Individual Support Services Inc

The agency failed to ensure infection control practices were followed in 1 of 3 home visits for hand hygiene.

The agency failed to ensure all staff followed standard precautions and infection control policies for 1 of 2 home health aide (HHA) observations (#1).

The registered nurse (RN) failed to ensure the comprehensive assessment contained all pertinent information regarding the patients' current health status for 2 of 8 active records reviewed (#1, 5).

Failed to ensure the comprehensive assessment contained the patient's goals, and care preferences, as well as information to demonstrate progress toward achievement of goals identified by the patient and measurable outcomes identified by the agency for 2 of 8 active records reviewed (#1, 4).

The agency failed to ensure the plan of care documented all medications the patient was taking for 1 (Patient #5) of 8 active records reviewed.

The agency failed to ensure the plan of care (POC) included all medications the patient was taking and all durable medical equipment (DME) and supplies for 2 of 8 records reviewed for 2 of 8 active records reviewed (#1, 5).

The agency failed to ensure home health aide provided services as ordered per the plan of care, failed to meet a patient's needs by failing to ensure a skilled nurse visited the patient daily to perform in and out catheterizations that should not have been performed by a home health a aide, and…

The agency failed to maintain compliance with the condition of participation of Clinical records, 42 CFR 484.110. The agency failed to ensure that the record contained all appropriate and accurate documentation (See G 1012); failed to ensure a home health aide documented when in and out…

The agency failed to implement their policy which prohibited the agency from requesting or obtaining a waiver of the client's rights; failed to demonstrate management knowledge to instruct staff of the purpose and extent of the release of rights form, or how the agency staff would inform/instruct…

The agency failed to ensure home health aide provided services as ordered per the plan of care for 4 of 7 (Patient #2, 3, 4, 5), failed to meet a patient's needs by failing to ensure a skilled nurse visited the patient daily to perform in and out catheterizations that should not have been performed…

The agency failed to ensure the patient's clinical record contained only their own clinical documentation to safeguard the clinical record from unauthorized access for 2 of 7 records reviewed.

The agency failed to ensure a patient was accorded the opportunity to participate in care planning in relation to number of daily home health aide care visits for 1 (#5) of 7 patients.

The agency failed to ensure patients received services as ordered on the plan of care for 2 of 7 records reviewed.

The agency failed to ensure the RN (Registered Nurse) accurately assess a patient's urinary elimination needs for 1 of 2 patients reviewed with a urinary catheter (Patient #4) in a total sample of 7. Findings include: An agency policy titled, "Plan of Care C-580" was reviewed and stated, "Home care…

The agency failed to revise the plan of care to ensure the home health aide visit frequency orders met the needs of the patient for 2 (Patient #2 and 5) of 7 patients and failed to ensure the registered nurse developed and evaluated the plan of care in partnership with the caregiver to accurately…

The agency failed to ensure the clinical records evidenced documentation of communication between the Registered Nurse and the Home Health Aide in 1 of 7 records reviewed.

The Registered Nurse/ Case Manager failed to ensure the plan of care was developed to include specific frequency of visits for HHA care to meet the patients' needs for 2 (Patients #2 and 5) of 7 patients, and the registered nurse failed to develop and evaluate the plan of care in partnership with…

The agency failed to ensure home health aide provided services as ordered per the plan of care for 4 of 7 (Patient #2, 3, 4, 5), failed to ensure that the home health aide did not provide services beyond their scope of practice for 1 of 7 (Patient #4) records reviewed, and failed to ensure a…

The RN (Registered Nurse) failed to conduct HHA (Home Health Aide) supervisory visits at least every 14 days for patient's receiving skilled nursing services for 2 of 7 clinical records reviewed.

The administrator failed to be responsible manage the day to day operations of the home health agency in accordance with agency policies, regulations, and rules for 1 of 1 administrator.

The agency failed to ensure clinical records were complete and contained all appropriate and accurate documentation for 4 of 7 records reviewed.

The agency failed to ensure a home health aide (Employee H) documented when in and out catheterizations were performed in the visit notes and the amount of urine output for 1 of 2 patients reviewed with a urinary catheter (Patient #4) in a total sample of 7. The findings included: An agency…