Pondera Medical Center

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Comprehensive Assessment of Patients.

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Organization and Administration of Services.

The agency failed to encode and electronically submit each completed OASIS (Outcome Assessment Information Set) assessment to the CMS iQIES information system within 30 days of completing the assessment for 4 (#s 1, 3, 8, and 11) of 11 sampled OASIS validation reported patients; and failed to…

The agency failed to ensure a plan of care was developed for 2 (#s 4 and 10) of 11 sampled patients.

The agency failed to follow accepted standards of practice by reusing single use dressing on negative pressure wound therapy for 1 (#1) of 11 sampled patients.

The agency failed to ensure skilled nursing services, including assessments related to cardiorespiratory care and wound care, were provided for 3 (#s 1, 6 and 9) of 11 sampled patients.

The agency failed to complete the initial assessment visit within 48 hours of the referral, or within 48 hours of the patient's return home for 3 (#s 1, 4, and 6) of 11 sampled patients.

The agency failed to ensure the Physical Therapy Start of Care (SOC) initial assessment was completed within 48 hours of the referral for 2 (#s 7 and 10) of 11 sampled patients.

The agency failed to complete a resumption of care for 1 (#9); and delayed completion of a resumption of care within 48 hours for 1 (#1) of 11 sampled patients.

The agency failed to update and complete a comprehensive discharge assessment of the patient at the time of a patient’s discharge for 2 (#s 7 and 10) of 11 sampled patients.

The agency failed to complete visits as ordered by the physician for 2 (#s 7 and 9) of 11 sampled patients.

The agency failed to ensure an administrator was actively involved, available, and responsible for all day-to-day operations of the agency.

The agency failed to ensure that a clinical manager was available during the agency hours of operation.

The agency failed to ensure the agency’s governing body approved in writing a pre-designated person to assume the roles and responsibilities of the administrator when the administrator was not available.

The agency failed to ensure patients’ needs were continuously assessed in the absence of the clinical manager.

The agency failed to notify the physician of a patient's change in condition related to a suprapubic catheter, bleeding, and emergency room visits for 1 (#3) of 7 sampled patients.