Ur Medicine Home Care, Certified Services, Inc

The agency failed to ensure the assessments were of sufficient scope to identify current patient needs.

Staff interviews for two (2) of three (3) patients (Patient #s: 1 and 2) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients.

Failure to obtain an order to update the POC has the potential for agency staff to act on inaccurate and incomplete information, and places patient health and welfare at risk.

The agency failed to ensure drugs and treatments are administered in accordance with physician orders.

Staff for one (1) of three (3) patients (Patient #2) the agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's status.

The agency failed to ensure the Authorized Practitioner is notified of changes in the patient's condition or needs that suggest the Plan of Care (POC) may need to be altered.

The agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care (POC).

The agency failed to follow agency policies and procedures, current clinical practice guidelines and accepted professional standards when providing services.

Staff interview for one (1) of three (3) patients (Patient #1) the agency failed to ensure the comprehensive assessment is updated and revised to reflect changes in the patient's health status.

The agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the Start of Care (SOC).

The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs.

The agency failed to ensure the primary caregiver was assessed on their ability to provide care.

The agency failed to ensure a comprehensive plan of care (POC), was developed to meet the individualized needs of the patients.

The agency failed to ensure the plan of care (POC) was reviewed and revised to reflect the patient’s current status.

The agency failed to ensure the clinician communicated with all physicians involved in the patient's care.

The agency failed to effectively coordinate services to support the objectives of the plan of care.

The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs.

The agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's current status.

The agency failed to ensure the initial comprehensive assessment is of sufficient scope to identify patient needs.

The agency failed to ensure the clinician communicated with all physicians involved in the patient's care.

The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs.

The agency failed to provide services in accordance with physician orders and the Plan of Care (POC).

The agency failed to ensure the Plan of Care (POC) was updated and revised to reflect the patient's current status.

The agency failed to ensure the Registered Nurse (RN) conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date.

The agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the Start of Care (SOC).

The clinical record lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns.

The agency failed to ensure comprehensive assessments are updated and revised within forty-eight (48) hours of the patient's return to the home from a hospital admission of twenty-four (24) hours or more.

The agency failed to ensure a comprehensive Plan of Care (POC), based on clinical assessments, was developed to meet the individualized needs of the patients.

Failed to include evidence that orders were obtained for changes in the plan of care.

The agency failed to ensure services and treatments are administered in accordance with physician orders.

The agency failed to ensure professional staff promptly alert the physician to any changes that suggest a need to alter the Plan of Care (POC).

The agency failed to communicate an appropriate discharge plan, based on the patient's current needs and plan of Care (POC), with the physician.

The agency failed to ensure there was communication with all physicians involved in the patient's care following the patient's physician appointment.

Agency staff failed to effectively coordinate services to support the objectives of the plan of care.

The agency failed to coordinate care delivery to meet the patient's needs.

The agency failed to ensure the Registered Nurse (RN) provided the patient with appropriate education regarding the medications identified in the Plan of Care (POC).

The agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes.

The agency failed to ensure adequate supervision of the PTA.

Specifically, the agency failed to ensure wounds were assessed and documented in accordance with agency policy.

The agency failed to complete a discharge summary and send it to the primary care practitioner within 5 (five) business days of the date of the order for discharge.