Complete Home Health Care LLC

The agency failed to ensure each patient received care as ordered by their physician in 4 of 9 active patient records reviewed (Patients #2, #5, #8 and #9).

The agency failed to ensure each patient's plan of care (POC) was reviewed by the physician at least every 60 days for 2 of 4 patients records reviewed who were on services longer than 60 days (Patients #4 and #8).

The agency failed to ensure the skilled nurse (SN) developed an accurate patient plan of care (POC) in partnership with the patient and the patient's physician in 2 of 9 active records reviewed (Patients #4 and #5).

The agency failed to ensure skilled nurses (SNs) prepared accurate clinical documentation in 3 of 9 active patient records reviewed (Patients #4, #5 and #9).

The agency failed to ensure a discharge summary was sent to the primary care practitioner (PCP) within five business days of discharge for 3 of 4 discharged patients records reviewed (Patients #10, # 11 and # 12).

The agency failed to ensure a registered nurse (RN) or other appropriate skilled professional familiar with the patient, the patient's plan of care and the written patient care instructions made an onsite visit to the patient's home no less frequently than every 14 days to conduct home health aide…

The agency failed to ensure the registered nurse (RN) made a supervisory visit to the patient's home at least every 60 days with the home health aide (HHA) present to ensure the aide was properly caring for the patient for 1of 5 patients reviewed requiring supervisory visits every 60 days.

The agency failed to implement a quality assessment and performance improvement (QAPI) program to measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable home health agencies to assess processes of care, services and operations…

The agency failed to ensure each patient's Plan of care was revised to reflect current information from the patient's comprehensive assessment for 2 of 2 patients requiring a revised plan of care (Patients #1 and #13).

The agency failed to ensure the patient's clinical record contained current and accurate documentation of clinical notes, Plans of Care and physician's orders for 10 of 17 patient records reviewed (Patients #1, #2, #7, #8, #9, #10, #13, #15, and #17).

The agency failed to ensure a discharge summary was sent to the primary care practitioner within five business days of the patient's discharge for 1 of 2 active patient records reviewed who were discharged and readmitted to the agency (Patient #7) and 2 of 5 discharged patient records reviewed…