who were on service more than 60 days (Patient #7).

The agency failed to record all patient care orders in the plan of care in 1 of 5 active patient records reviewed (Patient #6.) Findings include: AGENCY POLICY According to the policy, "Care Planning Process", In summary, the plan of care shall include but is not limited to types of services and…

The clinical staff routinely failed to ensure care followed a written plan of care which had been established and periodically reviewed by a physician.

The agency failed to ensure each patient's total individualized Plan of Care was reviewed and revised as frequently as the patient's condition or needs changed or at least every 60 days, beginning with the start of care date.

The agency failed to notify the physician of changes in the patient's condition in order to modify the Plan of Care 1 of 4 diabetic patient records reviewed and 1 of 2 focus diabetic patients reviewed.

The agency failed to communicate revisions to the Plan of Care related to patient discharge to the patient, representative and the patient's primary practitioner for 1 of 2 discharged patients records reviewed (Patient #2).

The agency failed to involve the patient, representative and caregiver in the coordination of care activities for 3 of 7 patients and 2 of 2 focus patients records reviewed (Patients #1, #2, #7, A and B.) Findings include: AGENCY POLICY According to the policy, "Care Coordination", In summary, a…

The Administrator failed to organize and direct the agency's ongoing functions and failed to effectively liaise with the governing body, which created a systemic lack of direction, organization and quality oversight.

The agency failed to ensure the patient's clinical record contained current and accurate documentation of clinical notes, Plans of Care and physician's orders in 4 of 5 active patient records reviewed (Patients #3, #5, #6 and #7).

The agency failed to maintain a clinical record for each patient that included all interventions, including medication administration, treatment and services and responses to those interventions.