Providence at Home With Compassus Home Health, Orange County South

The agency failed to ensure the physician was notified of the missed visit for one of three sampled patients (Patient 1).

The agency failed to ensure the review of the medications included the patient’s current medications to identify any potential adverse effects and drug reaction for one of three sampled patients (Patient 3).

The agency failed to ensure the patient received care and services as per the written POCs for one of three sampled patients (Patient 3).

The agency failed to ensure the coordination with the physician regarding obtaining the patient’s weight for one of three sampled patients (Patient 3).

The agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for two of three sampled patients (Patients 1 and 2).

The agency failed to ensure the agency's RN or other appropriately skilled professional provided the onsite supervision for the HHA no less frequently than every 14 days to ensure quality of care and services provided for one of three sampled patients (Patient 1).

The agency failed to revise and update the POC for two of 18 sampled patients (Patients 6 and 18), creating the risk for not providing necessary care and services to meet the care needs for these patients.

The agency failed to implement infection control practices related to hand hygiene and catheter care for four of 18 sampled patients (Patients 2, 3, 4, and 5), creating the risk of the spread of infection. #. Review of Patient 3's clinical record was initiated on 7/10/23. The clinical record showed…

The agency failed to accurately report the infection control data and analyze the different types of infection.

The agency failed to ensure the initial comprehensive assessments were completed accurately and consistent with the patients’ immediate care needs for ten of 18 sampled patients (Patients 2, 4, 6, 8, 9, 10, 12, 14, 17, and 18).

The agency failed to ensure the medication profiles were updated to reflect the patients' current medications and included the specific indications and parameters for their use for eight of 18 sampled patients (Patients 2, 3, 4, 5, 6, 12, 16, and 18).

The agency failed to ensure the updated comprehensive assessments were completed accurately and consistent with the patients’ immediate needs for three of 18 sampled patients (Patients 2, 8, and 9).

The agency failed to ensure the update comprehensive assessment were completed within 48 hours of the patient's return to home from the hospital for two of 18 sampled patients (Patients 6 and 14), creating the risk of not providing the necessary care and services timely to meet the care needs for…

The agency failed to ensure the comprehensive assessment was completed at discharge for one of 18 sampled patients (Patient 9), creating the risk of not updating the patient's status for this patient.

The agency failed to ensure the POCs were individualized and had patient-specific interventions and instructions for 12 of 18 sampled patients (Patients 3, 4, 6, 8, 9, 10, 11, 12, 13, 14, 16, and 17).

The agency failed to ensure the physician's order was dated accurately for one of 18 sampled patients (Patient 9).

The agency failed to coordinate the care to meet the patients' care needs for nine of 18 sampled patients (Patients 7, 8, 9, 10, 11, 12, 14, 15, and 16).

The agency failed to provide the written instructions on the SN visit schedule for three of 18 sampled patients (Patients 1, 4, and 7), creating the risk of not providing the necessary information to these patients.

The agency failed to provide the name and information of the clinical manager for two of 18 sampled patients (Patients 4 and 5).

The agency failed to ensure the care and services were provided in accordance with the POC for 10 of 18 sampled patients (Patients 1, 2, 4, 7, 8, 12, 14, 15, 16, and 17).

The agency failed to ensure the agency's skilled professionals prepared accurate and complete clinical notes for 11 of 18 sampled patients (Patients 1, 4, 6, 9, 10, 11, 12, 13, 14 16, and 17).

The agency failed to ensure the responsibility for the day-to-day operations by not implementing the agency's P&P as evidenced by: * The agency failed to ensure the written agreements for 11 of the 11 contractors (Contractors 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) included the required elements in…

The agency failed to ensure the discharge and transfer summaries were completed and sent to the physician timely for three of the 18 sampled patients (Patients 6, 12, and15).

The agency failed to develop and implement an emergency preparedness P&P addressing a system of medical documentation that protected confidentiality of patient information, and secured and maintained availability of records.

The agency failed to ensure the emergency preparedness P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

The agency failed to ensure the initial training in the emergency preparedness program was provided to all staff, including the contracted individuals providing services under arrangement.

The agency failed to ensure the OASIS data was transmitted within 30 days of completing the OASIS data sets, creating the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the HHA.

The agency failed to investigate the grievance filed by the patient's family member for two nonsampled patient (Patients A and D).

The agency failed to develop the individualized POC based on the problems identified in the initial and updated comprehensive assessments for one of 17 sampled patients (Patient 15), creating the risk of not addressing this patient care needs.

The agency failed to ensure the clinical records were complete for seven of 17 sampled patients (Patients 1, 3, 4, 5, 7, 8, and 12), creating the risk of substandard care provided to these patients as their clinical information was not complete.

The agency failed to ensure the initial assessment visit was conducted within 48 hours after referral for one of 17 sampled patients (Patient 14), creating the risk of not providing the necessary care and services to this patient timely.

The agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the SOC date for three of 17 sampled patients (Patients 3, 10, and 17), creating the risk of not identifying…

The agency failed to ensure the review of the patient's medications included all of the patient's medications and identified the duplicate drug therapy, significant drug interactions and its side effects for four of 19 sampled patients (Patients 3, 6, 8, and 13), creating the risk of not…

The agency failed to ensure the comprehensive assessments were updated within the last 5 days of every 60 days for two of 17 sampled patients (Patients 1 and 12), creating the increased risk of not addressing the care needs for these patients.

The agency failed to ensure the comprehensive assessments were completed at discharge for two of 17 sampled patients (Patients 16 and 17), creating the risk of not updating the patient's status for these patients.

The agency failed to ensure the POCs included specific interventions related to wound care and medications for two of 17 sampled patients (Patients 1 and 15), creating the risk of not addressing the care needs for these patients.

The agency failed to ensure the treatments were administered only as ordered by the physician for three of 17 sampled patients (Patients 1, 7, and 9), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to ensure the physician's orders were signed by the physician within 30 working days as per the State regulations for four of 17 sampled patients (Patients 2, 5, 9, and 13), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency failed to coordinate care to meet the patients' care needs for seven of 17 sampled patients (Patients 1, 7, 8, 9, 11, 12, and 17), creating the risk of not providing the necessary care and services to these patients.

The agency failed to ensure the skilled professionals provided care and services in accordance with the POC for eight of 17 sampled patients (Patients 1, 7, 8, 9, 12, 14, 15, and 16), creating the risk of not providing appropriate, consistent, and quality care to these patients.

The agency's Administrator failed to be responsible for the day-to-day operations as the agency's P&Ps related to cleaning of patient care equipment, PICC line management not being implemented for three of 17 sampled patients (Patients 4, 6, and 12), creating the risk of poor health outcomes for…

The agency failed to ensure the SN provided care and services related to the PICC line care in accordance with professional standards and principles for two of 17 sampled patients (Patients 6 and 12), creating the risk of not providing appropriate care to these patients.

The agency failed to ensure the completed discharge summaries were sent to the primary care practitioner after discharge from the HHA within five business days of the discharge date for two of five sampled discharge patients (Patients 15 and 17), creating the risk of not providing the necessary…