Star Home Health Inc

The agency failed to ensure an initial assessment was conducted within 48 hours of referral or the practitioner ordered start of care dated in 2 of 4 active records reviewed (Patients: #2 and 5) and 2 of 4 focused active records reviewed (Patients: #9 and 11).

The agency failed to ensure the comprehensive assessment included a review of all the medications, and allergies to include drug interactions in 1 of 1 active clinical record reviewed receiving in-center dialysis treatment.

The home health agency failed to ensure all patients had an emergency preparedness plan that was individualized in 7 of 7 clinical records reviewed.

The home health agency failed to ensure the registered nurse prepared clinical notes in accordance with patient's current status in 1 of 5 active clinical records reviewed . (patient #5) The findings include: Record review of an undated agency policy titled “Documentation of Patient Services”…

The home health agency failed to ensure the home health aide provided services as directed on the care plan for 1 of 1 patient where a home visit was conducted with the home health aide.

The home health agency failed to ensure the medical plan of care was followed in 1 of 7 clinical records reviewed.

The home health agency failed to ensure clarification and the execution of all physician orders, in 1 of 7 clinical records reviewed.

The home health agency failed to ensure coordination of care for outside tests/labs the patient was prescribed, and coordination of care with other healthcare entities to ensure comprehensive care of agency patients in 3 of 7 clinical records reviewed.

The home health agency failed to ensure a plan of care was given to the patient and filed in the patient's agency home folder, in 1 of 3 home health visits.

The home health agency failed to ensure the had a current, established quality assurance performance improvement program in place to evaluate and improve the complexity of the home health agency in 1 of 1 home health agency.

The home health agency failed to ensure all agency personnel followed standard/universal precautions during 1 of 3 home visits.

The registered nurse failed to ensure the supervisory visit of the home health aide was accurate in 2 of 2 records reviewed with home health aide services, out of a total sample of 7 clinical records reviewed.

The home health agency failed to ensure all clinical records were appropriately authenticated in 1 of 7 clinical records reviewed.

The home health agency failed to ensure a patient was informed of a home visit that would include the surveyor, home health aide and clinical supervisor in 1 of 1 refused home visits, out of a total of 3 home visits conducted.

The registered nurse (RN) failed to ensure an initial assessment was conducted within 48 hours of the patient's referral in 2 of 7 clinical records reviewed.

The comprehensive assessment failed to contain all information about the patient's current health status, in 1 of 7 clinical records reviewed.

The registered nurse failed to ensure all medications were listed in the medication profile and medical plan of care in 4 of 7 clinical records reviewed.

The home health agency failed to ensure all DME [durable medical equipment]/ supplies, nutritional requirements and medications were listed on the medical plan of care in 3 of 7 clinical records reviewed.

The home health agency failed to obtain physician orders for all changes in oxygen administration, wound care, and therapy prior to care being provided, in 2 of 7 clinical records reviewed.

The home health agency failed to ensure the physician was notified of changes in the patient's condition and/or services, in 3 of 7 clinical records reviewed.

The home health agency failed to ensure coordination of care for outside tests/labs the patient was prescribed, and coordination of care with other healthcare entities to ensure comprehensive care of agency patients in 3 of 7 clinical records reviewed.

The skilled professional failed to ensure they met all agency client's needs, in 1 of 7 clinical records reviewed.

All skilled professionals failed to provide all services indicated on the plan of care in 1 of 7 clinical records reviewed.

The skilled nurse failed to instruct the patient/caregiver on all areas directed on the medical plan of care in 2 of 7 clinical records with skilled nursing services.

The skilled nurse failed to complete the clinical notes to factors that were relevant to the patient each visit in 1 of 7 clinical records reviewed.

The registered nurse failed to ensure the licensed practical nurse followed the medical plan of care in 1 of 7 clinical records reviewed with skilled nurse services.

The home health aide failed to perform all tasks on the aide care plan with each home health aide visit, as directed by the registered nurse, in 1 of 2 clinical records reviewed with home health aide services, out of a total sample of 7 clinical records reviewed.

The clinical manager failed to ensure patient care that included a home visit was coordinated with the patient and the patient representative in 1 of 1 home visit refused, out of 3 home visits conducted.