Chemung Co Dept Health Chha

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

14) the agency failed to ensure all documentation is legible, clear, complete, consistent, and appropriately authenticated, dated, and timed, in accordance with accepted standards of practice.

The agency failed to ensure the Registered Nurse conducted an initial assessment of the patient within twenty-four (24) hours of referral, the patient's return home, 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 has the potential for the patient to experience medication side effects or to receive incorrect medication dosages.

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

Failed to include evidence that orders were obtained for changes in the plan of care.

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

The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest the plan of care may need to be altered.

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

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

The agency failed to ensure the Home Health Aide was supervised at least every fourteen (14) days.

The agency failed to follow the agency policy and procedure for patient discharge.

The agency failed to 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 ensure the clinician communicated with all physicians involved in the patient's care.

The agency failed to ensure OASIS data accurately reflects the patient's status at the time of the assessment.

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 comprehensive assessment is updated and revised to reflect changes in the patient's health status.

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

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

The agency failed to ensure the Registered Nurse (RN) 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 and to ensure the medication regime is appropriate has the potential for the patient harm.

The agency failed to develop individualized plans of care (POC) 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 ensure the physician is notified of changes in the patient's condition or needs that suggest that the Plan of Care (POC) may need to be altered.

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 prepare and document complete and accurate clinical notes.

The agency failed to follow agency policy and procedure, current clinical practice guidelines, and accepted professional standards when providing services.

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

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

The agency failed to ensure that patients are informed, before care is initiated, of their potential financial liability for services provided.

The clinical record lacked documented evidence of a complete review of all medications the patient is currently using to identify any potential adverse effects or drug reactions, and to ensure maintenance of an accurate and comprehensive medication profile.

The agency failed to ensure the plans of care (POC) are complete and of sufficient scope to address all the patient's needs.

The agency failed to include evidence that orders were obtained for changes in the plan of care (POC).

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 ensure the Skilled Nurse (SN) provided the patient with appropriate education regarding the care and services identified in the Plan of Care (POC).

The agency failed to ensure Home Health Aides (HHA) provide services as directed on the Aide Plan of Care.

The agency failed to follow current clinical practice guidelines, and agency policy and procedure.