Rhm Services LLC

The agency failed to ensure that the Alternate Clinical Manager Registered Nurse (RN), Admin 3, completed the start-of-care comprehensive assessment within 5 days after the start-of-care date in 1 of 2 patients admitted in the last 30 days.

The agency failed to ensure the individualized plan of care included all elements: pertinent diagnosis and their onset date, all supplies and equipment, specific frequency and duration of visits, nutritional requirements, requirements, all accurate medications, allergies, treatments, all necessary…

The agency failed to evidence all necessary medical information pertaining the patient's current course of illness and treatment, post discharge goals of care, and treatments to the receiving facility or health care practitioner to ensure safe and effective transition of care for 2 or 2 discharged…

The agency failed to document in the patient's clinical record the behaviors and circumstances that warranted patient discharge for cause as well as their efforts to resolve the problem for 1 of 2 discharged patients reviewed . (Patient #5) Findings include: A review of the Comforcare Home Health…

The agency failed to ensure that the Registered Nurse (RN) provided services in accordance with the physician ordered plan of care for 3 of 7 records reviewed (#3, 4, 6).

The agency failed to ensure all staff followed infection control policies and procedures for 2 of 3 home visit observations.

The agency failed to ensure that the aide care plan contained specific directions and parameters for the home health aide (HHA) for 1 of 7 records reviewed (#2).

The agency failed to ensure that all documentation was complete for 2 of 7 records reviewed (#3, 6).

The agency failed to ensure that an initial assessment was completed and documented for 7 of 7 records reviewed (#1, 2, 3, 4, 5, 6, 7).

The agency failed to ensure that the Registered Nurse (RN) completed a thorough and complete medication review and medication profile for 2 of 7 records reviewed (# 6, 7).

The agency failed to ensure that Outcome and Assessment Information Set (OASIS) items were incorporated in the agency's assessment for 1 of 7 records reviewed (#3).

The agency failed to ensure that a complete and accurate plan of care was created for 4 of 7 records reviewed (#1, 2, 3, 7).

The agency failed to ensure that coordination of care was completed between all disciplines for 3 of 7 records reviewed (# 3, 4, 5).

The Registered Nurse (RN) failed to ensure services were provided in accordance with the physician ordered plan of care for 3 of 7 records reviewed (#3, 4, 6).

The agency failed to ensure that the home health aide (HHA) provided services in accordance with the physician ordered plan of care for 6 of 7 records reviewed (#1, 2, 3, 5, 6, 7).

The agency failed to ensure that nurses performed a complete physical assessment per professional standards for 1 of 1 skilled nurse home visits.

The agency failed to ensure that the discharge summary was fully complete for 1 of 2 discharged records reviewed (#4).