McAuley Seton Home Care Corp Chha

The agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) were transmitted to the State/Centers for Medicare and Medicaid Services when completed.

The agency failed to ensure the assessments were of sufficient scope to identify current patient needs.

For one (1) of eighteen (18) patients (Patient #10) the agency nurse failed to accommodate the patient's request for disposal of soiled dressings in the patient's home.

The agency failed to ensure the Physical Therapist conducted an initial assessment of the patient within twenty-four (24) hours of referral or on the physician-ordered start of care date.

The agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the start of care.

The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs.

Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm.

15 and 16) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients.

The agency failed to ensure drugs and treatments are administered in accordance with physician orders.

The agency failed to coordinate care delivery and ensure patient needs are addressed.

The agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care.

The agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes.

The agency failed to ensure there was effective communication and follow-up with the physician involved in the patient’s plan of care.

The agency failed to ensure the Plan of Care (POC) was reviewed and revised to reflect the patient's current status.

Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm.

5) the agency failed to develop individualized plans of care (POC) that are complete and accurate and address the total needs of the patients.

Failure to obtain an order to update the POC has the potential for agency staff to act on inaccurate and incomplete information, and places patient health and welfare at risk.

The agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care (POC).

The agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes.

The agency failed to provide services in accordance with physician's orders.

The agency failed to ensure Outcome Assessment Information Set (OASIS) data accurately reflects the patient diagnoses and status at the time of the discharge assessment.

The agency failed to provide services in accordance with the Plan of Care (POC) and agency policy.

The Registered Nurse (RN) failed to ensure the Plan of Care (POC) was updated and revised to reflect the patient's current status.

The clinical record lacked documented evidence the initial comprehensive assessment was of sufficient scope to ensure all patient needs are identified.

The clinical record lacked documented evidence of a drug regimen review (DRR) of all medications to identify any potential adverse effects and drug reactions.

The agency failed to ensure a comprehensive Plan of Care (POC) was developed, based on interdisciplinary assessments, to meet the individualized needs of the patients.

The agency failed to promptly alert the physician to any changes in the patient's condition or needs to suggest that the Plan of Care (POC) may need to be altered.

The agency failed to provide care in accordance with the written Plan of Care (POC) and physician orders.

The Registered Nurse (RN) failed to prepare and document complete and accurate clinical and progress notes.

The agency failed to provide supervision at least every 14 days.