Memorial Home Health

The agency failed to ensure contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees.

The agency failed to ensure administrative policies and procedures related to an Emergency Preparedness Plan dissemination of PHI during plan activation for all patients and employees.

The agency failed to ensure patient centered QAPI Program activities that identified actions and self-monitoring efforts to identify problems, improve care, services and operations for all patients and employees.

The agency failed to ensure: intervention activities; analysis of data; follow up; PIP status for the agency in calendar years 2022 and 2023 for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI program plan and agency evaluation for all patients and employees.

The agency failed to ensure the development of a home health aide care plan for one (Patient #5) of 17 patients.

The agency failed to ensure governing body oversite of an operating budget, capital expenditure plan and allocation of resources activities for calendar year 2022 and 2023 for all patients and staff.

The agency failed to ensure individualized patient POC included: 1. Interventions and related goals for skilled diagnosis for two (Patients #2 and #3) of 17 patients; 2. Pain reporting parameters for physician notification and goals for three (Patients #2, 7 and 11) of 17 patients; 3. SN wound care…

The agency failed to ensure: 1. Physician ordered SN for indwelling urinary catheter treatment interventions for two (Patients #8 and #12) of 17 patients and; 2. Physician ordered wound site care and dressing materials for one (Patient #10) of 17 patients.

The agency failed to ensure care was coordinated between the agency and physician for four (Patient #1, 3, 6 and #7) of 17 patients.

The agency failed to ensure: SN conducted visit frequency as ordered on the POC for four (Patients #1, 5, 7 and 12) of 17 patients; PT conducted an evaluation as ordered for one (Patient #4) of 17 patients; SN conducted wound site assessment and care ordered on the POCs for three (Patients #6, 10…

The agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees.

The agency failed to ensure certified home health aide supervisory visits were completed every 14 days for one (Patient #5) of 17 patients.

The agency failed to ensure a completed transfer/discharge summary was provided for one (Patient #13) of 17 patients.

The agency failed to ensure emergency preparedness disaster table top exercises and drills conducted for fiscal years 2019 and 2020 documented agency staff participation for 273 patients and all staff members.

The agency failed to ensure conduction of patient centered QAPI Program activities for all 273 patients and all employees.

The agency failed to ensure governing body oversight of: 1) a patient centered QAPI Program and 2) an operating budget and allocation of resources for calendar years 2019 and 2020 effecting 273 patients and all staff.

The agency failed to ensure clinical records were complete for one (Patient #5) of 17 patients.

The agency failed to ensure medication embedded wound care supplies were included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for three (Pts #2, 7 and #12) of 17 patients.

The agency failed to ensure a discharge oasis were completed on patients discharged from the agency for four (Pts #7, 8, 15 and #17) of 17 patients.

The agency failed to ensure the individualized patient POC included: 1. Pain reporting ranges for six (Pts #1, 3, 4, 6, 8 and #10) of 17 patients and; 2. Recurring urinary catheter change due dates were documented for two (Pts #6 and #9) of 17 patients.

The agency failed to ensure SN visits were conducted as ordered by the physician for four (Pts #7, 10, 11 and #12) of 17 patients.

The agency failed to ensure completion of a transfer/discharge summary for six (Pts #7, 8, 12, 15, 16 and #17) of 17 patients.

The agency failed to ensure clinical records were complete, dated and signed for three (Pt #2, 7 and 8) of 15 patients.

The agency failed to ensure SNS completed timely clinical notes for two (Pt #1 and 3) of 15 patients.

The agency failed to ensure physician notification of multiple missed visits for two (Pt #3 and 10) of 15 patients.