Rosa Coplon Jewish Home & Infirmary Chha

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

The agency failed to ensure the Physical Therapist conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date.

Failure to conduct a complete medication review has the potential for the patient to experience medication side effects or to receive incorrect medication dosages.

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

The agency failed to ensure that discharge planning was communicated with the responsible physician prior to discharge from the agency.

The agency failed to ensure all clinical notes are complete and accurate and contain all pertinent information about the patient’s status.

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 develop a complete a discharge summary and send it to the primary care practitioner within 5 (five) business days of the date of the order for discharge.

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

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

The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs.

5 and 9) lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns.

The agency failed to ensure the OASIS data accurately reflects the patient's status at the time of the assessment; specifically, the Physical Therapist failed to identify the patient's urinary tract infection.

The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs.

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

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

For one (1) of seven (7) patients (Patient #7) the agency failed to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice.

Agency staff did not inform seven (7) of seven (7) patients (Patient #'s: 1, 2, 3, 4, 5, 6, and 7) of the extent of insurance coverage for various services available through home care.

6 and 7) lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns.

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

The agency failed to ensure that discharge planning was communicated with the responsible physician prior to discharge from the agency.

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

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

The agency failed to ensure agency staff communicated with the patient's physician regarding the patient's urine Foley catheter (a sterile tube that is inserted into the bladder to drain urine).

The agency failed to ensure staff follow current clinical practice guidelines and agency policies and procedures.

Staff interviews for one (1) of seven (7) patients (Patient #2) the Skilled Nurse (SN) failed to assess the patients current health, psychological, functional and cognitive status after the patient had a fall.

The agency failed to ensure the primary caregivers were assessed on their ability to provide care.

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

And#7) the agency failed to have a physician's order for treatments provided to the patient and/or the agency failed to follow the physicians orders for treatments provided to the patient.

The agency staff failed to promptly alert the physician to any changes in the patient's condition that suggests the need to alter the plan of care (POC).

For one (1) of seven (7) patients (Patients #2) the clinical record lacked documented evidence of effective communication and coordination of patient care.

The Registered Nurse (RN) failed to prepare and document a progress note that the physician was notified of a heart rate of 58. Failure to prepare a progress note has the potential for unmet patient needs.

#5 and #6) the agency staff failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice.