Up Health System Home Care and Hospice

The agency failed to ensure the patient was informed of, consented to, or refused care prior to treatment in 4 (P-5, P-7, P-8 and P-12) of 13 records reviewed, resulting in the potential for the violation of patient rights.

The agency failed to ensure the initial assessment, to determine immediate care needs of the patient, was conducted within 48 hours in 4 (P-1, P-5, P-10, and P-11) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the comprehensive assessment was completed within 5 calendars days after the start of care in 4 (P-6, P-7, P-8, and P-10) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-5 and P-8) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the medication reconciliation was accurate and up to date for 2 (P-5 and P-8) of 13 records reviewed, resulting in the potential for harmful medication interactions.

The agency failed to develop an individualized Plan of Care (POC) that included objective measurable goals specific to the needs of the patient in 8 (P-1, P-2, P-3, P-5, P-9, P-10, P-12, P-13) of 13 records reviewed.

The agency failed to ensure skilled professionals provided services, as ordered by the physician, in the plan of care for 1 (P-8) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes.

The agency failed to ensure the nurse created an aide care plan that reflected vital sign parameters as ordered by the physician in 1 of 4 (P-8) records reviewed with aide services, resulting in the potential for poor patient outcomes.

The agency failed to ensure that 1 (P-16) of 17 patients were included in their overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 5…

The agency failed to demonstrate the continuing need for home care for 1 of 1 (P-4) records reviewed in which patient care was recertified for additional episodes of care, resulting in the provision of home care services to a patient without documentation to support the need for continued care and…

The agency failed to ensure the registered nurse (RN) completed a comprehensive review of medications and notification to the physician for significant drug interactions according to agency policy in 1 (P-13) of 17 sampled records reviewed potentially resulting in harmful side effects from drug…

The agency failed to ensure skilled professionals performed assessments of the patient's health status and needs in 6 of 17 (P-3, 4, 8, 14, 15 and 17) records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes.

The agency failed to ensure clinical notes were accurate for 2 of 17 (P-15 and 16) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The Agency failed to ensure a transfer summary was complete, provided the patient's current health status at the time of transfer, progress toward goals, and forwarded to the physician within 2 days of transfer in 1 (P-15), of 1 transfer records, resulting in the potential for unidentified…

The Agency failed to ensure the patient's Activities of Daily Living {ADLs} needs were adequately met in the patient's home to assure safety of the patient during bathing for 1 of 17 sampled records reviewed (MR# 1) resulting in potential for poor hygiene, and the potential for injury.

The Agency failed to ensure the Resumption of Care Comprehensive Assessment included a review of all medications to determine any adverse effects and duplicate drug therapy in 1 (MR #12) of 2 records in which the patient resumed home care services post hospitalization, from a total of 17 sampled…

The Home Health Agency (HHA) failed to ensure the goals on the plan of care were measurable and the plan of care included patient specific/measurable interventions and goals that were based on patient needs in 11 of 17 records reviewed (MR#s 1, 2, 3, 4, 5, 6, 13, 14, 15, 16, and 17), from a total…

The agency failed to ensure that the Registered Nurse assessed the weight for 1 (MR #11) of 1 patient ordered to have weights checked every visit, as indicated in the plan of care, from a total of 17 sampled patients reviewed, resulting in the potential for unidentified health concerns and unmet…

The agency failed to ensure that a discharge summary was completed and sent to the physician within 5 business days of the patient's discharge for 1 (MR #9) of 5 records in which the patient was discharged from skilled services, resulting in the physician not having knowledge of the patient's…