Premier Home Health Agency

The agency registered nurse (RN) failed to complete an initial Comprehensive Assessment to determine the immediate care and support needs for two of seven active Licensed and Certified patients (Patients #2 and #9) whose clinical records were reviewed in that: 1. Patients #2 and #9 did not have a…

The agency failed to ensure that an individualized plan of care that identified patient-specific measurable outcomes and goals was written for two of seven active patients (Patients #2 and #9) whose clinical records were reviewed.

The agency failed to ensure skilled professionals developed Plans of Care (POC) for two of seven active patients (Patient #2 and #9) whose records were reviewed.

The Administrator failed to organize and direct the agency's ongoing functions as follows: A.

The agency failed to complete the Comprehensive Assessment that accurately reflected the patients specific status to include, but not limited to, patient history and diagnosis, risk assessment, elimination status, nutrition, neuro/emotional behavioral status, ADL (activity of daily living)/IADLs…

The agency failed to ensure that an individualized plan of care that identified patient-specific measurable outcomes and goals was written for two of seven active patients (Patients #2 and #9) whose clinical records were reviewed.

The Registered Nurse (RN) failed to ensure that a Home Health Aide (HHA) Care Plan, which included written instructions for patient care, was prepared for two of seven active patients (Patients #3 and #9) receiving HHA services whose clinical records were reviewed, in that; 1. Patients #3 and #9's…

The agency registered nurse (RN) failed to complete an initial Comprehensive Assessment to determine the immediate care and support needs for two of seven active Licensed and Certified patients (Patients #2 and #9) whose clinical records were reviewed in that: 1. Patients #2 and #9 did not have a…

The agency failed to complete the Comprehensive Assessment within five calendar days of the start of care, for two of seven active Licensed and Certified patients (Patients #2 and #9) whose clinical records were reviewed in that: 1. Patients #2 and #9 did not have a completed Comprehensive…

The agency failed to include a review of all medications in the Comprehensive Assessment for two of seven active patients (Patients #2 and #9) whose clinical records were reviewed in that: 1. Patient #2 and #9's Comprehensive Assessment did not include a medication review.

The agency failed to enforce its written policy to ensure that effective exchange of information regarding coordination of Patient services among personnel providing care and services for two of seven Patients (Patients #2 and #9) whose records were reviewed, in that: 1. Ex-Employee D (Registered…

The agency failed to ensure skilled professionals developed Plans of Care (POC) for two of seven active patients (Patient #2 and #9) whose records were reviewed.

The agency failed to prepare clinical notes that were in accordance with accepted principles of practice for two of seven active patients (Patients #2 and #9) whose records were reviewed in that: 1. Patient #2 and #9's Comprehensive Assessment and Plan of Care (POC) were not completed or…

The Registered Nurse (RN) failed to make an on-site supervisory Home Health Aide (HHA) visit, at least every two weeks for two of seven active patients (Patients #3 and #9) that received HHA services whose clinical records were reviewed.

The Administrator failed to organize and direct the agency's ongoing functions as follows: A.

The agency failed to ensure that an individualized plan of care that identified patient-specific measurable outcomes and goals was developed for two of seven active patients (Patients #2 and #9) whose clinical records were reviewed.

The agency failed to ensure entries to the clinical records were in accordance with accepted principles of practice for two of seven active patients (Patients #2 and #9) whose records were reviewed in that: 1. Patient #2 and #9's Comprehensive Assessment and Plan of Care (POC) were not completed or…