Alpha Therapeutics, PC

The Physical Therapist failed to monitor standing and active blood pressure in 1 (P-3) of 1 record reviewed with Orthostatic Hypotension (see G708); the agency failed to ensure services were provided as ordered by the physician as indicated in the plan of care in 2 (P-4 and P-7) of 7 records…

The agency failed to ensure 1 (P-6) of 1 patient whose record was reviewed, received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, resulting in the patient not receiving services based on their identified…

The agency failed to ensure the medical record was clear and complete in 1 (P-4) of 7 records reviewed, resulting in the potential for and unclear and incomplete medical record.

The agency failed to ensure patients were able to consent to or refuse care in advance of treatment in 2 (P-1, P-4) of 7 records reviewed, resulting in the potential for a violation of patient rights.

The agency failed to ensure the initial assessment was completed within 48 hours of referral in 1 (P-4) of 7 records reviewed, resulting in the potential for unmet care needs.

The agency failed to ensure the Initial Comprehensive Assessment was complete and accurately reflected the needs of 6 (P-1, P-2, P-3, P-4, P-6, and P-7) of 7 records reviewed, resulting in the potential for unidentified, untreated health care needs.

The agency failed to ensure activity of daily living needs were adequately met in the patient's home for 1 (P-6) of 1 patient who required assistance with grooming, resulting in the potential for low self-esteem, poor hygiene and unmet care needs.

The agency failed to ensure the comprehensive assessment included a review of all medications to identify potential drug interactions or drug duplications and an accurate medication profile in 6 (P-1, P-3, P-4, P-5, P-6 and P-7) of 7 records reviewed, resulting in the potential for harmful drug…

The agency failed to ensure the plan of care included all required information in 4 (P-1, P-4, P-5, and P-7) of 7 records reviewed, resulting in the potential for unmet care needs.

The agency failed to generate a Medication Profile that listed the patient's prescribed medications, frequencies and dosages for 1 (P-6) of 7 records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications.

The Physical Therapist failed to monitor standing and active blood pressure in 1 (P-3) of 1 record reviewed with Orthostatic Hypotension, which resulted in the potential hospitalization for a fall.

The agency failed to ensure services were provided as ordered by the physician as indicated in the plan of care in 2 (P-4 and P-7) of 7 records reviewed, resulting in the potential of unmet care needs and poor patient outcomes.

The agency failed to ensure the patient and caregiver were provided wound care teaching/instructions for 1 (P-1) of 7 records reviewed, for a potential of improper wound care and unmet care needs.

The agency failed to ensure the clinical record was completed and included detailed Physical Therapy notes for 1 (P-6) of 1 record reviewed with the ordered services, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs.

The agency failed to ensure the clinical record was complete and included a detailed Skilled Nursing evaluation for 1 (P-6) of 1 record with the ordered service, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs.

The agency failed to ensure a Skilled Nursing and Occupational Therapy discharge summary was fully completed, and forwarded to the physician within 5 days of discharge in 2 (P-1, P-6) of 3 records who were discharged from the agency's services, resulting in the potential for unidentified continuing…