Elite Home Health

The Agency did not include all current medications in the review and reconciliation of the client's medications in 2 (#9 & #10) of 10 (#1-#10) of clinical records reviewed.

The Agency failed to provide patients with a written copy of medication schedule / instructions in 1 ( #7) of 13 (#1 - #13) Clinical Records reviewed.

Staff interview the Agency failed to ensure a Discharge/Transfer Summary was completed and sent to the Physician after discharge in 1 (#12) of 4 (#11 - #13) Clinical Records reviewed with transfer/discharge status.

The Agency Staff did not develop an individualized Plan of Care (POC) with patient specific pain goals in 3 (#6, #7 and #10 ) of 10 (#1 - #10) Clinical Records reviewed and did not establish patient specific oxygen saturation levels to monitor for 1 (#3) of 8 (#2-#8 and #10) Clinical Records with…

The Skilled Nurse (SN) failed to follow the Attending Physician orders contained in the Plan of Care (POC) for 3 (#1, #5, and #6) of 10 (#1 - #10) Clinical Records reviewed.

The Skilled Nurse (SN) failed to follow accepted professional standards for infection control in 1 (#6) of 4 (#1 - #3 and #6) home visits conducted.

The Skilled Nurse (SN) did not conduct a review of medications the patient was currently using in 2 (#3 and #9) of 3 (#3, #4 and #9) Clinical Records reviewed with Physician orders for Therapy services only and no SN services.

The Licensed Practical Nurse (LPN) did not communicate with the Registered Nurse (RN) information regarding Patient status and health needs in 1 (#10) of 10 (#1 - #10) Clinical Records reviewed.

The Agency staff failed to ensure documentation of intervention for patient weights in 1 (#5) of 10 (#1 - #10) Clinical Records reviewed.