Serenity Home Health Care Inc

The provider failed to have the Registered Nurse (RN) prepare written patient care instructions for a home health aide in 1 out of 3 Sampled Patient (SP).

The provider failed to complete a discharge comprehensive assessment in a timely manner in 1 out of 3 Sampled Patient (SP).

The provider failed to include in the individualized plan of care the following: (ii) the patient's mental status; (iii) supplies, and equipment required; (iv)the frequency and duration of visits to be made; (vii) functional limitations; (viii) activities permitted; (ix) nutritional requirements…

The provider failed to have the Registered Nurse (RN) document verbal orders, to include signature, date, and time that must be included in the patient's clinical record in 1 out of 3 Sampled Patients (SP).

The provider failed to ensure that the revised plan of care for 1 out of 3 (#2) sample patients included accurate information regarding the patient's care.

The provider failed to consult the physician the patient's condition or needs that suggest the plan of care should be altered for 1 out 3 Sampled Patients (SP).

The provider failed to demonstrate effective coordination of care provided by all disciplines in 1 out of 3 Sampled Patient (SP).

The registered nurse failed to prepare and record clinical notes for 1 out of 3 Sampled Patients (SP).

The provided failed to demonstrate that nursing services are provided under the supervision of a registered nurse in 1 out of 3 Sampled Patients (SP).

The provider failed to ensure that an onsite visit to the patient's home no less frequently than every 14 days is conducted for supervision of the Home Health Aide (HHA) by a Registered Nurse or other appropriate skilled professional in 1 out of 3 Sample Patients (SP).

The provider failed to have the clinical manager assure the development, implementation, and updates of the individualized plan of care for 2 out of 3 Sampled Patient (SP).

The provider failed to ensure that the patients were informed in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished for 4 out of 4 Sampled Patients (SP).

The provider failed to ensure that the patients were informed in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished for 4 out of 4 Sampled Patients (SP).

The provider failed to include case conferences which establish interchange, reporting, and coordination of patient care needs in 4 out of 4 Sampled Patient (SP).

The provider failed to show that the plan of care was followed for 2 out of 4 (SP#1 and SP#4) Findings include: A review of SP#1's plan of care for certification period 11/30/2017 - 01/28/2018 revealed the patient was to receive skilled nursing 1 DA 14 days for wound care.

The provider failed to ensure the plan of care was completed based on the patient's immediate care needs in 1 out of 4 Sampled Patients (SP).

The provider failed to ensure that verbal orders for 2 out of 4 (SP#1 and SP#2) sample patients (SP) were signed by the registered nurse responsible for furnishing or supervising the ordered services.

The licensed practical nurse failed to prepare clinical and progress notes for 1 out of 4 Sampled Patients (SP) (SP#1).