Best Choice Home Care

The Agency failed to ensure admissions occurred within 48 hours of receiving/accepting the patients with 2 of 4 active clinical records reviewed who received Physical, Occupation and Speech therapy services.

The agency failed to ensure an individualized plan of care included all wounds and corresponding wound care orders, in 1 of 5 active clinical records reviewed, who received skilled nursing services for wound care.

The agency failed to ensure all treatments ordered by a physician were carried out, in 1 of 6 active clinical records reviewed, receiving only skilled nursing services for wound care.

The agency failed to notify the physician of a change in condition for 1 of 2 active clinical records reviewed, of patients who received Occupational and Speech therapy.

The agency failed to ensure revisions related to plans for discharge were communicated to the patient and/or the patient's representative in 1 of 3 active clinical records reviewed who received Physical Therapy and Skilled Nursing Services.

The agency failed to ensure the patient was informed of the frequency of visits in advance of the start of care in 2 of 10 records reviewed.

The agency failed to ensure a discharge summary was completed for 1 of 3 discharged patients from a sample of 10 records reviewed.

The agency failed to ensure that specific and measurable goals were included in the plan of care for 3 of 10 records reviewed.

The agency failed to ensure the development of a written policy and procedure for vaccine administration in 1 of 1 agency reviewed.

The agency failed to follow their policy to ensure verbal orders were signed by a physician, signed within 30 days by a physician, or that a verbal order was timed by the registered nurse in 5 of 10 records reviewed.

The agency failed to follow their policy to ensure the physician reviewed and signed the plan of care in a timely manner or within 60 days for 2 of 3 discharged patients in a sample of 10 records reviewed.

The skilled nurse failed to ensure the correct diagnosis was included in the skilled nurse visit notes for 1 of 7 active patients in a sample of 10 records reviewed.