Servant's Heart Home Health Services Inc

The home health agency failed to ensure the comprehensive assessment included the patient’s current health status for all diagnoses and conditions for 2 of 6 records reviewed (Patient #16, #17).

The home health agency failed to follow their own policies and failed ensure coordination of care to meet the patient's needs for 2 of 6 patient records reviewed (Patient #16, 17.) 3. A home visit observation was conducted on 12/28/2022 at 10:23 AM with Patient #16 and the Clinical Manager.

The home health agency failed to ensure all staff followed infection prevention policies and procedures for 1 of 3 observations of a home visit (Clinical Manager).

The home health agency failed to ensure the aide care plan was specific to the needs of the patient for 1 of 3 patients with home health aide services (Patient #14).

The home health agency failed to ensure the plan of care included all pertinent diagnoses, a medication list with clear directions for administration for topical medication and indications for as needed medications, and parameters for contacting the physician for high or low vital signs (See Tag…

The home health agency failed to develop policies and procedures regarding staff COVID-19 vaccination which included staff positions and roles for whom the COVID-19 vaccination was required, additional precautions for all staff not fully vaccinated for COVID-19 to mitigate the spread, a process for…

The home health agency failed to develop policies and procedures regarding staff COVID-19 vaccination to include staff positions and roles for whom the COVID-19 vaccination was required, additional precautions for all staff not fully vaccinated for COVID-19 to mitigate the spread, a process for…

The governing body failed to ensure the agency adhered to its Medicare agreement to accept and bill Medicare-covered patients, which had the potential to affect all referred and current patients for 1 of 1 agency.

The home health agency failed to ensure the plan of care included all pertinent diagnoses, a medication list with clear directions for administration for topical medication and indications for as needed medications, and parameters for contacting the physician for high or low vital signs, for 3 of 4…

The home health agency failed to obtain physician orders prior to administering medications, treating wounds, and providing skilled nursing and home health aide services for 3 of 5 active records reviewed (Patients #1, 2, 3, and 4).

The Registered Nurse (RN) failed to perform a complete comprehensive and skilled nurse visit assessment for 1 of 2 active pediatric patient records reviewed (RN #2).

The Licensed Practical Nurse (LPN) failed to ensure all patient medications were not expired for 1 of 1 home visit observations of an agency licensed practical nurse (LPN #1).

The registered nurse (RN) failed to ensure that the comprehensive assessment contained the patient's current health and psychosocial status (See G528); failed to ensure that the comprehensive assessment contained individual patient strengths and preferences (See 530); failed to ensure that the…

The Registered Nurse (RN) failed to ensure a complete and individualized plan of care was developed (see tag G 574); failed to ensure verbal orders were included in the plan of care (see tag G 576); failed to ensure physician orders were in place before providing care (see tag G 580); failed to…

The agency failed to develop an effective, ongoing, home health agency wide, data-driven Quality Assurance and Performance Improvement [QAPI] program (see tag G 640); failed to show measurable improvement in health outcomes, patient safety, and quality of care and failed to measure, analyze, and…

The agency failed to ensure personnel followed infection control precautions when caring for patients with communicable diseases and wounds (See Tag G 682) and failed to ensure that an agency-wide infection control program was maintained for the surveillance, identification, prevention, control of…

The SN (skilled nurse) failed to assess and provide patient care according to professional standards (See G706); failed to follow the plan of care (See G710); failed to provide patient /caregiver education (G714); failed to prepare clinical notes completely and accurately (See G716); failed to…

The agency failed to ensure the emergency preparedness plan had policies and procedures to inform state and local officials to follow up with staff and patients that they were unable to contact for 1 of 1 agency.

The agency failed to ensure the emergency preparedness plan contained a training and testing plan for staff for 1 of 1 agency.

The registered nurse (RN) failed to ensure the comprehensive assessments were updated with accurate and pertinent information and changes for 3 of 6 recertification records reviewed (#2, 3, 4).

The agency failed to ensure all staff followed infection control policies and standard precautions for 3 of 3 home visits observed (#1, 2, 3).

The agency failed to ensure that an agency-wide infection control program was maintained for the surveillance, identification, prevention, control of staff and patient infections for 1 of 1 agency.

The Registered Nurse failed to ensure that the aide care plan was indiidualized with specific, not generic, tasks to be completed for each shift the aides provided care for 1 of 7 charts reviewed (#2).

The registered nurse (RN) failed to ensure that the comprehensive assessment contained the patient's current health and psychosocial status for 4 of 7 records (#2, 3, 4, 7).

The registered nurse (RN) failed to ensure that the comprehensive assessment contained individual patient strengths and preferences for 4 of 7 records reviewed (#2, 3, 4, 7).

The registered nurse (RN) failed to ensure that the comprehensive assessment contained a complete review of medications and that the medication list was maintained for 7 of 7 records reviewed (#1, 2, 3, 4, 5, 6, 7).

The agency failed to ensure the plan of care (POC) included all pertinent treatments, goals, durable medical equipment, and correct frequencies of visits in 4 of 7 records reviewed.

The agency failed to ensure all physician orders were recorded in the plan of care (POC) for 1 of 7 records reviewed (#3).

The agency failed to ensure the skilled nurse did not provide wound care absent of a physician's order for 1 of 7 records reviewed (#2).

The agency failed to ensure registered nurse (RN) reported changes to the physician for 1 of 7 records reviewed (#2).

The agency failed to ensure the recertification plan of care (POC) contained revised and current information for 3 of 6 recertification records reviewed (#1, 3, 4).

The agency failed to ensure the skilled nurse (SN) coordinated care with the assisted living facility (ALF) for 1 of 1 records reviewed of patients in an ALF (#3).

The agency failed to ensure that a medication list in layman's terms was provided to the patient for 7 of 7 records reviewed (#1, 2, 3, 4, 5, 6, 7).

The agency failed to ensure the director of nursing's name and contact information was included in the admission packet and the patients were given a copy for 1 of 1 agency.

The SN (skilled nurse) failed to assess and provide patient care according to professional standards for 1 of 2 skilled nursing visits observed.

The registered nurse (RN) failed to follow the plan of care (POC) for 3 of 7 records reviewed (#2, 4, 5).

The skilled nurse (SN) failed to provide patient /caregiver education for 1 of 2 home visits with with skilled nursing (#3).

The skilled nurse (SN) failed to prepare clinical notes completely and accurately for 6 of 7 records of patients receiving SN services (#1, 2, 3, 4, 7).

The agency failed to ensure that all skilled nurses (SN) participated in the agency's quality assessment performance improvement (QAPI) program for 1 of 1 agency.

The agency failed to ensure a home health aide was not providing a service not within their scope of practice, such as wound care for 1 of 1 records reviewed of a patient receiving wound care from a home health aide in a sample of 7. (#2) Findings include: The clinical record of patient #2 was…

The agency failed to ensure a home health aide (HHA) failed to report changes in the patient condition and the refusal of the patient to take insulin as ordered for 1 of 7 charts reviewed (#2).

The agency clinical manager failed to provide oversight of patient care services provided for 1 of 7 record reviews (#2).

The Clinical Manager failed to ensure Registered Nurses updated and implementd changes to the plan of care (POC) to reflect the individual needs of the patient in 4 of 7 records reviewed (#1, 2, 3, 4).

The agency failed to ensure a written agreement was in place with the assisted living facility (ALF) for 1 of 1 patients reviewed who lived in an ALF (#3).

The Clinical Manager failed to ensure the Registered Nurse (RN) completed skilled care per professional standards for 2 of 2 home visits where the RN was observed (#1, 3).