Mercy Hospital Jefferson

The home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s medical and nursing needs in two of five records reviewed (Records/Patients #1 and #3).

The home health provider failed to ensure the plan of care (POC) included patient specific interventions and individualized goals in three of five records reviewed (Records/Patients #1, #2, and #3).

The home health provider failed to update the plan of care (POC) to reflect changes in wound care needs in two of five full records reviewed (Records/Patients #3 and #5).

The home health provider failed to ensure that staff were providing services that are ordered by the physician as indicated in the plan of care (POC) in two of five records reviewed (Records/Patients #1 and #4).

The agency failed to ensure staff provided ongoing assessments for three (Records/Patients #1, #2 and #3) of three records reviewed.

The agency failed to: - Develop a complete plan of care (G574); - Ensure treatments were provided only as ordered by the physician (G580); - Ensure coordination of care delivery (G608); - Promptly alert the physician to changes in the patient’s condition or needs that suggest that outcomes are not…

The agency failed to develop and implement an effective discharge planning process in one (Record/Patient #5) of one full discharge record reviewed.

The agency failed to incorporate Centers for Disease Prevention and Control (CDC) Guidance for COVID-19 by ensuring policies and procedures were followed for screening persons entering the agency and the agency failed to follow accepted standards of practice to prevent the transmission of…

The agency failed to ensure the registered nurse (RN) developed a complete aide plan of care (POC) for one (Record/Patient #1) of one record reviewed that received aide services.

The agency failed to ensure the registered nurse (RN) conducted an initial assessment within 48 hours of the referral, or within 48 hours of the patient's return home for one (Record/Patient #3) of five full records reviewed.

The agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, but not limited to, three (Records/Patients #1, #4 and #5) of five full records reviewed.

The agency failed to develop a complete plan of care (POC) for three (Records/Patients #3, #4, and #5) of five full records reviewed.

The agency failed to ensure treatments were administered only as ordered by the physician in one (Record/Patient #3) of five full records reviewed, This deficient practice has the potential to affect all patients served by the agency, Findings included: Review of the agency's policy titled, "Plan…

The agency failed to alert the physician to changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or the plan of care (POC) should be altered in three (Records/Patients #3, #4 and #5) of five full records reviewed.

The agency failed to ensure coordination of care delivery in three (Records/Patients #3, #4 and #5) of five full records reviewed.

The agency failed to provide the patient and caregiver with a copy of pertinent written instructions outlining treatments to be administered by agency personnel and personnel acting on behalf of the agency related to the patient's care and treatments.

The agency failed to provide services ordered by the physician as indicated in the plan of care in, but not limited to, two (Records/Patients #2 and #5) of five full records reviewed.

The agency failed to ensure the skilled professional staff assumed responsibility for patient and caregiver education in three (Records/Patients #1, #3, and #4) 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 registered nurse (RN) failed to provide an individualized, patient specific home health aide plan of care, therefore the home health aide was unable to specifically follow the plan of care in one (Record/Patient #1) of one record reviewed that received aide services.

The agency failed to alert the physician to changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered in, but not limited to, one (Record/Patient #3) of five records reviewed.

The agency failed to ensure physical assessments and/or care was provided as ordered by the physician as indicated by the plan of care in one (Record/Patient #5) of five records reviewed.

The agency failed to follow agency policy and procedures for infection control in one of three home visit observations (Record/Patient #1).