Elara Caring Xxiv

The agency failed to ensure: 1. SN notified the physician of a pain level outside the ordered parameters for one (Patient #1) of 19 patients; 2. SN frequencies were followed as ordered for two (Patient #2 and 14) of 19 patients.

The agency failed to ensure accurate treatment information were contained in the clinical record for three (Patients #10, 11 and 18) of 19 patients.

The agency failed to ensure frequencies were followed as ordered for one (Pt #16 and 17) of 17 patients.

The agency failed to ensure case conferences were conducted for one (Pt #13) of 17 patients.

The agency failed to ensure governing body oversite of the agency's budget, QAPI program and policies and procedures for all agency patients and employees during calendar year 2020. A review of administrative records for calendar year of 2020 showed no review and approval of: 1) annual budget; 2)…

The agency failed to ensure communication and coordination with the physician for: 1) a pain level above parameters ordered in the POC for one (Pt #7) of 17 patients; and 2) a heart rate above parameters ordered in the POC for one (Pt #17) of 17 patients.

The agency failed to ensure the accurate documentation of a clinical notes for one (Pt #2) of 17 patients.