Bower Enterprise II

The physical therapist (PT) failed to adequately assess and monitor the needs of the patient in 1 (P-5) of 1 record reviewed with therapy only services, out of a total sample of 7 records reviewed, resulting in the potential for unidentified care needs and poor clinical outcomes.

The Agency failed to ensure that 2 (P-1, P-6) of 3 patients observed during home visits, from a total of 7 sampled records reviewed, was included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of…

The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 3 (P-1, P-3, and P-5) of 3 records reviewed where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services…

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 3 (P-1, P-3, and P-7) records, from a total of 7 sampled records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients and for…

The Agency failed to ensure the plan of care included all pertinent diagnoses, treatments, reportable parameters, and measurable goals to meet the individualized needs of the patient for 2 (P-1, P-4) records, from a total of 7 sampled records reviewed, resulting in patient not receiving care based…

The agency failed to ensure services were provided only as ordered by the physician in 1 (P-4) of 7 records reviewed, resulting in the potential to negatively affect all 5 patients currently serviced by the agency.

The agency failed to ensure the Physician was promptly notified of elevated pain levels outside of the reportable parameters and blood sugar levels outside of reportable parameters for 1 (P-5) of 1 patient reviewed with therapy only services, out of a total sample of 7 records reviewed, resulting…

The agency failed to provide 1 (P-6) of 3 patients observed during home visits, an accurate medication profile that incorporated the correct insulin dosages based off the Plan of Care, out of a total sample of 7 records reviewed, resulting in the potential for unmet patient needs and a poor…

The agency failed to ensure its skilled disciplines provided care and services in accordance with the Physician's orders and plan of care for 2 (P#'s 1, 3) patients ordered to receive Skilled Nursing and/or Physical Therapy services, from a total of 7 sampled patients, resulting in the potential…

The agency failed to ensure the discharge summaries detailed the course of care provided with responses to treatment, the patient's health status at the time of discharge and forwarded to the Physician within the time frame set as this requirement for 2 (P-2, P-5) of 2 patients discharged from the…