Lutheran Home Health Agency

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 5 sampled patients receiving home health aide services (Patient #6).

The agency failed to follow physician orders for 1 of 7 sampled patients (Patient #2).

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 5 sampled patients receiving home health aide services (Patient…

The agency failed to ensure the clinical record included the development/review of patient's individualized emergency plan as part of the comprehensive assessment for 4 of 7 sampled patients (Patients #2, #3, #4 and #7) and the agency had a written policy and procedure that addressed the need to…

The agency failed to ensure 1 of 2 sampled contract therapists (Staff H, Physical Therapist) received training in the agency's emergency preparedness policies and procedures.

The agency failed to ensure agency staff accurately completed all of the components comprising the Plan of Care for 3 of 3 sampled patients (Patients #1, #2 and #3) with a home visit observation.

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 2 of 2 sampled patients receiving home health aide services…

The agency failed to complete a written emergency preparedness plan that included a process for cooperation and collaboration with local, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation…

The agency failed to complete a written emergency preparedness plan that included procedures to inform state and local emergency preparedness officials of homebound patients in need of evacuation.

The agency failed to complete a written emergency preparedness plan that included procedures to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency.

The agency failed to complete a written emergency preparedness plan.

The agency's emergency preparedness communication plan failed to include contact information for state and federal officials.

Staff interview the agency failed provide documentation that the agency developed and maintained an emergency plan that included primary and alternate means of communicating with the agency staff and federal, state, tribal, regional and local emergency management agencies.

The agency failed to ensure agency staff developed and maintained an emergency communication plan that included a method of sharing information and medical documentation for the agency clients to maintain the continuity of care.

The agency failed to ensure training in emergency preparedness for all employed staff and all individuals providing services under arrangement (contract staff), consistent with their expected roles on or prior to November 15, 2017. The agency reported utilizing a total of 13 employed staff and 10…

The agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 2 of 2 sampled patients with wound care.

The agency failed to provide individualized and specific written patient care instructions from a registered nurse to agency home health aides for 1 of 5 sampled patients receiving home health aide services (Patient #2).

The agency failed to ensure accurate and thorough completion of all pertinent components of the comprehensive assessment for 2 of 7 sampled patients (Patient #2 and #5).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all medications and medical equipment used by the patient for 5 of 7 sampled patients (Patients #1, #4, #5, #6 and #7).

The agency failed to update the Plan of Care with all new physician orders for 5 of 5 sampled patients with interim physician orders.

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 5 sampled patients receiving home health aide services (Patients…

The agency failed to document all required components of home health aide supervision including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies…

The agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 5 of 7 sampled patients (Patients #1, #2, #4, #6 and #7).