Canary Home Healthcare of Indiana Inc
Inspection 2026-04-09
· Recertification · 35 deficiencies · CMS source report (PDF)The home health agency failed to evidence a comprehensive plan that was updated every two years (see Tag E0004); failed to update delegations of authority and succession plans (see Tag E0007); failed to include a process for cooperation and collaboration with local, state and federal emergency…
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The agency failed to ensure services were provided as directed in the POC (see tag G0572); failed to ensure the POC included all medical equipment, patient-specific interventions, and measurable goals (see tag G0574); failed to ensure services were provided only as ordered by a physician (see tag…
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The agency failed to ensure: the quality assessment and performance improvement (QAPI) program was capable of showing measurable improvement in indicators affecting health outcomes, patient safety, and quality of care (G0642); the program utilized quality indicator data to include measures from…
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The agency failed to: follow standards of practice, including the use of standard precautions, to prevent the transmission of infections (See tag G0682); maintain program for the surveillance, prevention, control, and investigation of infections (See tag G0684); and follow agency policy to provide…
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The home health agency failed to ensure: the home health aide provide services that were included in the plan of care (see tag G0800); the RN completed a supervisory assessment of HHA services every 14 days (see tag G0808); and the home health aide supervision ensured the care provided followed the…
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The agency failed to evidence a comprehensive plan that was updated every two years in 1 of 1 agency.
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The agency failed to update delegations of authority and succession plans for emergency preparedness in 1 of 1 agency.
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The agency failed to include a process for cooperation and collaboration with local, state and federal emergency preparedness officials that included documented attempts to contact officials in an effort of collaboration and cooperative planning at least every two years in 1 of 1 agency.
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The agency failed to update the emergency preparedness communication plan in 1 of 1 agency.
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The agency failed to update name and contact information for local emergency preparedness staff in 1 of 1 agency.
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The agency failed to provide emergency preparedness training to staff at least every two years in 1 of 1 agency.
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The agency failed to update the comprehensive assessment with changes in the patient’s condition in 1 of 1 active clinical record reviewed with an onset of a new wound after the SOC in a total sample.
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The agency failed to implement its transfer/discharge policy in 1 of 2 closed clinical records reviewed.
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The agency failed to send all necessary information pertaining to patient’s current course of illness and post-discharge goals of care to the practitioner (or receiving facility) upon discharge within 48 hours of notification of transfer in 2 of 2 closed clinical records reviewed.
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The agency failed to ensure services were provided as directed in the POC in 2 of 5 active clinical records reviewed.
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The agency failed to follow standards of practice including the use of environmental cleaning and disinfection to prevent the transmission of infections and communicable diseases in 2 of 2 home visit observations with a RN.
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The agency failed to ensure a program was developed for the surveillance, identification, prevention, and control of infectious and communicable diseases specific to care and services provided in the home setting and was included in the agency’s Quality Assurance and Performance Improvement (QAPI)…
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The agency failed to provide infection control education to staff annually per its policy in 3 of 3 personnel records reviewed of licensed personnel that have been hired for greater than 1 year (CM, RN 1, PT 3) and failed to provide infection control education at time of hire in 1 of 2 personnel…
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The agency failed to ensure clinical records were accurate in 1 of 3 active clinical records reviewed with an infection.
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The agency failed to complete the comprehensive assessment in a timely manner in 1 of 2 clinical record reviews of new admission patients.
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The agency failed to ensure the comprehensive assessment included the physical, mental, and psychosocial status in 2 of 3 active clinical records reviewed with a wound present at time of the comprehensive assessment.
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The agency failed to ensure the comprehensive assessment included the need for nursing services in 1 of 2 active clinical records reviewed with a feeding tube.
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The agency failed to ensure the comprehensive assessment included a reconciliation of medications in 3 of 5 active clinical records reviewed.
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The agency failed to ensure the POC included all medical equipment, patient-specific interventions, and measurable goals in 4 of 7 clinical records reviewed.
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The agency failed to ensure services were provided only as ordered by a physician in 4 of 5 active clinical records reviewed.
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The agency failed to ensure physician’s verbal orders were documented in the clinical record per agency policy and signed and dated by the physician in 1 of 1 clinical record with a change in attending physicians.
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The agency failed to notify the physician with changes in patient’s condition or needs that suggest the POC should be altered in 5 of 8 clinical records reviewed.
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The agency failed to update the POC with changes as needed in 1 of 2 home visits with a RN.
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The agency failed to ensure care was coordinated with all disciplines providing care in 1 of 2 active clinical records reviewed with PT services (Patient #4) and in 1 of 2 closed clinical record reviewed.
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The agency failed to ensure the SN provided services ordered by the provider as indicated in the plan of care in 1 of 4 active clinical record reviews of patients who had received services for greater than 60 days.
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A clinical record review for Patient #8 evidenced the following: A comprehensive assessment dated 02/11/2026, that indicated that Patient #8 uses a nasal cannula for oxygen administration and did not indicate an assessed need for occupational therapy.A SN visit note, dated 02/17/2026, indicated…
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The agency failed to ensure the HHA provided the tasks as directed in the POC in 3 of 4 active clinical records reviewed with HHA services.
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The agency failed to ensure the RN completed a supervisory assessment of HHA services every 14 days in 3 of 4 active clinical records reviewed with HHA and skilled services.
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The agency failed to ensure the HHA was supervised to ensure the aides furnished care that followed the patient’s plan of care in 3 of 4 active clinical records reviewed with HHA services.
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The agency failed to coordinate patient care with other agencies servicing patients in 1 of 2 clinical record reviews of active patients on service less than 60 days.
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Inspection 2023-08-03
· Initial Certification · 25 deficiencies · CMS source report (PDF)The agency failed to ensure they developed and implemented an individualized comprehensive emergency preparedness plan to include hazard vulnerability assessment, employee contact information, collaboration with local officials, employee training, and arrangements made with other agencies to ensure…
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The agency failed to develop and implement individualized emergency preparedness plans for the patients which provided appropriate instructions, in the event of an emergency in 3 of 3 home visits conducted.
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The agency failed to update the comprehensive assessment in 1 of 1 clinical record reviewed with wounds.
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The agency failed to follow its policy for discharge planning in 1 of 1 clinical record reviewed with a planned discharge.
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The agency failed to ensure the transfer summary contained all necessary medical information pertaining to the patient’s current treatment to the receiving facility in 1 of 1 clinical record reviewed with a transfer to the hospital.
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The agency failed to ensure the plan of care was revised to include all current treatment orders for 2 of 4 active clinical records reviewed.
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The home health agency failed to ensure all employees practiced standard/universal precautions to prevent the transmission of infections and failed to follow agency infection control policies and procedures in 2 of 3 home visits.
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The home health agency failed to ensure all infections were tracked for 1 of 1 clinical record reviewed where an infection was identified.
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The agency failed to ensure the home health aides (HHA) had complete, patient-specific written patient care instructions to be performed by the home health aides in 2 of 4 clinical records reviewed with HHA services.
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The home health agency failed to ensure all patients were informed of changes to services as consented for 1 of 2 active clinical records reviewed with physical therapy services.
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The agency failed to ensure the comprehensive assessment included a review of the patient’s medications to identify any potential adverse effects and drug reactions in 1 of 1 clinical record reviewed with a hospitalization.
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The agency failed to ensure the plan of care was individualized to include medications, interventions, diagnoses, safety precautions and goals in 6 of 6 clinical records reviewed.
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The agency failed to ensure wound care was provided only as ordered by a physician in 1 of 1 clinical record reviewed with a wound.
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The agency failed revise the plan of care and ensure the practitioner responsible for the plan of care reviewed the plan of care as frequently as the patient’s condition required in 1 of 1 clinical record reviewed with a wound.
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The agency failed to ensure coordination of care with all providers servicing the patient in 1 of 1 home visits with a home health aide.
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The home health agency failed to ensure all required information was maintained in the patients home to include a written visit schedule for 3 of 3 home visits conducted (Patient # 1, 4, 5) The findings include: 1. During an observation of care at the home of Patient #1 on 8/2/2023, at 9:59 AM, a…
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The home health agency failed to ensure all required information was maintained in the patients home to include a a medication list with instructions for 3 of 3 home visits conducted (Patient # 1, 4, 5).
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The home health agency failed to ensure all required information was maintained in the patients home to include a plan for treatments provided for 3 of 3 home visits conducted (Patient #1, 4, 5).
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The home health agency failed to ensure all required information was maintained in the patients home to include the name of the clinical manager for 3 of 3 home visits conducted (Patient #1, 4, 5).
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The skilled professional failed to provide the services as directed in the plan of care in 5 of 6 clinical records reviewed.
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The skilled nurse failed to provide patient education in 2 of 5 clinical records reviewed with high risk medications.
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The skilled nurse failed to accurately prepare clinical notes in 4 of 6 clinical records reviewed.
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The agency failed to ensure the home health aide (HHA) provided services as directed in the aide care plan in 4 of 4 clinical records reviewed with HHA services.
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The agency failed to ensure the home health aide (HHA) was supervised to ensure the aide furnished care that followed the patient’s plan of care in 3 of 4 clinical records reviewed with home health aide services.
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The agency failed to ensure the clinical record contained all required clinical notes in 1 of 1 clinical record reviewed with more than 1 certification period.
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