Community Health Center of St. Mary's Healthcare & Nathan Littauer Hospital, Inc

The agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in five of eighteen patient records (Patient # 2, 3, 4, 6 and 14).

Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes.

Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes.

The agency failed to ensure services are provided in accordance with the Plan of Care (POC) in two out of seventeen records (Patient # 7, 10).

The agency failed to ensure in three out of seventeen records (Patient # 3, 7, 10) that professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care.

The agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in fifteen out of seventeen records (Patient # 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17).

The agency failed to ensure verbal orders are put in writing and authenticated by the physician in three out of seventeen records (Patient # 4, 5, 7).

Failure to notify the physician of changes that alter or suggest the need to alter the POC has the potential to result in unmet patient needs and negative patient outcomes.

The agency' policy and procedure and staff interview the agency failed to ensure adequate supervision and oversight of the Physical Therapy Assistant (PTA) in one out of four records of patients receiving PTA services (Patient # 2).

The agency failed to ensure professional staff made an onsite visit to the patient's home every two weeks to supervise the Personal Care Aide (PCA) in one out of four records of patients receiving paraprofessional aide services (Patient # 9).