Family Care Certified Services (Hempstead)

The Governing Authority failed to develop a comprehensive Emergency Preparedness Program.

The agency failed to develop a comprehensive Emergency Plan that includes procedures necessary to inform State and local officials of patients and staff location.

The agency failed to develop a comprehensive Emergency policy that includes use of volunteers and other contingencies.

Based record review and staff interviews, the Agency failed to develop a comprehensive Emergency Preparedness Plan.

The Agency failed to develop an Emergency Communication plan that complies with Federal, State, and local laws.

The agency failed to conduct emergency training and testing program that reflects risks.

The agency failed to participate in a full-scale community-based exercise to test the emergency plan.

The Agency failed to ensure that Outcome and Assessment Information Set (OASIS) data was transmitted to the Centers for Medicare and Medicaid System (CMS) within thirty (30) days.

The Agency failed to provide Physical Therapy services, Registered Nurse services, and patient care treatments are provided in accordance with the Plan of Care.

The Governing Authority failed to ensure that the Quality Assessment and Performance Improvement program identify quality indicators, establish data measures related to patient care, services and outcomes.

The Governing Authority failed to ensure quality indicators data measurement.

The Governing Authority failed to ensure data collection during the Quality Assessment and Performance Improvement activities was used to identify areas for improvement.

The Governing Authority failed to ensure ongoing QAPI activities.

The Governing Authority failed to maintain a coordinated agency-wide Infection Control program.

The Agency failed to obtain consent that includes all services ordered in the Plan of Care.

The Agency failed to ensure the Registered Nurse perform the initial patient assessment within forty-eight (48) hours of referral and/or return home from facility.

Based of clinical record review and staff interview, the Agency failed to ensure that comprehensive assessments include all pertinent current health status and past medical history.

The Agency failed to establish individualized Plans of Care.

The Agency failed to provide Physical Therapy services in accordance with Physican's Orders.

The Agency failed to ensure the coordination of care among all services.

The Agency failed to ensure the Physical Therapist Assistant supervision as per the Plan of Care.

The Agency failed to ensure that the clinical record includes all pertinent patient assessments, clinical notes and discharge summaries.

The agency failed to ensure that OASIS data was transmitted to Centers for Medicare and Medicaid System (CMS).

The agency failed to ensure that Skilled Services are provided in accordance with the physician's orders.

The Governing Authority failed to ensure that the Registered Nurse conduct the initial patient assessment within 48 hours of referral, or the Patient's return home to determine the immediate care and support needs of the patient.

The agency failed to develop complete and comprehensive Plans of Care.

The agency failed to ensure the Physician was alerted of the changes in the Patient's condition that may suggest the Plan of Care need to be altered.

The Agency failed to ensure the coordination of care provided by the disciplines to ensure the integration of services, identification of patient needs and treatment continuity and effectiveness.

The agency failed to ensure that only Registered Nurses perform assessments, and that nursing services are provided under the supervision of a Registered Nurse (RN).

The agency failed to ensure that services and/or treatments were provided in accordance with the Plans of Care (POC).

The agency failed to ensure that all patients were advised in advance of the disciplines that will furnish the care and the frequency of the visits to be provided.

The agency failed to ensure complete and comprehensive Follow-Up-Assessment conducted by the Physical therapist.

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

The agency failed to ensure that agency staff are reviewing and revising the individualized Plans of Care (POC) at least every sixty (60) days.

The agency failed to ensure that patients receive written instructions of any treatments to be administered by agency personnel.

The agency failed to ensure that all services ordered by Physicians and documented on the Plan of Care (POC) were provided to the patients.

The agency failed to ensure that Clinician's prepared and documented Clinical Notes.

The agency failed to ensure ongoing communication was maintained with each patient's Physician.

The agency failed to ensure adequate supervision and oversight of the Physical Therapy Assistant (PTA) in one (1) out of three (3) records of patients receiving PTA Services (Patient #3).