Caring for You Home Health Inc

The agency failed to ensure skilled nursing followed the written plan of care for one of three patients (Patient 1) whose records were reviewed.

The agency failed to protect the patient's rights by failing to ensure skilled nursing conducted all services outlined on the Plan of Care (POC) for one of three patients (Patient 1) whose records were reviewed.

The agency failed to ensure that entry to the client record contained documentation in accordance with accepted professional standards for five of 14 patients (Patients #1, #2, #4, #7, and #8) whose clinical records were reviewed in that: 1. Patient #1's clinical record contained an inaccurate plan…

The agency failed to ensure that the plans of care included all the required components for six of seven patients (Patients #1, #2, #3, #4, #5, and #7) whose clinical records were reviewed, in that the plans of care did not include: a) A description of the patient's risk for emergency department…

The agency failed to ensure the plans of care included all orders for care for four of seven patients (Patients #2, #3, #4, and #5) receiving licensed and certified services and whose records were reviewed, in that: 1. The plan of care for Patient #2 did not contain orders for the nurse to prefill…

The agency failed to enforce its written policy regarding physician orders for one of seven patients (Patient #7) receiving licensed and certified services and whose records were reviewed, in that, the nurse did not document an order to change wound care.