On Call Care Services Inc

The home health provider failed to ensure the accuracy of documentation in two of five full records reviewed (Records/Patients #1 and #3).

The home health provider failed to ensure the plan of care (POC) included all interventions and orders to address patient needs, safety measures, and all physicians that were providing orders, in two of five full records reviewed (Records/Patients #1 and #3).

The home health provider failed to provide a completed discharge summary to the health care provider care within five (5) days of discharge in one of two discharge records reviewed (Record/Patient #6).

The agency failed to ensure staff followed acceptable standards of practice for infection control in two (Records/Patients #2 and #3) of three home visit observations.

The home health provider failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, in but not limited to, two of five full records reviewed (Records/Patients #1 and #2).

The agency failed to ensure an accurate medication review and/or update of the patient medications was completed in, but not limited to, two of five full records reviewed (Records/Patients #2 and #3).

The home health provider failed to ensure that all patient care orders, including verbal orders, were recorded in the plan of care (POC), in two of five full records reviewed (Records/Patients #1 and #5).

The home health provider failed to promptly alert the physician to changes in the patient's condition, in one of five full records reviewed (Record/Patient #1).

The agency failed to ensure the plan of care was revised/updated to address patient's needs in one of five full records reviewed (Record/Patient #2).

The agency failed to ensure each patient received updated/current written instructions related to the patient’s medication schedule in, but not limited to, one of three home visit observations (Record/Patient #2).

The home health provider failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge, in two of two discharge records reviewed (Records/Patients #5…

The agency failed to update the written notice of patient rights to meet the requirements of the new Federal home health regulations effective 01/13/2018 to include the patient and representative (if any) has the right to be advised of the names, addresses, and telephone numbers of Federal and…

The agency failed to ensure the skilled clinician's assessments of patients accurately reflected the patient's current health, status for one (Record/Patient #4) of five records reviewed.

The agency failed to ensure a complete and accurate review of all medications the patient was currently using in three (Record/Patient #2, #3, and #4) of five records reviewed.

The agency failed to ensure that each patients' written individualized care plan included all the required items in, but not limited to, two (Record/Patient #3 and #4 ) of five records reviewed.

The agency failed to ensure the nurse recorded orders or verified orders from the physician for lab tests related to medications patients were taking for one (Record/Patient #2) of five records reviewed.

The agency failed to ensure each patient received written information related to visit schedule/instructions in three of three applicable cases (Records/Patient #2, #3, and #4).

The agency failed to ensure each patient received written information related to visit schedule/instructions in three of three applicable cases (Records/Patients #2, #3, and #4).

The agency failed to provide services as ordered by the physician on the plan of care (POC) in, but not limited to, one (Record/Patient #5) of five records reviewed.

The agency failed to assure all staff had the Employee Disqualification List (EDL) checked prior to hire and had the Family Care Safety Registry (FCSR) prior to patient contact when one (Employee- E1) of three employee files reviewed did not have this information available.

The agency failed to ensure a completed discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the agency/services within five business days of the patient's discharge in one…