Here is an example of a system failure:

The surveyor determined that the agency failed to enforce its client care policy regarding assessments.

• The agency's policy states, "Assessment(s) by additional discipline(s) will be completed as soon as possible, but no later than 72 hours of request for that discipline's services."
• Client #2 had an order for occupational therapy evaluation. Occupational therapy did not attempt to complete an evaluation visit until 20 days after the referral date.
• Client #7 had a physician's order for a medical social worker evaluation. The medical social worker evaluation was not completed until 16 days after the referral date.
• Client #17 had a physician's order for a medical social worker evaluation. The medical social worker evaluation was not completed until thirteen days after the referral date.
• Client #27's plan of care included orders for physical therapy services. The initial physical therapy evaluation visit was completed four days after the referral date.
• Client #36's plan of care included orders for physical therapy services. The initial physical therapy evaluation visit was completed five days after the referral date.
• In an interview, the Director of Nursing (DON) confirmed that each of these evaluation visits was completed outside the timeframes established by policy on the dates indicated in the clinical records. The DON stated, "It's really hard getting those therapists out to see our clients. They have a lot of clients all over town."