Saint Mary's Home Health Care, Inc

The Home Health Agency (HHA) failed to ensure medications ordered for one of three sampled home visit patients (Patient (P) 7) accurately matched the medications in their home, thereby preventing discrepancies, duplications, omissions, changes, and/or unclear information.

The facility failed to ensure 1 of 8 patients (Patient (P) 2) whose records were reviewed, had complete medical records related to missing skilled nurse (SN) visit notes to evidence care was provided as directed in the plan of care (POC).

The Home Health Agency (HHA) failed to meet the Condition for Coverage (CfC) for Emergency Preparedness (EP).

The agency failed to maintain a comprehensive emergency preparedness plan, and ensure the plan was evaluated and reviewed annually.

The agency failed to maintain a comprehensive emergency preparedness plan, failed to ensure the plan was evaluated and reviewed annually, and failed to address the patient population and the types of services the agency could provide in an emergency.

The agency failed to maintain a comprehensive emergency preparedness plan, failed to ensure the plan was evaluated and reviewed annually and included a process for cooperation and collaborations with local officials.

The agency failed to maintain a comprehensive emergency preparedness plan, failed to ensure the plan was evaluated and reviewed annually, and failed to have devices available for communication as indicated in the plan.

The agency failed to maintain a comprehensive emergency preparedness plan.

The agency failed to maintain a comprehensive emergency preparedness plan, failed ensure the "Emergency Preparedness Plan" (EPP) was evaluated and reviewed annually.

The agency failed to maintain a comprehensive emergency preparedness plan.

The agency failed to maintain a comprehensive "Emergency Preparedness Plan." The facility failed to ensure the plan was evaluated and reviewed annually and failed to consider the use of volunteers and other emergency staffing strategies.

The agency failed to maintain a comprehensive "Emergency Preparedness Plan (EPP)," to ensure the plan was evaluated and reviewed annually and failed to have a communication plan in place to implement in an emergency.

The agency failed to maintain a comprehensive "Emergency Preparedness Plan, (EPP)." The agency failed to ensure the plan was evaluated and reviewed annually.

The agency failed to maintain a comprehensive "Emergency Preparedness Plan (EPP)," and failed to ensure the plan was evaluated and reviewed annually.

The agency failed to develop and maintain a communication plan, including a method for sharing information and medical documentation for continuity of patient care in the event of an evacuation.

The agency failed to maintain a comprehensive "Emergency Preparedness Plan (EPP)," and failed to ensure the plan was evaluated and reviewed annually.

The agency failed to maintain a comprehensive "Emergency Preparedness Plan (EPP)," and failed ensure the plan was evaluated and reviewed annually.

The agency failed to participate in a full-scale exercise that was a community-based emergency preparedness exercise.

The facility failed to ensure that 4 of 7 (Home Health Aides (HHA) HHA1, HHA2, HHA3 and HHA4) received the mandatory 12 hours of inservices required per year.

The home health agency was not in compliance with rules regarding safeguarding personal health information and there was the risk of loss and unauthorized use of resident information.

The agency failed to complete a comprehensive assessment within five days of admission for 1 of 1 patients (Patient (P) 5) admitted in the last 30 days.

The facility failed to ensure 3 of 7 patients (Patients (P) P1, P3 and P5) received supervision visits for the Home Health Aides (HHA) every 14 days.

The facility failed to ensure 1 of 7 sampled (Patients) (P) P3) had complete medical records related to missing Home Health Aide (HHA) visit notes to evidence care was provided as directed in the plan of care (POC).

Base on record review, staff interview and review of the agency's policies and procedures, the agency failed to ensure an individualized emergency plan was included in the patient's comprehensive assessment for 2 (Patient (P)2, P5) of 7 patient charts reviewed.

The agency failed to ensure the physician was notified of the alteration in the plan of care for 1 (Patient (P)7) of 7 patients reviewed from a census sample of 41 patients.

The agency failed to ensure 1 of 2 Home Health Aides (HHA) hired prior to 2017 whose personnel files were reviewed, had completed 12 hours of in-service education in the previous calendar year (HHA 17).

The agency failed to ensure the patients were informed of their rights regarding services provided, advance directives and disclosure of financial responsibility at admission for 1 (Patient (P) 5) of 7 patients reviewed.

The agency failed to ensure the plan of care reflected the current needs of 5 (Patient (P) P1, P2, P5, P6, P7) of 7 patients reviewed.

The agency failed to ensure evaluation of therapy services and discharge assessment were completed for 1 (Patient (P) 1) of 5 patients who were receiving therapy services from a total patient sample of 7. Failure to evaluate the patient's needs after services were given had the potential to affect…

The agency failed to ensure the Registered Nurse (RN) followed the plan of care (POC) as ordered for 3 of 7 patients sampled (Patient (P)1 P3, and P4).

The agency failed to ensure home health aide (HHA) services were given according to the plan of care (POC) for 2 of 2 patients (Patient (P)1 and P3) reviewed who were receiving HHA services out of 7 sampled patients.

The agency failed to ensure the Registered Nurse (RN) made onsite supervisory visits every fourteen days to evaluate the home health aide services as written in the home health aides (HHA) plan of care (POC) for 2 of 2 patients receiving HHA services out of a total of 7 patients sampled (Patient's…