Charter Healthcare of Northern Colorado LLC

The agency failed to ensure services and treatments were provided in accordance with physician's orders for 1 of 7 patients who received Physical Therapy (PT) services (Patient #9).

The agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 1 of 4 patients who received Occupational Therapy (OT) services (Patient #5).

The agency failed to ensure a completed discharge summary was sent to the primary care practitioner within five business days of the patient's discharge for 1 of 3 discharged patient records reviewed (Patient #9).

The agency failed to ensure services and treatments were provided in conformance with physician's orders for 4 of 6 patient records reviewed (Patient's #1, #3, #4 and #5).

The agency failed to ensure the home health aide (HHA) accurately documented services provided each visit which were physician ordered and included in the Plan of Care for 1 of 2 patient records reviewed who required HHA services (Patients #6).

The agency failed to ensure home health Aide (HHA) supervision occurred at least every 14 days for 1 of 2 patients receiving HHA services (Patient #6) Findings include 1. The clinical record for Patient #6 was reviewed on 8/28/19. The Plan of Care for the certification periods dated 1/23/19 to…

The agency failed to ensure a completed discharge summary was provided within five business days to the physician responsible for the care of the patient in 2 of 3 discharged patients reviewed (Patients #1 and #2).

The agency failed to ensure services, treatments and interventions were provided in conformance with physician orders for 3 of 17 patient records reviewed (Patients #2, #14 and #15).

The agency failed to ensure the certified nurse aide (CNAs) completed the required observed competency evaluation program before furnishing home health services for 1 of 1 CNA personnel records reviewed , hired since 1/13/18 (Employee #13).

The agency failed to ensure the registered nurse (RN) or other appropriate skilled professional prepared complete patient-specific written care instructions for the certified nurse aide (CNA) for 1 of 1 patients reviewed who had a bowel program assigned (Patient #5).

The agency failed to ensure clinical record entries were legible, clear, complete and appropriately authenticated, dated, and timed for 4 of 17 patient records reviewed (Patients #3, #8, #11, and #15).

The agency failed to provide the complete clinical record for 3 of 17 patient records reviewed (Patients #2, #3, and #7) and failed to ensure all records were maintained and available for review for all patients admitted by the agency or to the State Agency (SA) prior to 4/1/18. Findings included…

The agency failed to ensure a registered nurse (RN) completed an initial assessment visit, to determine the immediate care and support needs of the patient, within 48 hours of referral for 1 of 15 patient records reviewed with SN services (Patient #1).

The agency failed to ensure a physical therapist (PT) completed an initial assessment visit within 48 hours of referral for 1 of 2 patient records reviewed with only rehabilitation therapy services (Patient #15).

The agency failed to ensure each patient's Plan of Care included all medications and patient-specific interventions identified by the home health agency (HHA) and the patient for 5 of 17 patient records reviewed (Patients #1, #2, #3, #5, and #14).

The agency failed to ensure the coordination of care and services with all disciplines providing care; with the patient and their representative; and with the patient's physician for 3 of 17 patient records reviewed (Patient #1, #2, and #4).

The agency failed to ensure the home health aide (certified nurse aide, CNA) completed appropriate records for 1 of 1 patient records reviewed who received CNA services for a bowel program (Patient #5).

The agency failed to ensure the clinical records contained accurate documentation of patient's clinical notes, plans of care, and physician orders for 1 of 17 patient records reviewed (Patient #10).