Little Sisters of the Assumption Family Health Services, Inc.

Did not provide an explanation for the findings.Based the Agency's Emergency Preparedness Plan dated 11/15/17 and record reviews, the agency failed to ensure the development and implementation of policies and procedures that includes Individualized Plans for each patient as part of the…

Based the Agency's Emergency Preparedness Plan dated 11/15/17, the agency failed to ensure the development of a policy which includes procedures for informing emergency preparedness officials of patients in need of evacuation.

Based the Agency's Emergency Preparedness Plan dated 11/15/17, the agency failed to ensure the development of a policy which includes procedures for maintaining a system for medical documentation during an emergency.

Based the Agency's Emergency Preparedness Plan dated 11/15/17, the agency failed to ensure the development of a policy which includes procedures for volunteers and /or other staffing options during an emergency.

Based the Agency's Emergency Preparedness Plan dated 11/15/17, the agency failed to ensure the development and implementation of a policy which includes procedures for a communication plan that complies with Federal and State laws during an emergency.

Based the Agency's Emergency Preparedness Plan dated 11/15/17, the agency failed to ensure the development of a policy which includes procedures for a communication plan that complies with Federal and State laws during an emergency.

Based the Agency's Emergency Preparedness Plan dated 11/15/17, the agency failed to ensure the development and implementation of a policy which includes procedures for Emergency preparedness training.

The agency failed to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments were transmitted to the State/CMS when completed.

The agency failed to ensure that all patients received the care that is written in the individualized Plan Of Care.

The Governing Authority failed to ensure measurable improvement in indicators for the clinical record reviews that were being conducted by the Professional Advisory Committee(PAC).

The Governing Authority failed to ensure the utilization of quality indicators from OASIS and other relevant data collected by the Professional Advisory Committee(PAC).

The Governing Authority failed to ensure that the quality improvement and patient safety program is defined, implemented, and maintained.

The Governing Authority failed to ensure that the quality improvement and patient safety program included, implemented, and maintained an Infection Control Program.

The agency failed to ensure that initial assessments were conducted within the required time frames for all patients.

The agency failed to ensure that the comprehensive assessments were updated within the last five (5) days of the sixty day (60) certification period for all patients.

The agency failed to ensure a Discharge OASIS (Outcome Assessment) was completed for all patients.

The agency failed to ensure that a comprehensive Plan Of Care was developed for all patients.

The agency failed to ensure that treatments are administered as ordered by the physician for each patient.

The agency failed to ensure that each patient's physician was notified of any changes in the patient's condition, that may need to alter the plan of care.

The agency failed to ensure that all employees are qualified and recieve adequate staff education including evaluations.

The agency failed to ensure complete discharge summary information documentation in all clinical records in a timely manner.