Warren Co Hlth Svs Chha

The agency failed to ensure in four of six records (Patient # 3, 4, 5, and 6) professional staff maintain an accurate, current and clearly documented clinical record related to the provision of the patient's care.

The agency failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS), regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the…

Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes.

The agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in nine of ten patient records reviewed (Patient # 1, 3. 4. 5. 6. 7. 8. 9 and 10).

The agency failed to ensure the comprehensive assessment was updated and revised, including the administration of the Outcome and Assessment Information Set (OASIS) as frequently as the patients condition warrants due to a major change in condition the patient's health status, but not less…

The agency failed to ensure services are provided in accordance with the physician's Plan of Care (POC) in one of ten patient records (Patient # 3).

Besed on clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individulaized neeeds of the patient in five of ten patient records (Patient # 1, 2, 5, 6 and 8).

Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes.

The agency failed to ensure a physician's plan of care (POC) reflects and/or is based on current information from the patient's updated comprehensive assessment in one of ten records reviewed (Patient #5).

The agency failed to ensure in three of three records of patients that have been discharged (Patient # 8, 9 and 10) that a comprehensive discharge summary was prepared and sent to the physician.

The agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in seventeen out of seventeen records (Patient # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17).

Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes.

The agency failed to ensure paraprofessional staff provided services as outlined in the Aide Plan of Care (aide POC) two of three records of patients receiving paraprofessional services (Patient # 1 and 9).

The agency failed to ensure professional staff made an onsite visit to the patient's home every two weeks to supervise the Home Health Aide (HHA) in one of three records of patients receiving paraprofessional aide services (Patient # 9).