Pns Homecare Services, Inc

The Agency failed to provide care and services in accordance with the plan of care in 4 (MR's # 1, 2, 3 and 6) of 7 records reviewed for provision of services, from a total of 7 records reviewed, resulting in the potential for decline in physical functioning and unmet care needs.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 7 of 7 (MR's #1, 2, 3, 4, 5, 6 and 7) records reviewed, resulting in incomplete clinical information to aid in determining the needs of this patient and for measuring the patient's…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required in 5 of 7 sampled records reviewed (MR's #1, 2, 3, 4 and 5), resulting in the potential for harmful…

The Agency failed to ensure a discharge summary was complete, that provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 2 (MR# 6 and 7), of 2 closed records, from a total of 7 records reviewed…

The agency failed to ensure that skilled nursing (SN) provided care as ordered by the physician in the plan of care for 2 of 6 records reviewed (MR's #2 and 3) in which care was provided by SN from a total sample of 7 records reviewed, resulting in the potential for harm to the patient.

The agency failed to ensure the plan of care (POC) included measurable outcomes and goals specific to the needs of the patient for 6 of 7 records reviewed (MR#s 2, 3, 4, 5, 6, and 7), resulting in patients not receiving care specific to their individual needs and the potential for poor patient…

The Agency failed to ensure that Master of Social Work (MSW) and Physical Therapy (PT) performed an initial evaluation during the agency's expected timeframe (within 5 days of the start of care) for 5 of 7 records reviewed (MR's # 1, 2, 4, 5, and 6) for therapy services from a total sample of 7…

The Agency (HHA) failed to ensure the discharge and transfer summaries were complete, detailed the course of care provided with responses, and provided the patient's current health status at the time of discharge/transfer and progress toward goals in 2 (MR# 2 and 6) of 2 closed/discharged records…