Cattaraugus County Department of Health Chha

The agency failed to develop an aide care plan of sufficient scope to meet the patient's needs.

The agency failed to ensure the Home Health Aide follows the aide plan of care for completion of assigned tasks.

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 was updated and revised to reflect the patient's current status.

The agency failed to ensure the Skilled Nurse or Therapist orients the Home Health Aide to the aide care plan prior to rendering patient services.

17) the agency failed to ensure all documentation is legible, clear, complete, consistent, and appropriately authenticated, dated, and timed, in accordance with accepted standards of practice.

The agency failed to ensure the Registered Nurse 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.

8) 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.

Staff interviews for two (2) of seventeen (17) patients (Patient #s 7 and 16) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients.

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

17) the agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the Plan of Care may need to be altered.

Two (2) of seventeen (17) clinical records (Patient #’s 16 and 17) lacked documented evidence of ongoing interdisciplinary assessments and coordination between skilled professionals to ensure the development and implementation of a plan of care that meets the patient's rehabilitation needs and…

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

The agency failed to ensure the Home Health Aide provides services as directed on the aide plan of care.

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

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

The governing body failed to ensure the agency is in compliance with Title 10 NYCRR 763.3(a)(2) of New York State laws and regulations to ensure the provision of Respiratory Therapy, and Audiology services.

Agency staff for two (2) of twenty (20) patient's (Patient's #3 and #20) the agency staff failed to follow accepted professional standards and agency policies for wound care measurement.

For one (1) of twenty (20) patients (Patients #18) the clinical record lacked documented evidence of effective communication and coordination of patient care.

#20) the agency failed to provide services in accordance with the Plan of Care (POC).

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

The Registered Nurse (RN) failed to ensure the initial Plan of Care (POC) was complete and revised as needed.

The Registered Nurse (RN) failed to prepare clinical and progress notes, coordinate services, and inform the physician of changes in the patient's condition and needs.

The agency failed to ensure that the plan of care (POC) addresses the patient's needs.

The aide failed to provide services ordered by the physician in the plan of care (POC).

The agency failed to promptly notify the physician regarding any medication discrepancies, side effects, problems or reactions.