Northwest Home Health Care Inc

The agency failed to ensure the discharge summary was sent to the physician within 5 business days of discharge per the agency’s policy in 1 of 1 closed record review of a patient discharged due to goals met.

The agency’s governing body failed to approve the frequency and detail of the data collection for the Quality Assessment and Performance Improvement Program in 1 of 1 agency.

The agency’s performance improvement activities failed to focus on high volume of hospital admissions to consider the severity of the problem that would lead to a correction of the identified problem in 1 of 1 agency.

The agency failed to ensure the timely documentation of clinical notes in 1 of 3 active clinical records reviewed with PT services.

The agency failed to ensure the written notice of Patient Rights were provided in a language the Patient/legal representative understood in 1 of 1 clinical record reviewed with Spanish as the primary language.

The agency failed to ensure medication interaction concerns identified during a patient’s medication review were reported to the physician in 5 of 5 active clinical records reviewed (Patient #1, 2, 3, 4, 5).

The agency failed to ensure the comprehensive assessment was completed within 48 hours of return home from the hospital in 1 of 1 active clinical record reviewed with a hospitalization.

The agency failed to ensure verbal orders were written and sent to the physician for signature in 1 of 1 active clinical records reviewed with a hospitalization.

The agency failed to notify the physician of a medication discrepancy in 1 of 1 active clinical record reviewed with a hospitalization.

The agency failed to integrate services to assure the identification of patient needs that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in 1 of 1 active clinical records reviewed with a home health aide (Patient #2).

The agency failed to ensure the home health aide provided services that were ordered by the physician and included in the plan of care in 1 of 1 active clinical records reviewed with a home health aide (Patient #2).

The agency failed to ensure the home health aide supervision by a registered nurse [RN] included that the home health aide was following the patient’s plan of care for completion of tasks in 1 of 1 active clinical records reviewed with a home health aide (Patient #2).

The home health agency failed to: ensure patients were accepted for care based on the expectation the home health agency was able to meet their needs (see tag G0570); ensure each patient received home health services written in their plan of care and the plan of care was individualized (see tag…

The agency failed to develop an emergency preparedness plan that was based on and included a documented facility-based and community-based risk assessment utilizing an all-hazards approach.

The agency failed to ensure the emergency preparedness communication plan included contact information for federal and state local emergency preparedness staff.

The agency failed to ensure OASIS data accurately reflected patient’s status at time of assessment in 3 of 5 active clinical records reviewed.

The agency failed to update the comprehensive assessment due to a major decline in patient’s health status in 1 of 5 active clinical records reviewed.

The agency failed to send all necessary medical information pertaining to the patient’s current course of illness and treatment to the health care practitioner in 1 of 2 discharge records reviewed.

The agency failed to ensure the patients received the services written in an individualized plan of care in 3 of 5 active clinical records reviewed.

The agency failed to ensure an initial assessment visit was conducted within 48 hours of referral or on the physician ordered start of care date in 1 of 5 active records reviewed.

The agency failed to ensure the comprehensive assessment accurately reflected the patients’ current health status in 2 of 5 active clinical records reviewed.

The agency failed to include the patient’s available support including their willingness and ability to provide care and availability and schedules in 1 of 5 active clinical records reviewed.

The agency failed to ensure the plan of care included nutritional requirements, type of supplies or equipment required, all medications and treatments, and/or all pertinent diagnoses in 4 of 5 active clinical records reviewed.

The agency failed to ensure all patient care orders were recorded on the plan of care in 1 of 3 home visits conducted.

The agency failed to ensure services and treatments were administered only as ordered by a physician in 2 of 5 active clinical records reviewed.

The agency failed to promptly alert the physician to any changes in patients’ condition or needs which suggested outcomes were not being achieved, or the plan of care needed to be altered in 2 of 3 home visits conducted.

The agency failed to coordinate care delivery to meet the patient’s needs and/or involve the patient in the coordination of care activities in 1 of 5 active clinical records reviewed.

The agency failed to ensure patients received written medication schedule/instructions which included all of the medication names, dosages, and frequency in 3 of 3 home visits conducted.

The agency failed to provide a copy of a written plan of care in 1 of 3 home visits conducted.

The agency failed to accurately prepare clinical notes in 1 of 5 active clinical records reviewed.

The home health agency failed to ensure communication with all physicians involved in the plan of care as related to the current plan of care in 1 of 5 active clinical records reviewed.

The home health agency failed to ensure a registered nurse made supervisory visits at least every 14 days in 1 of 5 active clinical records reviewed.

The home health agency failed to ensure the agency staff followed standard/universal precautions at home visits in 1 on 3 home visits conducted.

The home health aide failed to ensure they followed the home health aide care plan in 4 of 6 clinical records reviewed (#1, #2, #5, #6) and the registered nurse failed to include indications on prn tasks in 1 of 6 clinical records with home health aides, out of a total sample of 8 clinical records…

The home health agency failed to ensure the clinician appropriately signed and dated all clinical notes in 1 of 8 clinical records reviewed.

The home health agency failed to ensure to inform the patient of charges they may incur due to the addition of a home health service in 1 of 8 clinical records reviewed.

The home health agency failed to ensure all patients/ patient caregivers were aware of the state toll-free home health hotline number, or how to obtain the number, in 1 of 3 patients/ patient caregivers interviewed, out of a total sample of 8 clinical records reviewed.

The home health agency failed to ensure the initial assessment was performed by the registered nurse within 48 hours of the referral in 2 of 8 clinical records reviewed.

The home health agency failed to ensure all verbal orders received from the physician were documented and signed by the physician that gave the verbal order in 1 of 8 clinical records reviewed.

The home health agency failed to ensure the skilled nurse updated the plan of care following an extended hospital admission, in 1 of 8 clinical records reviewed.

The home health agency failed to ensure all patients home folders had a current visit schedule of agency staff that was to visit the patient for the current certification period, in 1 of 3 home visits observed.

The home health agency failed to ensure the skilled professional followed the medical/physical therapy plan of care in 3 of 8 clinical records reviewed with skilled nurse services.

The home health agency failed to ensure the skilled nurse provided education/instructions to the patient/ patient caregiver as indicated on the medical plan of care in 1 of 8 clinical records reviewed.

The home health agency failed to ensure the skilled nurse completed all skilled nurse visit notes in accordance with agency policy in 3 of 8 clinical records reviewed.