Intermountain Health Homecare - Denver

The agency failed to coordinate care delivery to meet the patient's needs and to involve the patient and caregiver(s), as appropriate, in the coordination of care activities for 1 of 3 patient records reviewed (Patient #2).

First, the review revealed the agency failed to complete the start of care assessment within 48 hours.

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.

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 agency failed to ensure care was provided according to each patient's individualized written plan of care, including any revisions or additions to care, services and treatments and were in conformance with physician orders for 6 of 17 patient records reviewed (Patients #1, #6, #9, #10, #13, and…

The agency failed to ensure the registered nurse (RN) or other appropriate skilled professional prepared patient-specific written care instructions for the home health aide (HHA) for 5 of 6 patients reviewed who received CNA services (Patients, #9, #10, #11, #12, and #16).

The agency failed to ensure clinical record entries were legible, clear, complete and appropriately authenticated, dated, and timed for 4 of 17 patient records reviewed (Patient #10, #12, #13 and #16).

The agency failed to ensure all complaints made by the patient or the patient's representative were 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 1 of 17 patient records reviewed (Patient #9).

The agency failed to ensure the registered nurse (RN) accurately reflected the patient's current health status on the comprehensive assessments for 3 of 17 patient records reviewed.

The agency failed to ensure all patient medications were reviewed and reconciled for potential interactions, significant side effects, duplications, discrepancies, noncompliance, ineffective therapy or adverse effects for 3 of 17 patient records reviewed (Patients #6, #8 and #9).

An agency Registered Nurse (RN) failed to ensure a complete comprehensive assessment was updated and revised (including the administration of the Outcome and Assessment Information Set (OASIS) within 48 hours of the patient's return home from a hospital admission of 24 hours or more, for 2 of 4…

The agency failed to provide services and treatments only as ordered by the physician for 7 of 17 patients selected for record review.

Citation Text for Tag 0584, Regulation D101 Based on interview and record review, the agency failed to ensure services provided were based on physician's verbal orders, and were documented in the clinical record, with the signature, and date in which the orders were received by the registered nurse…

The agency failed to ensure professional staff promptly alerted the physician of symptoms, concerns and conditions that suggested a need to alter the Plan of Care for 2 of 17 patients reviewed (Patients #13 and #15).

The agency failed to coordinate care delivery and involve the patient, representative and caregiver in the coordination of care activities in order to meet the needs of the patient for 3 of 17 patient records reviewed.

The agency failed to ensure home health Aide (HHA) supervision occurred at least every two weeks for 2 of 3 patients receiving CNA services greater than two weeks (Patient #10 and #16).

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 for 9 of 17 patient records reviewed (Patients #2, #4, #5, #6, #8, #9, #10, #16 and #17).