Interim Healthcare of the Triad Inc.

Staff interview the agency failed to follow the plan of care for assessing vital signs for 2 of 22 records reviewed (#17 and #20).

The agency failed to accurately assess patients’ medications on the OASIS (Outcome and Assessment Information Set—standardized assessment) for 4 of 18 patients (#2, 11, 3 and 14).

The agency failed to obtain vital signs in accordance with physician's orders for 2 of 18 patients [#6 and 18]. The findings included: 1. Patient # 6 had a Start of Care date of 2/1/23. Review of the Plan of Care for the certification period 5/2/23 to 6/30/23 revealed a diagnosis of pressure ulcer…

The RN failed to document external catheter length and arm circumference on 2 of 3 patients with a PICC line (#7 and 15); and to measure wounds for 1 of 8 patients with a wound (#6).

Staff interviews the patient care instructions for the home health aide failed to give clear instructions on the type of bath the patient should receive for 1 of 1 patient with home health aide services [#18]. The findings included: Patient # 18 had a Start of Care date of 5/7/23 and admitting…

Staff interviews the agency failed to complete the comprehensive assessment within 5 days for 1 of 2 patients with order for ST [speech therapy] [#13]; and failed to conduct MSW [medical social work] evaluation for 1 of 1 patient with orders for MSW evaluation [#18]. The findings included: The…

The agency failed to conduct a comprehensive medication review for 8 of 18 patients (#1, 2, 11, 17, 12, 13, 14, and 16).

Staff interviews the plan of care failed to include complete medication orders [#3, 9, 14, and 18]; failed to provide accurate primary diagnosis for 1 of 4 discharged patients [#9]. The findings included: The policy, Developing a Plan to Meet Patient/Client Needs [no date], was provided by the…

The agency provided surgical site care without an order for 1 of 5 patients with a surgical site (#5); and failed to follow the plan of care for obtaining blood via a PICC (peripherally inserted central catheter—IV access to large central veins) line for 1 of 3 patients with a PICC line (#15).

Staff interview the agency failed to notify the physician of vital signs outside of parameters for 2 of 18 patients (#1 and 18); blood sugars outside of parameters for 2 of 3 diabetic patients (#1 and 15); a delay in physical therapy for 1 of 11 patients that received physical therapy (#1); and to…

Staff interviews the agency failed to communicate with the physician when SN and PT visits were not made in accordance with the POC for 2 of 18 patients [#6, 18]. The findings included: The policy, Variances from the Plan of Care/Service Plan [no date], was provided by the agency administrator on…

The agency failed conduct a visit as requested by the patient for 1 of 3 patients with a vascular access device (#15).

The agency failed to conduct home health aide supervisory visits at least every 14 days for 1 of 1 patient receiving home health aide services [#18]. The findings included: Patient # 18 had a Start of Care date of 5/7/23 and admitting diagnoses of acute and chronic respiratory failure and chronic…

Staff interviews the agency failed to ensure interventions/goals were correct for 1 of 4 discharged patients [#4]; failed to ensure laboratory results were placed on the clinical record for 1 of 2 patients with lab work ordered [#8]; and failed to ensure the clinical record contained accurate…

The nurse failed to complete documentation for 1 of 5 patients with lab orders (#2); document PICC (peripherally inserted central catheter—IV access to large central veins) line dressing changes/cap changes for 1 of 3 patients with a PICC line (#7); and the visit notes had inconsistent…

Staff interviews the agency failed to include the patient/caregiver in developing the plan of care for 1 of 1 patient receiving occupational therapy services who requested " a change in staff " [#21]. The findings included: The policy, Developing a Plan to Meet Patient/Client Needs, was provided on…

Staff interviews the agency failed to provide services as ordered by the physician for 2 of 4 patients with wounds (#6), and physical therapy services for 1 of 5 discharged records (#4).

The agency failed to include wound measurements in the clinical record for 1 of 7 patients with wounds [#13]. The findings included: Patient # 13 had a Start of Care date of 1/1/20 and diagnoses of Pressure Ulcer of Right Ankle [stage 4], Diabetes Mellitus with other Skin Ulcerations and Diabetes…