Lake Martin Home Health

The agency failed to ensure staff followed agency policy for hand hygiene (HH) and glove changes.

The agency failed to ensure staff completed accurate documentation and authentication of Skilled Nursing (SN) Visits, Home Health Aide (HHA) visits, and physician orders in the electronic medical record within 24 hours per agency policy.

The agency failed to ensure the medications were reconciled and all current medications were listed on the Medication Summary.

The agency failed to ensure the patient and caregiver (pt/cg) were provided oxygen safety signage for the home.

The agency failed to ensure staff obtained physician order's for Peripheral Inserted Central Catheter (PICC) dressing changes.

The agency failed to ensure nursing staff documented the care provided to a Peripheral Inserted Central Catheter (PICC).

The agency failed to ensure staff provided a copy of the transfer summary to the receiving provider.

The agency staff failed to ensure physician orders were followed for: 1. Laboratory (lab) testing.

The agency failed to ensure staff followed infection control practices for hand hygiene and glove change during wound care.

The agency failed to investigate, analyze and implement an improvement plan for infectious disease prevention.

The agency failed to ensure a current and accurate Medication Profile was maintained on all patients.

The agency failed to ensure the staff provided and documented discharge instructions.

The agency failed to ensure the staff provided education This affected 3 of 13 MRs reviewed, including MR # 6, MR # 3, MR # 5 and had the potential to negatively affect all patient's served by the agency.

The agency failed to ensure the Home Health Aide ( HHA) followed the written plan of care in 1 of 1 HHA visit observation.

The agency failed to ensure staff followed their own policy and procedure and submitted the transfer summary to the receiving provider when a patient was transferred to an inpatient facility.

The agency failed to ensure: a) 1 of 1 HHA received at least 12 hours annual training for 2017. b) The HHA in-service training program was supervised by a registered nurse (RN). c) The RN prepared clearly written instructions for the HHA to perform that meets the needs of the patient. d) An onsite…

The staff failed to follow the agency policy and procedure, the Plan of Care Visit (POC) frequency and reschedule missed/attempted visits within the agency medicare treatment week.

The agency failed to ensure staff: a) Performed hand hygiene according to agency policy. b) Maintained clean versus dirty area with bag technique and supplies. c) Cleaned reusable equipment before returning to bag.

The agency failed to investigate, analyze and implement an improvement plan for infectious disease prevention.

The agency failed to ensure that training and skills competency evaluations related to Peripheral Inserted Central Catheter (PICC) removal were complete affecting 3 of 3 Registered Nurse (RN) personnel records reviewed.

The agency failed to ensure 1 of 1 HHA received at least 12 hours annual training for 2017. This had the potential to affect all patients who received HHA services.

The agency failed to ensure the Registered Nurse (RN) prepared clearly written instructions for the Home Health Aide (HHA) to perform and to meet the needs of the patient.

The agency failed to ensure discharged patient records were safe and not accessible to unauthorized persons.

The agency failed to provide patients with the correct state agency hotline telephone number.

The agency failed to ensure: a) The staff provided care and follow up to patients for calls made to the agency after hours. b) Documentation of calls received after hours were obtained from the answering service. c) The staff completed on call logs per policy. d) Medical Records contained…

The agency failed to ensure an up to date Medication Profile was maintained on all patients.

The agency staff failed to perform an initial assessment visit within 48 hours of discharge from an acute care facility.

The staff failed to notify the physician of: a) Patients complaints of pain and weakness.

The agency failed to ensure discharge instructions were provided to patient before discharge and discharge summaries were completed.

The agency staff failed to follow the physician's plan of care that included: a) Provide education after hospitalization on new and discontinued medications resulting in re-hospitalization. b) Education and assessment of pain. c) Perform and and document daily weights. d) Assess patients for…

The agency failed to ensure staff: a) Completed documentation per policy that included the actual date completed. b) Documented actual care provided in the home. c) Assessed and documented patient's response to care and services. d) Documented the amount of wound drainage. e) Assessed a patient…

The agency failed to ensure the agency HHA in-service training program was supervised by a registered nurse (RN).

The agency failed to ensure Home Health Aide (HHA) supervision was performed every 14 days in 3 of 4 records reviewed with HHA services.

The agency staff failed to ensure EI # 6's competency evaluation included the successful demonstration for routine HHA skills and current CPR (cardiopulmonary resuscitation) training.

The facility failed to ensure Employee Identifier (EI) # 7, Registered Nurse (RN) had a demonstrated clinical competency for removal of the PICC.