Delmar Gardens Home Care Inc

The home health provider failed to complete the initial assessment within 48 hours of referral date in two of five full records reviewed (Records/Patients #2 and #4).

The provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, but not limited to, two of three home visit observations (Records/Patients # 1 and #3).

The provider failed to ensure that each patient’s written individualized plan of care (POC) included all the required elements, in two of five full records reviewed (Records/Patients #1 and #3).

The home health provider failed to provide services that are ordered by the physician as indicated in the plan of care in one of five full records reviewed (Record/Patient #4).

The provider failed to ensure the registered nurse (RN) or other appropriate skilled professional completed home health aide supervisory visits no less frequently than every 14 (fourteen) days in one of one applicable records reviewed (Record/Patient #3).

The provider failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services after discharge from the provider within five business days of the patient’s discharge in one of two…

The agency failed to ensure an accurate medication review and/or update of the patient's medication profile occurred when there were new/changed/discontinued medications in, but not limited to, two (Records/Patients #2 and #3) of five records reviewed.

The agency failed to ensure each patient received written information related to visit schedule/instructions in two of three applicable cases (Record/Patient #2 an #3).

The agency failed to ensure a completed comprehensive discharge summary to include all necessary components was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the agency/services within five…

The agency failed to document the patient was informed in advance of the initial services and proposed visit frequencies in two of five applicable records (Record #2 and #3).

The agency failed to document whether or not the patient had an advance directive in one of five applicable records (Record/Patient #3).

The agency failed to ensure staff followed the plan of care as ordered by the physician for two (Record #1 and #3) of five applicable records.

Staff interview the agency failed to ensure the registered nurse (RN) prepared complete clinical and progress notes regarding the patient's condition and progress toward goals in two (Record/Patient #1 and #2) of five applicable records.

The agency failed to maintain an accurate and updated medication profile in one (Record/Patient #1) of five applicable cases.