Jefferson Homecare

The Skilled Nurse (SN) failed to ensure the patients Plan of Care (POC) included the required elements of all medication and treatments in 1 (#11) of 17 (#1- 17) patient records reviewed with orders for medications and 1 (#16) of 1 patient record reviewed with orders for enteral nutrition.

Staff did not follow Physician orders for visit frequency in 1 (5) of 17 (#1 – 1 7) records reviewed.

The Agency failed to communicate with the laboratory, physician or patient to ensure coordination of patient care in 1 (#7) of 17 (#1 - #17) records reviewed.

The Agency staff did not follow the Attending Physician orders contained in the Plan of Care (POC) for 1 (#6), of 17(#1 - #17) Clinical Records reviewed.

The Agency Clinical staff failed to notify the patients and/or caregiver of the dates and times the Clinician would arrive at the patient's homes for visits in 3 (#6 #10, and #11) of 7 (#6 - #12) Patient telephone interviews.

The Skilled Nurse (SN) failed to alert the Physician to changes in patient’s condition which may have necessitated an alteration in the Plan of Care (POC) in 1 (#8) of 17 (#1-#17) Clinical Records reviewed.

The Agency did not ensure an effective process to provide written information specific to the patients Plan of Care (POC) to patients or caregivers in 7 (#11 - #17) of 7 (#11 - #17) (100%) of home visits conducted.

The Occupational Therapist (OT) did not conduct an Initial Evaluation within 5 days of the Start of Care (SOC) as part of the Comprehensive Assessment in 1 (#1) of 6 (#,1, #6, #10, #13, #15 and #16) Clinical Records reviewed with orders for OT services.

The Agency staff did not provide care in accordance with the written Plan of Care (POC) in 4 (#1, #4, #7, and #10) of 17 (#1 - #17) Clinical Records reviewed.

The Clinical Manager did not ensure coordination of care regarding Medical Social Work (MSW) in 1 (#1) of 1 (#1) Clinical Record reviewed with orders for MSW to conduct an evaluation.

The Skilled Nurse (SN) did not ensure current and accurate documentation of medications in 1 (#9) of 17 (#1 - #17) Clinical Records reviewed.

The Agency did not ensure a complete Discharge/Transfer Summary was sent within the required time period after transfer/discharge to the a facility in 2 (#1 and #3) of 5 (#1 - #5) Clinical Records reviewed with transfer/discharge status.