Virginia Gay Hospital Home Health Agency

The home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 3 of 7 sampled patients (Patients #1, #2 and…

The agency failed to administer drugs, services and treatment as ordered by the physician for 2 of 7 sampled patients (Patient's #2 and #4).

The agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 3 of 7 sampled patients (Patients #4, #6 and #7).

The agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 2 of 2 sampled patients with wound care.

The agency failed to ensure timely authentication of skilled nurse visit notes in the patient's medical record for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #6 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 2 sampled patients requiring a resumption of care assessment (Patient #3).

The agency failed to update the Plan of Care with all new physician orders for 7 of 7 sampled patients with interim orders.

The agency failed to ensue a current plan of care completed every 60 days to provide services only as ordered by the physician for 1 of 7 sampled patients (Patient #4).

The agency failed to maintain a clinical record containing current information in the patient's clinical record including all current interventions and services provided in the patient record for 3 of 7 sampled patients (Patients #2, #4 and #5).

The patient home lacked a copy of an emergency preparedness plan. 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 have a policy and procedure to notify State and local officials of any on-duty staff or patients the agency was unable to contact.

The agency failed to provide written information which informed the patient, caregiver and representative of what services to expect and the purpose of each service for 1 of 3 sampled patients with home visit observations (Patient #3).

The agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 3 of 3 sampled patients (Patient #1, #2 and #3) with home visits.

The agency failed to ensure the registered nurse updated the written patient care instructions for home health aides for 2 of 2 sampled patients receiving home health aide services (Patients #2 and #6).

The agency failed to ensure authentication of hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature for 2 of 2 sampled patients (Patients #2 and #5) receiving therapy services.

The facility failed to accurately complete a drug regimen review, including completion of all required components including times of administration for 6 of 7 records reviewed (Patient #3).

The agency failed to ensure accurate completion of all pertinent components of the resumption of care 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).

Agency policy review the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.

The agency failed to obtain a temperature as part of the vital sign assessment ordered by the physician for 1 of 7 sampled patients (Patient #6).

The agency failed to ensure patients were informed of revisions to the plan of care for 1 of 7 sampled patients (Patient #3).

The agency failed to provide to the patients medication lists written in plain language that included medication name, dosage, frequency, administration times and which medications will be administered by agency personnel for 2 of 3 sampled patients with home visit observations (Patients #2 and #3).

The agency failed to provide the patient and caregiver with a copy of written instructions outlining any treatments to be administered by the agency personnel and personnel acting on behalf of the agency for 1 of 3 sampled patient's with home visits (Patient #3).

The agency failed to ensure home health aide supervision was completed with all required components for 1 of 2 sampled patients who received home health aide services (Patient #6).

The clinical manager failed to coordinate services in order ensure implementation of physician's orders and ensure the electronic clinical record was updated with changes in physician's orders for 1 of 7 sampled patients (Patient #3).

The agency failed to ensure a transfer summary was sent in a timely manner to the facility assuming the patient's care for 1 of 1 sampled patients (Patient #6).