Vna of Western Ny Chha

The agency failed to review and/or revise the Plan of Care in accordance with patient needs.

The agency failed to provide care in accordance with the written Plan of Care.

Failure to complete the Notice of Medicare Non-Coverage form with the patient prior to discharge has the potential to result in negative patient outcomes.

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

In one (1) of one (1) patients (Patients # 3), requiring a resumption of care assessment, that the comprehensive assessment for the resumption of care was not of sufficient scope to ensure all patient needs are identified.

The agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) were transmitted to the State/Centers for Medicare and Medicaid Services when completed.

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

The agency failed to ensure a legal representative (an individual who has been legally designated or appointed as the patient's health care decision maker), a power of attorney for health care decision-making, or a designated health care agent are provided written notice of the patient's rights and…

Failure to complete the Notice of Medicare Non-Coverage form with the patient prior to discharge has the potential to result in negative patient outcomes.

5 and 13 ) 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.

17) 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.

16) the agency failed to develop individualized Plans of Care that are complete and accurate and address the total needs of the patients.

16) lacked evidence an order was obtained to update the Plan of Care to reflect the patient's status.

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.

Staff interview for two (2) of seventeen (17) patients (Patient #'s: 13 and 14) the agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the Plan of Care.

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

The agency failed to ensure the HHA is 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.

This condition was not met as evidenced by: Failure to provide all services outlined in the plan of care for two of three patients.

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

The agency failed to provide all services outlined in the plan of care.

The agency failed to ensure care and treatments is provided based on patient needs.

The agency failed to ensure care and treatment is provided when requested and needed.

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 effectively coordinate services to support the objectives of the plan of care.

The PT failed to ensure a safe and effective environment was established prior to discharging the patient from therapy services.

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

The agency failed to ensure care assigned was within the aide’s scope of practice.

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.

For one (1) of two (2) patients (Patient #1) the agency failed to ensure the Registered Nurse (RN) conducted an initial assessment of the patient within 48 (forty-eight) 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 (SOC).

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 ensure the physician is notified of changes in the patient's condition or needs that suggest the Plan of Care (POC) may need to be altered.

The agency failed to ensure that discharge planning was communicated with the patient/caregiver and the responsible physician prior to discharge from the agency.

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

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

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 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.

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).

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

20 and 23) the agency failed to develop individualized plans of care (POC) that are complete and accurate and address the total needs of the patients.

Two (2) of twenty-three (23) patient records (Patient #"s: 15 and 19) lacked evidence an order was obtained to update the Plan of Care (POC) to reflect the patient's status.

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 (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 ensure ongoing interdisciplinary assessments and communication between skilled professionals occurred to meet the patient's needs and goals.

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

The agency failed to ensure referrals for home care are coordinated.

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

The Registered Nurse (RN) failed to prepare and document a complete discharge summary process.

Staff for one (1) of one (1) patients (Patient #2) the agency failed to adequately document, investigate, and resolve complaints.

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

The Registered Nurse (RN) failed to ensure the comprehensive assessment was correct and accurately reflected the patient's status.

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

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

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

9) the agency failed to ensure the Registered Nurse (RN) conducted an initial assessment of the patient within 48 (forty-eight) hours of referral, the patient's return home, or on the physician-ordered start of care date.

The agency failed to ensure the Physical Therapist (PT) conducted an initial assessment of the patient within 48 (forty-eight) hours of referral, the patient's return home, or on the physician-ordered start of care date.

Staff interview for two (2) of seventeen (17) patients (Patient #s: 1 and 7) 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).

Agency staff for (2) of seventeen (17) patient records (Patient #'s: 1 and 2) lacked documented evidence of a complete review of all medications the patient was currently using to identify any potential adverse effects, drug reactions, or concerns.

The agency failed to ensure a comprehensive Plan of Care (POC) was developed, based on interdisciplinary assessments, to meet the individualized needs of the patients.

The agency failed to ensure that treatments, drugs or services are administered in accordance with physician orders.

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

The agency failed to ensure that discharge planning was communicated with the responsible physician prior to discharge from the agency.

For one (1) of one (1) Telehealth patients (Patient #8) the clinical record lacked documented evidence the staff coordinated effectively to support the objectives outlined in the plan of care and to ensure that the patient's needs were met.

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

One (1) of seventeen (17) clinical records (Patient #8) lacked documented evidence of ongoing interdisciplinary assessments and coordination between skilled professionals to ensure the development and implementation of a plan of care that meets the patient's rehabilitation needs and goals.

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

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

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

3) the agency failed to follow current clinical practice guidelines, and agency policy and procedure.