A Plus Teresa Home Health Care

The agency failed to ensure documents in the clinical records were complete and appropriately authenticated with a signature and title, dated, and timed in 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, resulting in records that are not authenticated, accurate, timely, and do not portray the care…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine potential adverse interactions and failed to follow proper medication application dosing in 1 (P-2) of 7 records reviewed, resulting in the potential for harmful medication effects for all…

The agency failed to ensure the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 1 (P-3) of 1 record reviewed with skilled nursing, resulting in the potential for poor patient outcomes and unmet care needs for…

The agency failed to ensure medications and visit frequencies were provided only as ordered by the physician for 2 (P# 4, 6) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services.