Home Care for the 21ST Century - Chester

The agency failed to ensure the physician ordered plan of care to ensure pertinent diagnoses for one (1) out of three (3) CR's reviewed (CR#1), failed to ensure the plan of care included clear treatment and intervention orders for one (1) out of three (3) CR's reviewed (CR#1), failed to ensure…

The agency failed to ensure the transmittal of OASIS data for agency patients receiving skilled services, over eighteen years of age, for three (3) out of three (3) clinical records (CR) reviewed and failed to ensure the agency's OASIS policy to contain language regarding OASIS data transmittal for…

The agency failed to ensure the physician ordered plan of care contained pertinent diagnoses for one (1) out of three (3) CR's reviewed (CR#1), and failed to ensure the plan of care included clear treatment and intervention orders for one (1) out of three (3) CR's reviewed (CR#1).

The agency failed to ensure the registered nurse resolved wound care orders with discrepancies in the plan of care for one (1) out of three (3) CR's reviewed (CR#2) and failed to ensure the registered nurse resolved medication orders with discrepancies in the plan of care for two (2) out of three…

The agency failed to ensure all entries in the clinical record to be legible for one (1) out of three (3) clinical records reviewed (CR#3).

The agency failed to ensure the physician ordered plan of care contained pertinent diagnoses for one (1) out of three (3) CR's reviewed (CR#1), and failed to ensure the plan of care included clear treatment and intervention orders for one (1) out of three (3) CR's reviewed (CR#1).

The agency failed to ensure medications and treatments were provided in accordance with physician's orders for two (2) out of three CR's reviewed (CR #1 and CR#2).

The agency failed to ensure the plan of care to be updated to include all medication orders for one (1) out of three (3) CR's reviewed (CR#1) and failed to ensure the plan of care was updated to include all wound care orders for one (1) out of three CR's reviewed (CR #1).

The agency failed to ensure completed ventilator competency skills validation checklists for three (3) out of three (3) personnel files (PF) reviewed (PF#1-PF#3).

The agency failed to ensure the patient's physician to be notified of change in patient's condition for one (1) out of three (3) clinical records (CR) reviewed (CR#1).

The agency failed to ensure the Physician Ordered Plan of Care to include an ordered visit frequency for one (1) out of four (4) CR's reviewed (CR#4) Review of policy "Physician's Plan of Treatment" on 8/22/2022 at approximately 10:40 AM states " A physician's plan of treatment must be signed by…

The agency failed to ensure the patient's visit frequency to be conducted in accordance with physician's orders for one (1) out of four (4) CR's reviewed (CR#3), failed to ensure wound care treatments to be conducted in accordance with physician's orders for one (1) out of four (4) CR's reviewed…

The agency failed to ensure all entries in the clinical record to include authentication consisting of a title (occupation) for two (2) out of four (4) clinical records reviewed (CR#3 and CR#4).