Schofield Certified Home 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 all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice.

Staff for two (2) of seven (7) patients (Patient #s: 5 and 6) the agency failed to ensure a complete and accurate comprehensive assessment consistent with the patient's immediate needs was completed within five (5) days of the start of care.

The clinical record lacked documented evidence of a complete review of all medications the patient is currently using to identify any potential adverse effects and drug reactions or concerns.

5 and 6) 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 provide services in accordance with physician orders and the Plan of Care.

The agency failed to document complete and accurate clinical notes.

The agency failed to ensure staff develop, evaluate and update the plan of care (POC) based on the patient’s needs.

This condition was not met as evidenced by: Failure to provide skilled nursing services in accordance with federal laws, rules and regulations for two of six patients.

The recertification comprehensive assessment was not of sufficient scope to identify the current patient needs.

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

The agency failed to ensure the clinician 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.

The agency failed to ensure ongoing interdisciplinary involvement of all staff involved in the patient’s plan of care (POC).

The agency failed to ensure staff develop and evaluate the plan of care (POC) based on the patient’s needs.

The agency failed to ensure Outcome Assessment Information Set (OASIS) data accurately reflects the patient’s status at the time of the discharge assessment.

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 physician orders and the Plan of Care (POC).

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

Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm.

4 and 6) the agency failed to develop individualized plans of care (POCs) that are complete and accurate and address the total needs of the patients.

Failure to obtain an order to update the POC has the potential for agency staff to act on inaccurate and incomplete information, and places patient health and welfare at risk.

The agency staff failed to promptly alert the physician to any changes in the patient's condition that suggests the need to alter the plan of care (POC).

The agency failed to ensure the Registered Nurse (RN) provided the patient/caregiver with appropriate education regarding the care and services identified in the plan of care (POC).

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

The agency failed to ensure agency staff communicated with the patient's physician.

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

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

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

For two (2) of ten (10) patients (Patient #s: 1 and 5) the agency failed to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice.

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 (SOC).

The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs.

The clinical record lacked documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns.

The agency failed to ensure the Plan of Care (POC) was of sufficient scope to address all the patient's needs.

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

The agency staff failed to promptly alert the physician to any changes in the patient's condition that suggests the need to alter the plan of care (POC).

The agency failed to ensure there was communication with all physicians involved in the patient's care following the patient's physician appointment.

The agency failed to effectively coordinate services to support the objectives of the plan of care.

The agency failed to ensure the Skilled Nurse (SN) provided the patient with appropriate education regarding the care and medications identified in the Plan of Care (POC).

The agency failed to ensure staff prepare and document complete clinical and progress notes.

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

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

The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs.

The agency failed to ensure Registered Nursing (RN) services were provided in accordance with current clinical practice guidelines.