A&D Health Care Professional

The agency failed to ensure that 2 (P-8, P-18) of 18 sampled records reviewed, 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, resulting in a lack of inclusion…

The Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (P-7) of 4 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered…

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 6…

The agency failed to ensure the patient's Activity of Daily Living/Grooming needs were adequately met in the patient's home for 1 (P-9) of 1 patient who required assistance with grooming, from a total of 18 sampled patient's reviewed, resulting in the potential for loss of self-esteem, poor hygiene…

The agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 5 of 18 (P-1, P-3, P-12, P-14, P-17) records reviewed, resulting in the potential for harmful medication effects for all…

The agency failed to ensure the plan of care included objectively measurable goals and interventions specific to the individualized needs of the patient in 8 records (P-2, 4, 7, 8, 12, 13, 14, 15, 16, 17), and failed to include safety precautions for 2 records (P-1, 2) from a total of 18 sampled…

The Registered Nurse failed to ensure the Physician was promptly notified of 1 (P-7) patient observed during a home visit, who experienced a how heart rate, and failed to ensure services were provided only as ordered by the physician in 1 of 18 (P-13) records reviewed, from a total of 18 sampled…

The agency's skilled professional services failed to coordinate and maintain communication with the physician regarding the patient’s condition and medication for 1 of 18 (P-15) resulting in the potential of unmet care needs.

The agency failed to provide 3 (P-7, P-8, P-18) of 5 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, from a total of 18 sampled records reviewed, resulting in lack of…

The agency failed to ensure the registered nurse performed baseline and ongoing assessments of the patient's health status and needs in 2 (P-7, P-10) records of patients who required ongoing monitoring, from a total of 18 sampled records reviewed, resulting in the potential for unidentified health…

The agency failed to ensure clinical notes were accurate for 1 of 18 (P-17) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The agency failed to ensure the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, services provided, medications and other related information required to maintain continuity of care in 1 (P-1) of 4…

The agency failed to report a branch location to the state survey agency for 1 of 2 (Branch#2) branches operated by this agency, resulting in the state survey agency having no knowledge or oversight regarding the existence of an operational branch location.