Unique Home Health Care Solutions, LLC

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status and baseline data for future assessments, in 3 of 3 records reviewed (MR# 1, 2, 3) out of a total of 3 records reviewed, resulting in the potential for unmet care…

The Agency failed to ensure the plan of care (POC) covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the individualized needs of the patient in 3 (P-1, 2, 3) records, from a total of 3 sampled records reviewed, resulting in the potential…

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments…

The agency failed to ensure that all entries in the medical record were legible and authenticated by a signature, date and title for 1 of 7 sampled records reviewed (MR#6), resulting in a lack of validation as to the correctness of the entries in the medical record.

The agency failed to ensure the plan of care covered all pertinent interventions with reportable safety parameters, and objectively measurable goals specific to the needs of the patient for 6 records (MR#s 1, 2, 4, 5, 6, 7) from a total sample of 7 records reviewed, resulting in patients not…

The agency failed to provide nursing services in accordance with the plan of care in 1 of 7 records reviewed (MR #1), resulting in the physician not having a clear and concise clinical picture of the patient's health status, resulting in the potential for unmet needs.

The agency failed to ensure clinicians documented clear, complete, timely and dated clinical notes in 2 of 7 records reviewed (MR#s 1 and 4) resulting in a lack of documentation of the care provided.