Westwood Home Health

The home health provider failed to ensure vital signs were assessed as written in the plan of care in one of five full records reviewed (Record/Patient #5).

The home health provider failed to ensure that documentation was completed in a timely manner in one of five full records reviewed (Record/Patient #5).

The home health provider failed to ensure staff maintain an accurate and updated medication profile in, but not limited to, two of three home visit observations (Records/Patients #3 and #4).

The agency failed to: - Write an individualized plan of care that identified patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician or allowed practitioner (G572); - Provide an individualized plan of care that included, but not…

The agency failed to ensure that the patients received the home health services that were written on the individualized plan of care when the patients did not receive visits according to the visit frequency ordered on the plan of care in four (Records/Patients #2, #3, #4, and #5) of five full…

The agency staff failed to follow accepted standards of practice/infection control measures during a home visit observation for one (Record/Patient #1) of three home visits conducted.

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 #1) of five records reviewed.

The agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, two (Records/Patients #2 and #3) of five full records reviewed.

The agency staff failed to complete a comprehensive assessment to include the patient's primary caregiver(s), if any, and other available supports, including their willingness and ability to provide care, and availability and schedules in, but not limited to one (Record/Patient #5) of five records…

The agency failed to ensure that each patient's written individualized plan of care (POC) included all the required elements in one (Record/Patient #5) of five full records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in two (Records/Patients #4 and #5) of five full records reviewed.

The agency failed to ensure coordination of patient care delivery in one (Record/Patient #5) of five full records reviewed.

The agency failed to provide a written visit schedule that included disciplines that would visit and the frequency of visits in one (Record/Patient #3) of three home visit observations performed.

The agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey.

The agency failed to ensure that the aide provided services that were included in the plan of care in one (Record/Patient #4) of two applicable records.

The agency failed to ensure that the clinical manager assured that patient needs were continually assessed in two (Records/Patients #3 & #5) of five full record reviews.

The agency failed to assure that the clinical manager (CM)/director of nursing (DON) has effectively assumed responsibility for overall supervision and direction of skilled professional services and actively participated in all activities relevant to the professional services furnished, including…

The agency failed to provide a discharge summary that included all necessary components was sent to the primary care physician after discharge within five business days of the patient's discharge in one (Record/Patient #6) of two discharge records reviewed.

The agency failed to ensure/maintain an accurate and complete review of all medications the patient was currently using in, but not limited to, three (Records/Patients #1, #2, and #3) of five cases.

The agency failed to ensure an accurate and complete plan of care was developed in, but not limited to, three (Records/Patients #1, #2, and #3) of five cases.

The agency failed to ensure new physician orders were documented in the patient's record in, but not limited to, one (Record/Patient #2) of five cases.

The agency failed to notify the physician of changes in the patient's condition in, but not limited to, two (Records/Patients #2 and #3) of five cases.

The agency failed to ensure that the home health aide documented/provided care as directed on the aide assignment sheet in one (Record/Patient #3) of one applicable record.

The agency failed to ensure that the agency staff evaluated the aide for all of the required elements during the aide supervisory visits in one (Record/Patient # 3) of one applicable record.