Home Health Professionals & Hospice

The Agency failed to encode and transmit Outcome and Assessment Information Set (OASIS) patient data within the required 30 days of the assessment completion date.

The Skilled Nurse (SN) failed to include all medications utilized by the patient on the medication list in 1 (#8) of 8 (#1-#8) clinical records reviewed.

The Agency failed to deliver care and services in accordance with physician orders in 3 (#1, #5 and #7) of 8 (#1 - #8) Clinical Records reviewed, failed to obtain Physician Orders for treatment and services provided to patients in 2 (#3 and #4) of 8 (#1 - #8) Clinical Records reviewed, and failed…

The Skilled Nurse (SN) did not follow the Physician orders in the Plan of Care (POC) in 3 (#1, #5, and #7) of 8 (#1 - #8) Clinical Records reviewed.

The Skilled Nurse (SN) failed to include all medications during the review of the patients medications in 5 (#1, #2, #5, #6 and #8) of 8 (#1 - #8) clinical records reviewed.

The SN failed to obtain a Physician's orders for care and treatments for 2 (#3 and #4) of 8 ( #1 - #8) Clinical Records reviewed.

Agency staff Clinicians failed to notify the Physician when the updated Comprehensive Assessment indicated a change in condition in 5 (#1, #2, #3, #4, and #6) of 8 (#1 - #8) Clinical Records reviewed.

Based Clinical Record review and staff interviews, the Agency Skilled Nurse (SN) failed to establish a written individualized Plan of Care (POC) with patient specific interventions and measurable goals based on the patients identified needs in 1 (#1) of 10 (#1 - #10) Clinical Records reviewed.

The Agency failed to ensure the patients Plans of Care (POC) included the required elements of the patients psychosocial status, risk of Emergency Room (ER) visit/hospitalization, advance directive (if any), education to facilitate a timely discharge or patient identified goals in 10 (#1 - #10) of…

The Agency failed to notify the Physician of changes in the patients condition in 3 (#1, #3, #7) of 10 (#1 - #10) Clinical Records reviewed.

The Agency Skilled Nursing (SN) staff failed to document wound assessments and responses to wound care in 2 (#1 and #3) of 10 (#1 - #10) Clinical Records reviewed.

Staff interview the Agency failed to ensure a complete Discharge/Transfer Summary was sent to the Physician after discharge or to the In-Patient Facility upon patient transfer in 4 (#2, #8, #9, #10 ) of 4 (#2, #8, #9, #10) Clinical Records reviewed with transfer/discharge status.