At Home Nursing and Therapy Services LLC

The agency failed to ensure all of the patient's medications were included on the plan of care for three (3) of 15 active records reviewed (CR2, CR13, & CR14).

The agency failed to promptly notify the physician to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered for eight (8) of 17 records reviewed (CR1-CR4, CR6, CR9, CR11, & CR14).

The agency failed to coordinate care with all physicians for two (2) of 15 active records reviewed (CR2, & CR14).

The nurse failed to ensure ongoing interdisciplinary assessment for two (2) of two (2) patients (CR14, & CR17) with peripherally inserted central catheters.

The agency failed to send a discharge/transfer summary containing all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care and treatment preferences, to the receiving facility or health care practitioner to ensure the safe…

The agency failed to arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities for one (1) of one (1) clinical record who was discharged (CR1).

The agency failed to ensure the clincial record contained a discharge summary sent to the primary care practitioner and the receiving home health agency when the patient required continued home health services for one (1) of one (1) clinical who was discharged from the agency but required continued…