Essex County Nursing Service

The agency failed to ensure all paraprofessionals receive a complete Home Health Aide plan of care when providing patient care.

The agency failed to ensure in one of six clinical records (Patient # 2) professional staff maintain an accurate, current and clearly documented 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…

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

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 in two out of ten records (Patient # 3 and 5) professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care.

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 two of ten patient records reviewed (Patient # 3 and 10).

The agency failed to ensure services were provided in accordance with the aide Plan of Care (POC) in one of six records (Patient # 6) of patients receiving paraprofessional aide services.

The agency failed in one of three records (Patient # 10) to ensure a comprehensive discharge summary was prepared.

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