Lutheran Home for the Aged

The agency failed to provide care and services that met the requirements for the Condition of Participation: Patient Rights.

The agency failed to provide care and services that met the requirements for the Condition of Participation: Care Planning, Coordination of Services and Quality of Care.

The agency failed to provide care and services that met the requirements for the Condition of Participation: Infection Prevention and Control.

The agency failed to meet the requirements for the Condition of Participation: Organization and Administration of Services.

The agency failed to test and analyze the testing results of the emergency preparedness plan at least annually.

The agency failed to assure the accuracy of the Outcome and Assessment Information Set (OASIS) data in, but not limited to, two (Records/Patients #3 and #4) of five full records reviewed.

The agency failed to ensure that infection control and adverse patient events were measured, analyzed, and tracked, to assess processes of care, services and operations.

The agency failed to assure that performance improvement activities track adverse patient events, analyze their causes, and implement preventive actions.

The agency failed to ensure the governing body evaluated the quality assurance and performance improvement (QAPI) activities.

The agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in, but not limited to, one (Record/Patient #1) of three home visit observations conducted.

The agency failed to assure that a coordinated agency-wide program for the surveillance, identification, prevention, control, investigation of infectious diseases was an integral part of the agency quality assurance and performance improvement (QAPI) program.

The agency failed to provide infection control education to the staff.

The agency failed to ensure skilled professional services were delivered according to the agency’s policies and procedures in, but not limited to, two (Employee A and Employee B) of eleven Covid-19 vaccination records reviewed and in one (Employee B) of four employee records reviewed.

The agency failed to ensure the governing body assumed full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, its operational plans, and its quality assessment and performance improvement (QAPI) program.

The agency failed to update the written notice of patient rights to include: - Written notice of the patient’s rights and responsibilities under this rule, and the agency transfer and discharge policies as set forth in paragraph (d) of this section; - Written notice of the patient’s rights must be…

The agency failed to provide the written notice of patient rights that included the patient’s right to have a copy of the patient’s rights and responsibilities and the agency’s transfer and discharge policies provided to a patient-selected representative within four business days of the initial…

The agency failed to update the written notice of patient rights to include the patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to completion of all assessments, expected outcomes of care…

The agency failed to include the right to receive proper written notice, in advance of a specific service being furnished if the home health agency (HHA) believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care.

The agency failed to provide patients with the correct hours of operation for the state toll free home health hotline telephone number.

The agency failed to ensure the patient was advised of the name, address, and telephone number of the Federally-funded and state-funded entities that serve the area where the patient resides.

The agency failed to provide the written notice of patient rights to include that the patient and representative (if any) have a right to be informed that the agency may only transfer or discharge the patient from the agency if the transfer or discharge is necessary for the patient’s welfare…

The agency failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient’s return home, or on the physician ordered start of care date in, but not limited to, two (Records/Patient’s #2 and #4) of five full records reviewed.

The agency failed to ensure the skilled clinician’s assessments of patients accurately reflected the patient’s current health status for one (Record/Patient #4) of five full records reviewed.

The agency failed to ensure the registered nurse performed an accurate review/update of all medications the patient was currently using in, but not limited to, three (Records/Patients #1, #2, and #3) of five full records reviewed.

The agency failed to include all the elements of an individualized plan of care in, but not limited to, four (Records/Patients #1, #2, #3, and #4) of five full records reviewed.

The agency failed to promptly alert the physician to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered in two (Records/Patients #1 and #2) of five full records reviewed.

The agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey.

The agency failed to ensure the administrator reports to the governing body.

The agency failed to ensure a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator when the administrator is not available.

The agency failed to provide written notice regarding the patient's financial obligation in one (Record/Patient #2) of five records reviewed for this standard.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for a discharge for…

The agency failed to ensure an accurate medication review and/or update of the patient medication profile when there were new/changed medications in, but not limited to, two (Records/Patients #2, and #5) of 5 records reviewed.

The agency failed to provide an individualized plan of care that included all types of services, supplies, and equipment required for care for one (Record/Patient #2) of five records reviewed.

The agency failed to ensure staff obtained a copy of a Durable Power of Attorney (DPOA, enables a trusted person to handle affairs if one becomes mentally incapable of making decisions) upon admission to the home health agency in, but not limited to, one (Record/Patient #2) of five records reviewed.