Willcare Chha (Buffalo)

This condition was not met as evidenced by: Failure to obtain the patient’s or legal representative’s signature confirming that they have received a copy of the notice of rights and responsibilities.

This condition was not met as evidenced by: Failure of the Registered Nurse to conduct an initial assessment within 48 (forty-eight) hours of referral, within 48 (forty-eight) hours of the patient's return home, or on the physician-ordered start of care date.

This condition was not met as evidenced by: Failure to develop comprehensive plans of care addressing each patient's individual needs.

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 within thirty (30) days of completion.

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

Staff interview for two (2) of seventeen (17) patients (Patient #8 and 14) 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 ensure clinicians follow accepted standards of infection control practices.

The agency failed to provide infection control education to the patient and caregiver.

The agency failed to obtain either the patient's or the patient's legal representative's signature confirming the patient received a copy of the patient rights and responsibilities at start of care (SOC).

Staff interview for one (1) of seventeen (17) patients (Patient #8) the agency failed to ensure the patient maintained the right to participate in all decisions regarding the provision of care.

Agency staff for two (2) of seventeen (17) patients (Patient #'s 8 and 11) the agency failed to ensure that patients are informed, before care is initiated, of their potential financial liability for services provided.

The agency failed to ensure the patient achieved the outcomes and goals in the plan of care and that the physician agreed to the patient’s discharge.

The agency failed to ensure the Registered Nurse (RN) completed 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 the initial comprehensive assessment was of sufficient scope to identify patient needs.

The Registered Nurse stated there was a phone call to the physician's office regarding the medications but failed to document the conversation in the record.

The agency failed to ensure the comprehensive assessment included information regarding the patient’s representative.

The agency failed to document a complete agency discharge summary, discipline discharge (Outcome and Assessment Information Set discharge assessment), and failed to communicate the discharge from services and the agency with the physician, and all other disciplines involved in the plan of care.

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

13) the agency failed to ensure that all physician orders were included in the Plan of Care.

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

The agency failed to ensure the plan of care (POC) is reviewed and revised by the physician who is responsible for the plan of care and the agency as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days.

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 clinicians communicate with all physicians involved in the patient's care.

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

The agency failed to ensure the patient/caregiver receives appropriate education and training regarding the care and services identified in the plan of care.

17) the agency failed to prepare and document complete and accurate clinical notes.

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

This citation was corrected.

The agency failed to provide service 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.

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

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 assessments were of sufficient scope to identify 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 the Plan of Care (POC) is reviewed and revised to reflect the patient's current status.

The agency failed to ensure written patient care instructions prepared by a skilled professional were made available in the patient's home.

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.

17) 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 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 prepare and document complete and accurate clinical notes.

The agency failed to ensure adequate supervision of the Licensed Practical Nurse (LPN) staff in one (1) out of four (4) records of patients receiving care by the LPN (Patient # 9).

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

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) was reviewed and revised to reflect the patient's current status.

The agency failed to ensure written patient care instructions prepared by a skilled professional were made available in the patient's home.

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

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

The agency failed to ensure there is ongoing interdisciplinary assessments and communication for patients receiving nursing and rehabilitation services.

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

The agency failed to ensure there was communication with the physician involved in the plan of care (POC).

The agency failed to ensure the Home Health Aide (HHA) provides services as directed on the Aide Plan of Care (POC).

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

14 and 15) the agency staff failed to follow accepted professional standards and agency policies when providing services.