Senior Home Care Connections

The agency failed to ensure documents in the clinical records were legible, clear, complete, and appropriately authenticated with a signature and title, dated, and timed in 1 of 6 (P-4) records reviewed, resulting in records that are not authenticated, accurate, timely, and do not portray the care…

The agency failed to ensure the initial assessment visit was completed within 48 hours of the referral or within 48 hours of the patient's return home in 2 of 6 (P-5, P-6) records reviewed.

The agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 5 of 6 (P-1, P-3, P-4, P-5, P-6) records reviewed, resulting in the potential for harmful medication effects for all patients…

The agency failed to ensure the plan of care covered all safety measures and objectively measurable goals specific to the individualized needs of the patient in 6 (P- 1, 2, 3, 4, 5, 6) records, from a total of 6 sampled records reviewed, resulting in the potential for poor patient outcomes and…

The agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 6 of 6 (P-1, P-2, P-3, P-4, P-5, P-6) discharge records reviewed, resulting in a lack of information to ensure continuity of care.