Prohealth Home Care, Inc

The Home Health Agency (HHA) failed to ensure their clinical records (comprehensive, chronological documents detailing a patient's health history, including assessments, diagnoses, treatments, and plan of care) contained accurate documentation that met the standards of practice (a set of standards…

The agency failed to ensure the Outcome and Assessment Information Set (OASIS, a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services, (CMS)) data was transmitted…

The agency failed to ensure patients received home health services in accordance with the individualized plan of care for 3 of 17 sampled patients when: Patient 7 did not receive the Occupational Therapy evaluation ordered in the plan of care; and,Patient 3 had a missed home health aide visit that…

The facility did not ensure all entries to the patient’s clinical records were clear, complete, accurate and appropriately authenticated for five of 17 sampled patients (Patient 3, Patient 4, Patient 5, Patient 8 and Patient 9) when: 1. Patient 3’s “HOME HEALTH PHYSICAN ORDERS,” (signed only by the…

The facility failed to document the initial assessment and care provided for two of seventeen sampled patients (Patient 4 and Patient 5) when the Outcome and Assessment Information Set (OASIS: a group of standard data elements integrated into the comprehensive assessment and reported to the Centers…

The facility failed to ensure medication safety for one out of 17 sampled patients (Patient 5) when Patient 5 had medications that were not verified during the comprehensive review (a systematic pharmacist-led evaluation of all a patient's medications to identify, resolve, and prevent…

The facility failed to generate a Plan of Care (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) for one of 17 sampled patients, (Patient 3) when Patient 3's medical record was reviewed and determined to not have a POC for the…

The facility failed to ensure the physician's orders were authenticated and/or signed by the physician in accordance with state law and facility policy for three of 17 sampled patients (Patient 2, Patient 3, and Patient 8) when: 1. Patient 2’s physician's orders were not signed by the physician for…

The agency failed to coordinate care to meet the needs of one of 17 sampled patients (Patient 10), when Patient 10 did not receive physical therapy services until two weeks after his start of care (SOC) date, due to agency staffing concerns and a scheduling miscommunication.

The facility failed to ensure a licensed vocational nurse (LVN-focus on basic bedside care and must operate under an RN or doctor's supervision) visit was supervised by a registered nurse (RN-handle complex assessments, create care plans, and manage advanced procedures) for 1 of 17 sampled patients…

The agency failed to ensure supervisory assessments of home health aide services were completed at least every 14 days for 1 of 17 sampled patients reviewed for home health aide (HHA - assist patients with personal care and daily living activities at home) supervision when Patient 3 went…

The agency failed to ensure the personnel they hired were qualified for employment when: 1. Pre-employment background checks (screening for criminal history, offender registry checks and identity verification) were not completed prior to employment for 4 of 11 sampled employees’ (Licensed Nurse…

The facility failed to ensure patient safety in accordance with professional standards of practice for one of ten sampled patients (Patient 1) when Physical Therapist (PT) 2 was escorting Patient 1 from her living room to her bedroom and did not place Patient 1’s feet in the wheel chair foot rests…

The facility did not ensure current comprehensive assessments (a thorough, interdisciplinary evaluation process that gathers information about a patient's physical, psychological, social, and functional status), clinical notes (dated, written, or electronic records created by healthcare…

The facility failed to document all interventions, treatments, services, and responses to interventions for two of 17 sampled patients (Patient 7 and Patient 8) when: 1. An order for the intervention of an occupational therapy evaluation (OT -a comprehensive assessment conducted by an occupational…

The agency failed to complete and submit the Outcome and Assessment Information Set (OASIS, a standardized data and assessment collection form) data in a timely manner for three of 12 sampled patients (Patient 3, Patient 10, and Patient 11).

The agency failed to ensure 5 of 12 sampled patients (Patient 2, Patient 3, Patient 6, Patient 7, and Patient 10) had a Plan of Care (POC).

The Home Health Agency (HHA) failed to ensure that services and treatments were administered as ordered by the physician for two of 12 sampled patients (Patient 5 and Patient 10).

The Home Health Agency (HHA) failed to provide an accurate and complete medication profile for 2 of 12 (Patient 3 and Patient 8) sampled patients when: 1.Patient 8's medication profile did not reflect Patient 8's medications in the home and 2. Patient 3's medication profile was not completed.

The agency failed to ensure discipline specific discharge summary for 1 of 12 sampled patients (Patient 4) was completed in timely manner.

The agency failed to adequately meet the patients’ needs and coordinate the care delivery between clinicians for two of 12 sampled patients (Patient 5 and Patient 10), when Medical Social Worker (MSW) services were not provided to Patient 5 and Patient 10 per physician’s orders.

The agency failed to ensure therapy services (exercises to help a patient regain movement or strength) and nursing services were in accordance with the Plan of Care (POC) for six of 12 sampled patients (Patient 3, Patient 4, Patient 1, Patient 7, Patient 5, and Patient 9), and Patient 3 failed to…

The agency failed to ensure the registered nurse (RN) supervised the care provided by licensed vocational nurses (LVNs) for two of 12 sampled patients (Patient 5 and Patient 10), when there were no supervisory visits completed and no monitoring and evaluation of LVNs performance documented.

Failed to make supervisory onsite visits to the patient's home no less frequently than every 14 days for 3 of 10 sampled patients (Patient 1, Patient 7, Patient 8) receiving Home Health Aide (HHAide) services.

The agency failed to maintain effective coordination of care for 1 of 10 sampled patients (Patient 6), when nurses did not coordinate to ensure timely laboratory monitoring.

The agency accepted 1 of 10 sampled patients (Patient 2) whose needs were not met when Physical Therapy (PT) services were not provided a week after her start of care date.

The agency failed to ensure nursing visits were in compliance with physician orders when an extra visit was conducted for 1 of 10 sampled patients.

The agency failed to maintain comprehensive and timely clinical records for 2 of 10 sampled patients (Patient 4 and Patient 1) when: 1. Patient 4's physician orders for an additional 7 weeks of nursing visits were not updated until after Patient 4 was discharged; and, 2. Patient 1's record did not…