Vn Home Health Care

The agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every two years, resulting in lack of direction for agency personnel in the event of an actual emergency or disaster.

The agency failed to ensure its Emergency Preparedness policies and procedures were reviewed and updated at least every 2 years, resulting the potential for undesired responses in the event of an emergency.

The agency failed to ensure an individual Emergency Preparedness Plan was completed for 1 (P-2) of 3 patients observed during a home visit, resulting in the potential for unprepared responses in the event of an actual emergency or disaster.

The agency failed to develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section, that had been reviewed and updated at least every two years.

The agency failed to ensure the Plan of Care (POC) for skilled nursing (SN) included objective measurable goals in 4 (P-4, P-5, P-6, and P-7) of 7 records reviewed; failed to provide skilled nursing services as ordered in 1 (P-6) of 7 records reviewed; and failed to include pertinent safety…

The agency failed to ensure its discipline utilized Infection Control standards of practice during the provision of care and services for 1 (P-2) of 3 patients observed during home visits, resulting in the potential for the development and spread of infection.

The agency failed to ensure the registered nurse included safety measures in the aide plan of care in 1 (P-6) of 2 records reviewed with home health aide services, resulting in the potential for the provision of unsafe care.

The agency failed to provide proper written notice of non-coverage prior to terminating ongoing services for 1 (P-1) of 3 patients discharged from the agency's services.

The agency failed to ensure the Registered Nurse conducted the initial assessment visit within 48 hours of referral to determine the immediate care and support needs of the patient, for 1 (P-2) of 1 patient in which nursing services was ordered, resulting in the delay in nursing services and the…

The agency failed to ensure the Physical Therapist conducted the initial assessment visit within 48 hours of referral to determine the immediate care and support needs of the patient, for 1 (P-1) of 1 patient in which therapy services was ordered.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status in 3 (P-4, P-6 and P-7) of 7 records reviewed, resulting in a lack of information to aid in determining patient care needs and the potential for poor clinical outcomes.

The agency failed to ensure the Initial Comprehensive Assessment included a thorough and accurate review of all medications for 1 (P-2) of 1 patient observed during a home visit, resulting in the potential for harmful medication effects.

The agency failed to ensure the plan of care (POC) included pertinent safety precautions in 2 (P-6, P-7) of 7 records reviewed, resulting in the potential for poor clinical outcomes and patient harm.

The agency failed to ensure the physician was promptly notified of a significant change in condition for 1 (P-2) of 1 patient who experienced a significant reduction in weight, resulting in the potential for unidentified, underlying, untreated patient care concerns.

The agency failed to ensure that patient care services were coordinated to meet the clinical needs of a patient in 1 (P-7) of 2 records reviewed with hospital transfers, resulting in the potential for an unnecessary hospital transfer.

The agency failed to provide 1 (P-2) of 3 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, resulting in lack of direction for medication administration and the potential for…

The agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The agency failed to ensure Occupational Therapy services were provided as ordered by the Physician and in the Plan of Care for 1 (P-2) of 2 patients with Occupational Therapy services ordered; and failed to ensure Speech Therapy services were provided for as ordered for 1 (P-6) of 1 patient with…

The agency failed to ensure a clinical manager was available during operating hours, resulting in the potential for unmet health care needs for all 12 patients currently receiving services at the time of the survey.

The agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 4 (P-1, P-2, P-4, and P-7) of 4 patients who were discharged from the agency or agency services, and failed to ensure a transfer summary was sent to the physician within 2…

The Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators in order to assess processes of care and services for calendar year 2021, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all…

The Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of diseases; and failed to develop a method of screening all staff employed by this Agency, including field staff who were granted clinical privileges, resulting in the potential for…

The Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster.

The Agency failed to ensure their Emergency Preparedness policies and procedures were reviewed and updated at least every 2 years, resulting in the Agency's inability to ensure staff actions during an emergency aligned with current practices and guidelines.

The Agency failed to provide documented evidence that all staff employed by this Agency, including contracted staff and volunteers as appropriate, received initial and ongoing training in emergency preparedness policies and procedures; and failed to maintain documentation of trainings, resulting in…

The Agency failed to provide documentation for the required community/facility based full-scale exercises, from an all hazards approach, nor any documentation of an actual event that would qualify as a test of the emergency plan since its initiation in 2009, resulting in the potential to affect all…

The Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators in order to assess processes of care and services for calendar year 2021, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all…

The agency failed to ensure that the collected data was used to monitor the effectiveness and safety of services provided with opportunities for improvement; and failed to ensure the Governing Body approved the program's frequency and detail of data collection, resulting in the potential for poor…

The Agency failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2021 and 2022 calendar years, resulting in the Agency's inability…

The Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the…

The Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of diseases; and failed to develop a method of screening all staff employed by this Agency, including field staff who were granted clinical privileges, resulting in the potential the…

The Agency failed to provide documented evidence that Infection Control in-services and education had been provided to all staff employed by this Agency, including contracted staff, resulting in the potential for the development and spread of the infection to staff and all 11 patients currently…

The Agency failed to establish Vaccine protocol written policies and procedures to ensure that all staff are fully vaccinated against the Covid-19 novel virus, that included (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for…

The Agency failed to provide documented evidence to support that 1 of 1 Home Health Aide employed by this Agency was trained, qualified and deemed competent, by a Registered Nurse, prior to the provision of care and services to the Agency's patient population, resulting in the potential for the…

The Agency failed to ensure the Registered Nurse prepared clear written patient care instructions for the Home Health Aide regarding safety precautions and client needs, prior to providing care in 1 (MR #2) of 2 records in which Home Health Aide services were ordered, from a total of 7 sampled…

The agency failed to ensure that 1 (MR #1) of 1 patient observed during a home visit, was included in the 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, from a total of 7 sampled…

The Agency failed to ensure the patient's Skilled Nursing and Home Health Aide needs were adequately met in the patient's home for 1 (MR #1) patient who required Nursing assessments for management of diagnosis of heart failure; and 1 (MR #7) patient who required assistance with grooming and…

The Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to ensure the Registered Nurse provided oversight of the review process; failed to document the findings of the drug regime review as required and failed to ensure…

The Agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 4 (MR's #1, 4, 5, 7) records, from a total of 7 sampled records reviewed, resulting in patients not receiving care…

The Agency's Skilled disciplines failed to ensure the Physician was promptly notified of a change in condition in 1 (MR #1) patient diagnosed with heart disease with increased weight gain and; 1 (MR #4) patient with increased pain levels, from a total of 7 sampled records reviewed, resulting in…

The Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns.

The Agency failed to ensure its skilled disciplines performed baseline and ongoing assessments of patient's edema, weights and overall health status of 2 (MR's #4, 7) patients who required specialized monitoring of health status, from a total of 7 sampled records reviewed, resulting in the…

The Agency failed to ensure the clinical record was completed and included detailed Physical Therapy for 1 (MR #1) record with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs.