The Evangelical Lutheran Good Samaritan Society

The agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed direct observation of a home health aide's performance of all required health aide skills assigned beyond the basics on a home health patient…

The agency failed to ensure completion of documentation for routine visit notes were completed within the agency's administrative expectations for 4 of 7 sampled patients (Patients #2, #3, #4, and #7).

The agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #6).

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 2 of 3 sampled patients with surveyor home visit observation(Patients #1 and #3).

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 3 sampled patients receiving home health aide services…

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.

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 3 of 7 sampled patients (Patients…

The agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 2 of 4 sampled patients requiring a recertification assessment (Patients #2 and #4).

The agency failed to ensure accurate completion of all pertinent components of the resumption of care comprehensive assessments within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 2 sampled patients requiring a resumption of care assessment (Patient #1).

Agency staff and patient the agency failed to ensure the accurate completion of all components comprising the POC (Plan of Care), including assessment of risk for hospitalization and emergent care for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7).

Staff failed to report changes and coordinate care with the patient's physician for 2 of 7 sampled patients (Patients #3 and #6).

The agency failed to ensure the patient's clinical record included documentation of all nursing visits and interventions provided by the agency for 3 of 7 sampled patients (Patients #3, #5 and #6).