Premium Select Home Care, Inc

The agency's staff failed to prepare complete written patient care instructions for a home health aide in one patient receiving Personal Care Aide Services only (Patient # 1).

The agency's clinician failed to document a complete assessment at discharge in one (1) of one (1) closed clinical record for a patient discharged from the agency (Patient #6).

The agency's clinician failed to ensure individualized plans of care included all required elements in one (1) of 10 clinical records (Patient #6).

The agency's staff failed review and revise of the plan of care to reflect any verbal order received during the certification period so that all HHA staff are working from a current plan in one (1) of ten (10) clinical records (Patients #1).

Agency staff failed to ensure that the developed Plan of Care identified patient-specific measurable outcomes and goals in one of seven clinical records (Patient # 5).

The agency's staff failed to consistently ensure the Home Health Aides (HHAs) receive at least 12 hours of in-service training, during each 12-month period in one of four personnel records (Employee #16).

The agency's staff failed to conduct accurate medication reviews for two of three home visits conducted (Patients #2 and 3).

Agency staff failed to ensure consistent use of the current version of the Outcome and Assessment Information Set (OASIS) items, in one of seven clinical records (Patient # 4).

The agency's clinician failed to document a complete and accurate comprehensive assessment in one of two closed clinical records for discharged patients (Patient # 5).

Rehab Services Supervised By Pt, Ot

The agency's clinician failed to document complete, updated and revised comprehensive assessments at discharge to include summaries of patients' progress in meeting care plan goals in two of two closed clinical records for discharged patients (Patients #4 and 5).