Mitchell County Home Health Care/ Public Health

The agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 3 of 3 sampled patients (Patient #1, #2 and #3) with a home visit observation of staff.

The agency failed to include all medications in Plans of Care for 4 of 7 patients with home visits (Patient #1, #2, #3 and #4).

The agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 2 of 5 sampled patients with new verbal/interim orders.

The agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 7 sampled patients (Patients #5 and #6).

The agency failed to obtain and follow a written Plan of Care established and periodically reviewed by a doctor of medicine, osteopathy or podiatry for 5 of 7 sampled patients (Patients #1, #2, #3, #4 and #6).

The agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 3 of 4 sampled patients who required wound assessments (Patient #2, #3, and #6).

The agency failed to ensure 6 of 7 sampled home health aides (Staff F, G, H, I, J and K), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 2 sampled patients (Patients #2 and #5), had documented evidence of competency by a registered nurse (RN) in…

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 6 sampled patients receiving home health aide services (Patient #2).

The agency failed to ensure authentication of electronic clinical record entries made in each patient's clinical record included the employee's title as part of the signature for 3 of 7 sampled patients (Patients #1, #2, #7).

The agency failed to complete a drug regimen review which included all of the patient's current medications with each comprehensive assessment for 2 of 7 sampled patients (Patients #1 and #2).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and accurate medication orders for 4 of 7 sampled patients (Patients #1, #2, #4 and #7).