Brooks-Tlc Hospital System, Inc.

Agency staff for one (1) of ten (10) patients (Patient # 8) the agency failed to ensure the Outcome Assessment Information Set (OASIS) data accurately reflected the patient's diagnoses and status at the time of the discharge assessment.

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

The agency failed to ensure the CLIA Certificate of Waiver was kept current.

The agency failed to obtain either the patient's or the patient's legal representative's signature confirming the patient received a copy of the patient rights and responsibilities at start of care (SOC).

10) the agency failed to ensure a complete and accurate comprehensive assessment consistent with the patient's immediate needs was completed within five (5) days of the start of care.

The clinical record lacked documented evidence of a drug regimen review (DRR) of all medications to identify any potential adverse effects and drug reactions.

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 agency staff communicated with the patient's physician.

The agency failed to ensure the Home Health Aide (HHA) provides services as directed on the Aide Plan of Care.