Personal Assistance Services of Colorado LLC

The agency failed to ensure continuity of care upon discharge.

The agency failed to ensure care was provided according to each patient's individualized written plan of care, in conformance with physician orders, for 1 of 2 discharged patients reviewed who received certified nursing assistant (CNA) services (Patient #3).

The agency failed to ensure care was provided according to each patient's individualized written plan of care, in conformance with physician orders, for 1 of 1 patients reviewed receiving private duty nursing (PDN) services (Patient #7), 1 of 1 patients receiving therapy services (Patient #11), and…

The agency failed to ensure medication reconciliation occurred and the Plan of Care was updated with current medication orders in 2 of 17 records reviewed (Patients #14 and #16).

The agency failed to ensure the individualized Plan of Care for 6 of 6 patients with side (bed) rails whose records were reviewed included safety measures to protect against injury (Patients #6, #7, #8, #12, #13, and #16).

The agency failed to ensure nursing staff promptly alerted the physician of changes in the patient's condition that suggested a need to alter the plan of care for 1 of 1 patients whose record was reviewed and who had a wound (Patient #11).

The agency failed to ensure a registered nurse (RN) or other appropriate skilled professional familiar with the patient, the patient's plan of care and the written patient care instructions made an onsite visit to the patient's home no less frequently than every 14 days to conduct certified nursing…

The agency failed to ensure all complaints made on behalf of agency patients were documented in the agency's complaint log.

The agency failed to ensure each patient's Plan of Care reflected and covered, patient specific treatments for wound care, types of services required, coordination of care, and any safety measures to protect against injury for 1 of 3 patient records reviewed (Patients #1).

The agency failed to ensure new wound care orders were administered by agency staff only as ordered by a physician for 1 of 3 patients reviewed with a wound (Patient #1).

The agency failed to ensure patient-specific written care instructions for the Certified Nurse Aide (CNA) were prepared by the registered nurse (RN) for 1 of 3 patients reviewed who received CNA services (Patients #1).

The agency failed to ensure certified nursing assistants (CNAs) provided patient specific services as set forth on the plan of care orders for 1 of 3 patients reviewed who received CNA services (Patient's #1).

The agency failed to ensure certified nurse aides (CNAs) were providing only simple procedures which did not require nursing judgement in 1 of 3 cases reviewed for patients who received wound care (Patient #1).