Visiting Nurse Association of Southeast Missouri, Inc

The home health provider failed to ensure staff maintained an accurate/updated medication profile in three of three home visit observations conducted (Records/Patients #1, #2, and #3).

The home health provider failed to ensure that the patient’s individualized plan of care (POC) included the types of services, supplies, and equipment needed for patient care in one of five full records reviewed (Record/Patient #4).

The home health provider failed to ensure clinicians promptly notified the patient's physician/allowed practitioner of any changes in the patient's condition or needs that suggested that outcomes were not being achieved and/or that the plan of care should be altered in two of five full records…

The provider failed to ensure the clinicians provided services that are ordered by the physician or allowed practitioner as indicated in the plan of care in one of five full records reviewed (Record/Patient #2).

The agency failed to ensure the accuracy of the Outcome and Assessment Information Set (OASIS) data in, but not limited to, one (Record/ Patient #3) of five full records reviewed.

The agency failed to ensure the patient received written wound care instructions in one (Record/Patient #1) of three home visit observations.

The agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in three (Records/Patient’s #1, #2, and #7) of three home visit observations conducted.

The agency failed to develop and implement policies and procedures that include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. This deficient practice has the…

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, but not limited to, one (Record/Patient #3) of five full records reviewed.

The agency failed to ensure staff maintained an accurate/updated medication profile in two (Records/Patients #1 and #2) of three home visit observations.

The agency failed to ensure staff developed an individualized plan of care (POC) in four (Records/Patients #1, #2, #3, and #5) of five full records reviewed.

The agency failed to ensure each patient received updated written information related to the visit schedule, in one (Record/Patient #1) of three home visit observations.

The agency failed to ensure each patient received updated written information related to the medication schedule, in one (Record/Patient #1) of three home visit observations.

The agency failed to provide services as directed by the physician ordered plan of care (POC) in one (Record/Patient #1) of five full records reviewed.

The agency failed to ensure the accuracy of clinical records to include all interventions, including medication administration, treatments, and services, and responses to those interventions in, but not limited to, two (Records/Patients #2 and #3) of five full records reviewed.

The agency failed to ensure an accurate medication reconciliation was completed at the start of care in, but not limited to, one (Record/Patient #2) of eight records reviewed.

The agency failed to develop a complete plan of care (POC) that included the following required elements in, but not limited to, two (Records/Patients #1 and #4) of eight records reviewed: - The types of services, supplies, and equipment required; and - All medications and treatments including…

The agency failed to ensure the skilled nurse (SN) provided ongoing assessments in, but not limited to, one (Record/Patient #4) of eight records reviewed.

The agency failed to ensure a discharge summary was sent to the physician within five business days of discharge for one (Record/Patient #7) of three discharge records reviewed.