Vitalcaring Group

The provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, but not limited to, two of three home visit observations (Records/Patients #2 and #3).

The provider failed to ensure the plan of care contained pertinent diagnoses and interventions to address the needs of the patient as identified in the initial comprehensive assessment in one of five records reviewed (Record/Patient #4).

The agency failed to ensure staff followed infection control standards of practice in two (Records/Patients #3 and #5) of three home visit observations.

The agency failed to ensure the registered nurse (RN) documented specific comments regarding the tasks observed and the aides performance as required in one (Employee #1) of one home health aide employee file reviewed and failed to ensure all the required tasks had been completed before providing…

The agency failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one (Patient/Record #2) of five records reviewed.

The agency failed to maintain a complete/accurate medication profile in three (Records/Patients #1, #2 and #5) of five records reviewed.

The agency failed to ensure a complete/accurate plan of care (POC) that included all required information was completed in, but not limited to, one (Record/Patient #2) of five records reviewed.

The agency failed to ensure staff promptly notified the physician for a change of condition in four (Records/Patients #1, #2, #3 and #4) of five records reviewed.

The agency failed to ensure staff provided patient's ongoing education and training in, but not limited to, two (Records/Patients #2 and #3) of five records reviewed.

The agency failed to ensure the name and contact information of the home health agency clinical manager was listed in the admission packet of information left in patient homes in three (Records/Patients #1, #3, and #5) of three home visits.

The agency failed to provide/send a completed transfer summary within two business days of becoming aware of an unplanned transfer in one (Record/Patient #7) of two closed records reviewed.

The agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in one (Patient/Record #3) of one home visit observation performed.

The agency failed to provide services as ordered by the physician on the plan of care (POC) in, but not limited to, two (Record/Patient #2 and #3) of three records reviewed.

The agency failed to assure that skilled professionals assumed the responsibility for communication with all physicians involved in the plan of care related to the current plan of care in one (Record/Patient #2) of three records reviewed.

The agency failed to ensure the registered nurse (RN) performed an accurate and complete review/update of all medications the patient was currently using in, but not limited to, two (Records/Patients #1 and #2) of five cases reviewed.

The agency failed to ensure skilled professional services were provided/documented according to physician orders as reflected in the patient's plan of care in, but not limited to one (Record/Patient #1) of five cases reviewed.

The agency failed to ensure communication with the physician involved in the plan of care and/or other health care practitioners; and failed to obtain physician orders to ensure accurate medications on the plan of care in, but not limited to, two (Records/Patients #2 and #4) of five records…

The agency failed to ensure patients and/or representatives were provided written information regarding the Missouri case law "The Cruzan Case" in five (Records/Patients #1, #2, #3, #4 and #5) of five records reviewed; and failed to assess and/or document the patient's status regarding advance…

Staff interview Healthback Home Health Agency failed to meet the following requirements of this condition of participation: - Ensure the plan of care included patient specific interventions and education (G574); - Ensure treatments are provided as ordered by the physician (G580); - Review and…

The agency's complaint report and staff and patient interview the agency failed to adequately document complaint investigations and resolution/follow up with the patients for three of three complaint reports.

The agency failed to ensure the plan of care included patient specific interventions and education, regarding monitoring of a surgical wound dressing, and failed to ensure complete physician orders were obtained, in, but not limited to one (Patient #3) of three records reviewed.

The agency failed to ensure nursing staff followed physician orders in, but not limited, two (Patient #1 and #2) of three records reviewed.

The agency failed to ensure the skilled nurse would obtain revised physician orders for care and maintenance of the intravenous port access (a device implanted under the skin to deliver medications directly into the bloodstream) in one (Patient #2) of three records reviewed.

The agency failed to ensure nursing staff documented education with the patient and caregiver regarding dressing orders, education related to administration of intravenous (IV) antibiotics and competency of administration for one patient (Patient #3) out of three clinical records reviewed.