Madlyn and Leonard Abramson Center for Jewish Life

Agency Administrator/Director Nursing the agency failed to ensure the physician was notified for Occupational Therapy and Social Worker evaluation that were not completed for one (1) of seven (7) clinical records reviewed.

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases and failed to follow their own policy to conduct quarterly Infection Control Committee Meetings.

The agency failed to ensure an initial Occupational Therapy assessment was conducted and incorporated into the Plan of Care (POC) no later than five (5) calendar days after the start of care for one (1) out of seven (7) patient clinical records (CR) reviewed (CR #3).

The agency failed to incorporate all new medications the patient is currently using for one (1) of seven (7) CRs reviewed (CR #4).

Agency staff failed to promptly alert physician to changes in patient condition for one (1) of seven (7) records reviewed.

Agency failed to provide documentation that a discharge summary was sent to the physician within five (5) days of discharge for one (1) of two (2) discharge records reviewed (CR #7).

The facility failed to include documentation that the emergency preparedness plan be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered, demonstrate that each separately certified facility…

Staff interview the agency failed to conduct performance improvement projects after July 13, 2018, that reflected the scope, complexity, and past performance of the agency's services and operations.

The agency failed to provide services according to the plan of care for three (3) out of eight (8) clinical records reviewed.

The agency's administrator failed to follow the agency's personnel policy to ensure that personnel files contain yearly performance evaluations for three (3) of eight (8) PF reviewed (PF # 1, 2, & 4).

The governing body failed to assume full legal authority for the operation of the agency by failing to approve the appointment of a qualified alternate administrator, supervising Registered Nurse and alternate supervising Registered Nurse.