Interim Healthcare of NE Wi Inc.

The agency failed to develop plan of care (POC) goals that were measurable, time specific and/or individualized to meet the needs of the patient in 7 of 7 patients reviewed (Patient #1, #2, #3, #4, #5, #6, and #7).

The agency failed to ensure that Occupational Therapy (OT) evaluations and treatment orders were followed per physician signed orders in 4 of 5 eligible patients that had OT evaluation and treatment orders (Patients #1, #3, #4, and #7) in a total of 7 records reviewed.

The agency failed to document patient progression toward agency established goals in the patient plan of care and/or clinical record in 3 of 5 eligible active patient records reviewed (Patients #1, #3, and #4) in a total of 7 patient records reviewed.

The agency nurse failed to remain with the patient requiring medical intervention or EMS (Emergency Medical Services) in 1 of 6 patients reviewed (Patient #1).

The agency nurse failed to notify the physician in changes in the patient condition in 1 of 6 patient records reviewed (Patient #1).

The agency nurse failed to meet patient needs by remaining with and assessing the patient with a potential change in condition in 1 of 6 patient records reviewed (Patient #1).

The agency failed to ensure staff were oriented and trained to medical emergency procedures in 1 of 5 personnel records reviewed (Registered Nurse B).

The agency failed to inform patients in writing of their rights and responsibilities to receive or refuse care in advance of and during treatment in 1 of 10 patients records reviewed (Patient #8).

The agency administration or designee failed to be available during all operation hours in 1 of 1 agencies reviewed (Agency F).