Scotland County Home Health Agency

The home health provider failed to ensure emergency preparedness (EP) training was documented on hire of two employees (RN (registered nurse) A and Clinical Manager) and failed to ensure a contract employee received the provider’s EP training every two years (Contract PT (physical therapist)).

The home health provider failed to maintain documentation of exercises conducted annually to test the emergency plan and analyze the provider’s response to all drills, tabletop exercises, and emergency events and revise the emergency plan as needed.

The home health provider failed to ensure that the patients received the home health services that were written on their individualized plan of care when wound care was not received as ordered on the plan of care in one of five full records reviewed (Record/Patient #1).

The home health provider failed to ensure staff followed infection control standards of practice in two of three home visit observations (Records/Patients #1 and #2).

The home health provider failed to ensure staff were provided infection control training on hire in two of three employee files reviewed (RN A and clinical manager).

The home health provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, two of three home visit observations (Records/Patients #1 and #2).

The home health provider failed to obtain medication orders in one of five full records reviewed (Record/Patient #3).

The home health provider failed to promptly alert the physician when one patient had elevated blood sugars out of the parameters and missed visits due to patient refusing visits in one of five full records reviewed (Record/Patient #4).

The home health provider failed to ensure contract staff were provided annual agency in-service training in one of one contract employee files reviewed (Contract PT).

The home health provider failed to: - Request and obtain results of findings of the Employee Disqualification List (EDL) prior to hire in one of three employee files reviewed (clinical manager (CM)); and - Show documentation of Alzheimer’s training upon hire in two of three employee files reviewed…

The agency failed to develop and implement an emergency preparedness communication plan that included the names and contact information for the patient's physicians.

The agency failed to ensure staff followed infection control standards of practice in one (Record/Patient #2) of three home visit observations.

The governing body failed to assume full legal authority and responsibility for the operation of the agency.

The agency failed to ensure all documented entries included appropriate authentication and completion in a timely manner at the time the care was completed in, but not limited to, one (Record/Patient #3) of five full records reviewed.

The agency failed to ensure an accurate medication reconciliation was completed in, but not limited to, four (Records/Patients #1, #2, #3, and #5) of five records reviewed.

The agency failed to ensure that each patient's written individualized plan of care (POC) included all the required elements in one (Record/Patient #5) of five full records reviewed.

The agency failed to ensure written instructions were provided to the patient/caregiver outlining the visit schedule, including the frequency of visits in two (Record/Patients #2 and #3) of three home visit observations.

The agency failed to provide services as ordered by the physician on the plan of care (POC)/medication list in one (Record/Patient #1) of five records reviewed.

The agency failed to ensure that patient and caregiver education was accurately provided in, but not limited to, one (Record/Patient #2) of five records reviewed.

The agency failed to assure agency clinicians effectively communicated with all physicians or other health care practitioners related to the patient's current plan of care (POC) in, but not limited to, two (Records/Patients #3 and #5) of five full record reviews.

The agency failed to ensure a qualified, pre-designated person who is authorized in writing by the administrator and the governing body to assume the same responsibilities and obligations as the administrator when the administrator is not available.

The agency failed to ensure a completed transfer summary was sent within two business days of an unplanned transfer to the receiving facility in one (Record/Patient #5) of two transferred or discharged records reviewed.

The agency failed to follow their emergency preparedness plan training program that included initial training in emergency preparedness policies and procedures to all new and existing staff, maintained documentation of all emergency preparedness training, and demonstrated staff knowledge of…

The agency failed to ensure agency staff complied with accepted professional standards and principles related to performing care and maintaining adequate and appropriate infection control measures in, but not limited to, two of three patient observations (RECORDS/PATIENTS #1 and #4).

The agency failed to effectively review all medications the patient was using in order to identify any duplicate drug therapy in five of five (Records/Patients #1, #2, #3, #4 and #5) and noncompliance with drug therapy in, but not limited to, two (Records/Patients #1, and #4) of five records…

The agency failed to ensure the registered nurse included all required information on the plan of care for one (Record/Patient #3) of five records reviewed.

The agency failed to ensure therapy services coordinated and communicated the patient needs to all disciplines in one of four patient's receiving therapy services.

The agency failed to ensure the physical therapist (PT) provided complete and accurate clinical notes/assessments in two of four patients receiving therapy services (Records/Patients #1 and #5) This deficient practice has the potential to affect all patients receiving therapy services by the agency.

The agency failed to ensure contracted physical therapy (PT) staff completed agency in-service training/education in one applicable case physical therapy assistant (PTA 1).

The agency failed to: - Perform an employee disqualification list (EDL) check prior to hire for one employee (RN 1) and failed to request/obtain results from the Family Care Safety Registry prior to patient contact for two employees (RN 1, PTA 1).