Taylor County Public Health Agency

Agency staff interview review the agency failed to ensure accurate and thorough completion of a comprehensive assessment of wounds for 1 of 1 sampled patients with wounds (Patient #4).

The agency failed to complete an accurate drug regimen review with each comprehensive assessment for 2 of 3 sampled patients with home observation visits (Patients #1 and #3).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient for 2 of 3 sampled patients with surveyor home visit observation (Patients #2 and #3).

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 4 sampled patients receiving home health aide services (Patients…

The agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who…

The agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles initially and annually thereafter for 2 of 2 sampled staff employed by contract (Staff E, Occupational Therapist, and Staff F, Physical Therapist).

The agency failed to ensure registered nurses provided individualized and specific written patient care instructions to agency home health aides for 1 of 3 sampled patients receiving home health aide services (Patients #1).

The agency failed to ensure agency staff accurately completed a drug regimen review, including completion of all required components within the required time frames as part of the comprehensive assessment for 2 of 7 records reviewed (Patients #3 and #5).

Agency clinicians failed to complete updates to the comprehensive assessment at recertification in the last 5 days of each certification period for 2 of 3 sampled patients requiring a recertification assessment (Patients #1 and #2).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care for 2 of 7 sampled patients (Patients #1 and #7).

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 1 of 3 sampled patients receiving home health aide services…

The updates to the comprehensive assessment, completed at recertification, dated 6/21, 8/19 and 10/21/19, lacked documentation of an individualized emergency/disaster plan assessment for the patient. b.

The agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation.

The agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles for 6 of 6 contracted staff.

The hospice failed to ensure participation in 1 of 2 emergency preparedness exercises prior to 11/15/17 and documented 4 drills/actual events in 2018 with no analysis of the event.

The agency failed to notify the physician of changes in visit frequency ordered on the Plan of Care for 3 of 8 sampled patients (Patients #4, #5 and #7) . The agency reported a current census of 27 patients, including 19 patients at the parent office in Bedford and 8 patients at the branch office…

The agency staff failed to complete supervision of physical therapy assistants periodically to evaluate the services furnished to ensure the patient's needs are met for 1 of 1 patients sampled patients who received physical therapy services provided by a physical therapy assistant (Patient #1).

The agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 4 sampled patients receiving home health aide services (Patient #5).

Agency policy review and staff interview the agency failed to ensure authentication of plan of care and electronic entries and hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature for 4 of 8 sampled patients (Patients…

The agency failed to ensure the completion of all pertinent components of the comprehensive assessments completed at the start of care by the fifth day after the start of care for 2 of 7 sampled patients admitted after 12/7/16 (Patients #4 and #7).

The agency failed to complete a drug regimen review, including all required components, with each comprehensive assessment for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7 and #8).

The agency failed to ensure accurate completion of all required components of the update of the comprehensive assessment completed at the time of recertification between day 56 and 60 of each 60 day certification period for 3 of 5 sampled patients requiring a recertification assessment (Patients…

The agency failed to ensure the timely completion of all pertinent components of the update to the comprehensive assessment at the resumption of care within 48 hours of the agency's knowledge of the patient's return home from an inpatient facility for 2 of 3 sampled patients requiring a resumption…

Agency staff and patient the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 7 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #7 and #8).

Staff failed to report changes and coordinate care with the patient's physician for 1 of 8 sampled patients (Patient #1).

The agency failed to ensure 1 of 3 sampled home health aides (Staff E), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 4 sampled patients (Patient #6) with home health aide services, had documented evidence of competency by a registered…

The agency failed to ensure the clinical record contained complete and up to date information for 2 of 8 sampled residents.