North Shore Healthcare, Inc

The Agency failed to review and update its Emergency Preparedness plan.

In 4 of 18 (Employees #11, 12, 14 and 15) Employees, the Agency failed to conduct staff training, relative to the Agency's Emergency Preparedness plan.

In 151 of 476 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning.

In 5 of 7 (Pts. #6, 3, 4, 5 and 7) clinical records reviewed, the clinical records were not completed as required.

In 5 of 7 (Pts. #1, 2, 3, 4 and 5) clinical records reviewed, the patient care was not provided as ordered by the physician.

In 2 of 2 (Pts. #6 and 7) discharged records reviewed, the discharge summaries were not complete.

The Agency Staff failed to conform with the Physician orders.

The Agency failed to ensure services were provided as ordered by the Physician in the Plan of Care.

The Agency failed to ensure that as part of the Administrator's responsibility of day to day operations, therapy services were provided to the clients . This was found in 2 of 4 (Pts. #1 and 5) records reviewed with therapy services required.

The Agency failed to ensure an individualized Emergency Plan is developed, documented and available in the clinical record as well as the individual Patient's home.

The Agency failed to ensure that documentation entered into the clinical record was complete.

The Agency failed to ensure the POC was complete.

The Agency failed to ensure staff provided care, services and treatment, as indicated on the POC.

The Agency failed to ensure clinical notes/documentation was entered into the patient's record in a timely manner.