Platinum Care Home Services, Inc

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 1 of 10…

The agency failed to ensure patients were informed of the Administrator's name during the initial evaluation visit for 4 of 4 (MR# 3, 4, 8, 9) joint surveyor home visits, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect the quality of…

The agency failed to advise patients of the names, addresses and telephone numbers of Federally funded and State funded entities that serve the areas where the patients reside for 4 of 4 (MR# 3, 4, 8, 9) joint surveyor home visits, resulting in a lack of information regarding available resources…

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 2 of 8 (MR# 6, 8) records reviewed with skilled nursing starts of care, resulting in a delay in determining the immediate care and support needs for these patients.

The agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 2 of 2 (MR# 4, 7) records reviewed with therapy only services, from a total of 10 records…

The Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 5 of 10 (MR#s 1, 2, 6, 7, 8) records reviewed, from a total of 10 records reviewed, resulting in the potential for unmet patient care needs.

The agency failed to notify the physician of plan of care (POC) changes, for 1 of 3 records (MR# 5) with home health aide (HHa) services provided, from a total sample of 10 records reviewed, resulting in the potential for unmet patient care needs.

The agency failed to ensure the clinical record contained completed visit notes for 1 of 8 (MR #6) records reviewed with skilled nursing care, resulting in a lack of information for the physician and all agency staff caring for this patient.

The agency failed to include discharge summaries in the patient record that summarized the care provided and failed to document submission to the physician in 3 of 4 records (MR #'s 1, 2, 7) that were discharged from a total of 10 records reviewed, resulting in the potential for unidentified…

The Registered Nurse (RN) failed to prepare clearly written patient care instructions, safety precautions, develop an aide care plan, instruct on wound care, and include vital sign parameters on the aide's care plan, in 4 of 4 records in which Home Health Aide (HHa) services were provided (MR#s 3…

The agency failed to inform the patient in advance of the disciplines that will furnish care and the proposed visit frequency in 2 of 10 records reviewed (MR# 3 and 4) from a total sample of 10 records reviewed, resulting in the potential for patients not having knowledge of the plan for treatment…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regimen review as required and failed to ensure the physician was notified of potential drug interactions in 6 records…

The agency failed to ensure the plan of care included all pertinent interventions, all services ordered on the referral, and safety precautions for 4 of 10 records reviewed (MR#s 1, 2, 4, 5) resulting in patients not receiving care specific to their individual needs, safety precautions, and the…

The agency failed to provide and document home health aide supervision every 14 days in 1 of 4 records reviewed with aide services (MR# 3), out of a total sample of 10 records reviewed.