At Home Quality Care

Failed to ensure it maintained an agency specific comprehensive emergency preparedness program, which included an emergency plan, policies and procedures, communication plan, or testing and training program; failed to evidence the program was reviewed and/or updated as often as necessary, but at…

The agency failed to ensure all patients received an OASIS (Outcome and Assessment Information Set) privacy notice for all patients for whom the OASIS data was collected, prior to furnishing care/services (See G416); failed to ensure all patients received the agency’s information on how to make a…

The immediate jeopardy remained unabated upon the survey exit on 12/15/2021, due to an additional record review with a home visit observation that was completed on 12/17/2021, for a newly admitted patient (#11), start of care 12/7/2021, primary diagnosis unstageable pressure ulcer of sacral (lower…

The home health agency (HHA) failed to develop and implement an effective discharge planning process for the agency; failed to develop/maintain discharge/transfer summary policies which included discharge/transfer summary content, and procedure(s) to ensure the agency provided the receiving…

This record review and home visit failed to evidence effective care coordination between agency, FNP(family nurse practitioner) C and ALF (assisted living facility) K to meet the patient’s needs; failed to evidence the patient’s plan of care was accurate, individualized, included patient-specific…

The home health agency failed to evidence it implemented, evaluated, and maintained an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement (QAPI) program that concentrated on infection control issues and adverse events (See tag G642); failed to evidence it…

The agency failed to ensure all agency employees provided quality health care services in a safe environment for its patients, which resulted in the citing of an immediate jeopardy (IJ) on 12/06/2021 (See G510, G570); ensured the patients’ rights were upheld (See G406); ensured an effective…

The patient’s clinical record failed to include all physician orders (See G1012); failed to document the patient’s response(s) to interventions provided, and/or failed to document the date and/or time, or name of physician or representative spoken to, when a physician was contacted for orders…

The agency failed to ensure all patients received the agency’s discharge policy.

The home health agency failed to ensure the registered nurse (RN) assesses or reassessed 8 of 8 patients who experienced and/or were reported to have a change in condition which resulted in new and/or worsening symptoms, new and/or worsening wounds, wound infection(s), aspiration pneumonia…

The home health agency failed to develop and implement an effective discharge planning process for the agency.

The home health agency failed to ensure it sent discharge summaries with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, and/or discharge orders for 1 of 1 records reviewed with…

The agency failed to ensure all patients received the home health services that were written in the plan of care, and/or ensured the patient’s plan of care was individualized for 11 of 11 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11).

The home health agency failed to implement, evaluate, and maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement (QAPI) program that concentrated on infection control issues and adverse events.

The agency failed to evidence it collected and utilized agency specific data to monitor the effectiveness and safety of services and quality of care provided by the agency, identify opportunities for improvement, or the agency’s governing body approved the frequency and detail of the data…

The agency failed to evidence it conducted and documented performance improvement projects (PIPs) for the agency’s quality assessment performance improvement (QAPI) program.

The agency failed to ensure the governing body ensured the agency’s QAPI program was developed, implemented, and maintained.

The governing body failed to ensure the agency’s operational policies were revised and implemented; ensured all agency personnel had access to agency policies at all times; ensured the responsibilities of the governing body, administrator, and clinical manager were not delegated to another…

The agency failed to ensure all clinical documents were complete, appropriately authenticated, dated, and timed; and/or authentication included a secured computer entry of the primary author who reviewed and approved the entry for 9 of 11 records reviewed (#1, 2, 3, 5, 6, 7, 9, 10, 11).

The agency failed to ensure all patients received an OASIS (Outcome and Assessment Information Set) privacy notice for all agency patients for whom the OASIS data was collected, prior to furnishing care/services.

The agency failed to ensure all agency patients received the agency’s information on how to make a complaint.

The agency failed to ensure all patients and/or family/caregivers were informed about and participated in deciding what services/care was furnished based on the comprehensive assessment, and/or the frequency of visits for 11 of 11 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11).

The agency failed to ensure all agency patients were advised of the Indiana Department of Health’s (IDOH) toll free home health hotline telephone number, contact information, or hours of operation.

The agency failed to ensure all agency patients received the name, address, and telephone number of the current federally funded Quality Improvement Organization (QIO) prior to furnishing care/services.

The agency failed to ensure all patients received information on auxiliary aids and language services, or how to access these services.

The physical therapist (PT) failed to ensure the comprehensive assessment was completed within 5 calendar days after the start of care for 1 of 2 records reviewed when therapy was the only service(s) provided (#3).

The registered nurse (RN) and/or physical therapist (PT) failed to ensure the patient’s comprehensive assessment included the patient’s current health, psychosocial, and/or cognitive status for 11 of 11 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11).

The registered nurse and/or physical therapist failed to ensure the patient’s comprehensive assessment included the patient and/or caregiver’s personal goals, care preferences, and/or included information to demonstrate the patient's progress toward goals for 11 of 11 records reviewed (#1, 2, 3, 4…

The registered nurse failed to ensure the patient’s comprehensive assessment included patient specific discharge planning needs for 11 of 11 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11).

The registered nurse (RN) failed to perform a drug regimen review (DRR), and/or identified any major drug reactions for 8 of 10 records reviewed for patients with medications (#1, 2, 3, 4, 5, 6, 7, 11 ).

The registered nurse (RN) and/or physical therapist (PT) failed to ensure the comprehensive assessment included the patient’s primary caregiver’s (and/or other available supports) willingness, ability to provide care, and/or their availability for 11 of 11 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8…

The registered nurse (RN) failed to conduct a comprehensive assessment visit within 48 hours of a hospital discharge for 1 of 2 records reviewed for a patient who was hospitalized as an inpatient for 24 hours or more (#2).

The agency failed to ensure the patient’s plan of care included all pertinent diagnoses, the patient’s psychosocial, and/or cognitive status, supplies and equipment needed, prognosis, functional limitations, activities permitted, nutritional requirements, all medications and/or treatments, safety…

The home health agency failed to ensure the clinician promptly notified the patient’s physician or family nurse practitioner (FNP) for 6 of 7 records reviewed with patients who experienced a significant change in physical and/or psychosocial condition which required medical intervention(s) (#1, 2…

The agency failed to ensure all patients received written information of the name and contact information of the clinical manager for 6 of 6 home visits observed (#1, 2, 4, 6, 7, 11).

The agency failed to evidence it focused on high risk, high volume, or problem-prone areas for the agency’s quality assessment performance improvement (QAPI) program.

The agency failed to address the prevalence of wounds for the agency’s quality assessment performance improvement (QAPI) program.

The agency failed to evidence it implemented immediate corrective action(s) for new/worsening wounds or hospitalization/re-hospitalizations that directly or potentially threatened the health and/or safety of patients in the agency’s quality assessment performance improvement (QAPI) program.

The agency failed to evidence it implemented any actions aimed at performance improvement for the agency’s quality assessment performance improvement (QAPI) program.

The agency failed to ensure the administrator reported to the governing body.

The administrator failed to be responsible for the day-to-day functions of the agency.

The home health agency failed to ensure the registered nurse contacted the patient’s physician(s) to verify and/or obtain order(s) for medications a family reported he/she administered to the patient, instructed a family member to administer medication(s) to the patient without first verifying…

The patient’s clinical record failed to include physician orders for 5 of 11 records reviewed (#1, 2, 3, 4, 5).

The skilled nurse (SN) failed document the patient’s response(s) to interventions provided; and/or failed to document the date and/or time, or name of physician or representative spoken to, when a physician was contacted for orders and/or order requests, for 9 of 11 records reviewed (#1, 2, 5, 6…

The agency failed to ensure the plan of care was individualized and specific to the patients' needs for 2 of 2 active records reviewed (#1 and #2) of patients with wounds observed at skilled nursing visits (Employee B, RN, and Employee E, LPN).

The agency failed to ensure coordination of care activities occurred and were documented for 1 (Patients #1) of 1 incenter hemodialysis patient with bilateral heel wounds and need for fluid restriction.