Pulaski County Health Dept
Inspection 2018-11-16
· Recertification · 23 deficiencies · CMS source report (PDF)The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. The agency failed to provide in writing, in advance of furnishing care, the following information listed as patient rights to include: - If a…
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The agency failed to meet the requirements for the Condition of Participation: Care Planning, Coordination of Services, and Quality of Care, when the agency failed to: - Develop a plan of care that addressed patient needs as identified during the comprehensive assessment (G572); - Establish an…
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include if a patient has been adjudged to lack capacity to make health care decisions as established by state law by a court of proper…
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that information must be provided to patients in plain language and in a manner that is accessible and timely to (1) Persons with…
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The agency failed to develop a plan of care that addressed patient needs as identified during the comprehensive assessment in one (Record/Patient #5 ) of six records reviewed.
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and…
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the rights regarding expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; and any factors…
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to receive all services outlined in the plan of care.
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the right to have a confidential clinical record; and access to or release of patient information and clinical records is permitted in…
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The agency failed to: - Update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the right that the agency must advise the patient and representative of these (financial liability) changes as soon as possible, in…
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the right to be informed of access auxiliary aids and language services, and how to access these services.
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of…
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the home health agency (HHA) must take action to prevent further potential violations, including retaliation, while the complaint…
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The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include any home health agency (HHA) staff (whether employed directly or under arrangement) in the normal course of providing services to…
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The agency failed to: - Establish an individualized plan of care that included a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors in, but not limited to three (Records/Patients #2, #3…
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The agency failed to: - Ensure drugs and treatments were administered only as ordered by a physician in, but not limited to, one (Record/Patient #1) of six cases reviewed; and - Ensure services followed the plan of care as ordered by the physician in, but not limited to four (Records/Patients #3…
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The agency failed to ensure all verbal orders were timed in six (Records/Patients #1, #2, #3, #4, #5 and #6) of six records reviewed.
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The agency failed to alert the physician to a change in the patient's condition in, but not limited to, one (Record/Patient #3) of six cases reviewed.
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The agency failed to provide the patient and/or caregiver a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel in, but not limited to one (Records/Patients #1) of two home visits conducted.
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The agency failed to ensure that the agency staff evaluated the aide for all of the required elements during the aide supervisory visits in one (Record/Patient # 1) of one record reviewed that received aide services.
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The agency failed to include Missouri Case Law in the advance directive information given to patients as required in 42 CFR 489.102 (a)(1)(i), in, but not limited to, two (Records/Patients #1 and #2) of six cases reviewed; and failed to ensure staff used appropriate bag technique during home visits…
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The agency failed to ensure that the clinical record contained documentation for all of the interventions/treatments ordered on the plan of care in, but not limited to, two (Records/Patients #4 and #5) of six records reviewed.
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The agency failed to ensure the discharge summary was sent to the physician within five business days of discharge in one (Records/Patient #1) of one applicable case reviewed where a discharge occurred after 1/13/18 when the new federal regulations became effective.
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