Home Health Services of Gary Inc

The home health agency failed to send all necessary information pertaining to the patient’s current course of illness and treatment to the receiving facility to ensure the safe and effective transition of care in 2 of 2 patient’s transferred to a hospital (Patient #4, 7).

The home health agency failed to ensure the patient received home health services as ordered per the plan of care in 1 of 4 active clinical records reviewed with a start of care after 07/16/2022 (Patient #2).

The home health agency failed to follow the accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in 1 of 3 patient home visits (Patient #3).

The agency failed to maintain a program for the surveillance, identification, and investigation of infections in 2 of 2 records reviewed of patients that received antibiotics within the past 12 months (Patients #1 and 4).

The agency failed to ensure the comprehensive assessment was complete in 5 of 7 records reviewed (Patient #1, 2, 3, 4, 7).

The home health agency failed to include a review of all of the patient's medications to identify any potential adverse effects and drug reactions, including significant drug interactions in 1 of 4 active clinical records with only a skilled nurse (Patient #3) and 1 of 2 discharged records reviewed…

The home health agency failed to include all medication, treatments and safety measures to protect against injury in 1 of 3 active clinical records with a home visit (Patient #3), and 2 of 2 discharged records reviewed (Patient #6, 7).

The nurse failed to complete clinical notes in 1 of 3 active records reviewed receiving only skilled nursing (Patient #1).

The home health agency failed to have a Registered Nurse (RN) supervise the care provided by the Licensed Practical Nurse (LPN) in 1 of 1 clinical records reviewed with a LPN home visit (Patient #3).

The home health agency failed to ensure the plan of care was developed and individualized, included patient-specific discharge plans and patients received services in the plan of care in 7 of 9 clinical records reviewed.

The home health agency failed to follow accepted standards of practice for infection control in 2 of 3 home visits conducted.

The home health agency failed to maintain a program for identification, prevention, control and investigation of infectious and communicable diseases specific to care and services provided in the home setting.

The agency failed to ensure the registered nurse provided a complete and appropriate care plan for the home health aide [HHA] in 1 of 1 home visits conducted with a home health aide.

The home health agency failed to ensure all clinical record entries are legible, clear, complete, and appropriately authenticated in 7 out of 9 patient records reviewed.

The home health agency failed to retain records for a minimum of 5 years in 1 of 4 discharged records reviewed.

The agency failed to ensure patients were advised of the state toll free home health telephone hotline, its contact information, and that its purpose is to receive complaints or questions about local home health agencies in 1 of 3 home visits conducted.

The home health agency failed to ensure the comprehensive assessment was individualized and reflected the patient's current status in 7 of 9 clinical records reviewed.

The home health agency failed to identify patient centered goals, strengths and care preferences in 2 of 3 discharged clinical records reviewed, out of a total of 9 clinical records reviewed.

The home health agency failed to meet the patient's needs as evidenced in the comprehensive assessment, in 1of 4 discharged clinical records reviewed, out of a total of 9 clinical records reviewed.

The home health agency failed to ensure the correct medications were listed on the plan of care in 2 of 9 clinical records reviewed.

The agency failed to ensure the individualized plan of care included all medications and treatments in 6 of 9 clinical records reviewed.

The home health agency failed to ensure orders were obtained by a physician in 2 of 5 active clinical records reviewed, out of a total of 9 clinical records reviewed.

The home health agency failed to ensure verbal orders were signed by the physician in 1 out of 1 clinical records reviewed with insulin orders.

The agency failed to promptly alert the physician to changes in the needs or conditions of patients in 6 of 9 clinical records reviewed.

The home health agency failed to integrate services to ensure coordination of care provided by all disciplines and outside healthcare entities who serviced their patients in 3 of 6 active clinical records reviewed, out of a total sample of 9 clinical records reviewed.

The agency failed to ensure each patient and his or her caregiver received ongoing education and training in 3 of 3 clinical records of patients who were blind, out of a total sample of 9 records reviewed.

The home health agency failed to ensure their patients received a written visit schedule in 2 of 3 home visits conducted.

The agency failed to ensure patients were provided a current written patient medication list in 2 of 3 home visits conducted (#1, #3) The findings include: 1. Observation of a home visit for patient #1 on 1/13/2021 at 8:00 a.m., failed to evidence a current patient medication list provided by the…

The agency failed to ensure all skilled professional staff were involved in the patient's physical therapy plan of care and the physical therapy plan of care was signed and approved by the primary care physician, in 1 of 2 clinical records reviewed of patients receiving physical therapy, out of a…

The skilled nurse failed to provide services ordered by the physician as indicated in the plan of care in 8 of 9 records reviewed receiving skilled nursing services.(#2, #3, #4, #5, #6, #7, #8, #9) The findings include: 1. Record review on 1/19/2021, evidenced an agency policy titled "Skilled…

The home health agency failed to ensure the skilled nurse prepared the clinical notes accurately and completely in 7 of 9 clinical records reviewed.

The agency failed to ensure the home health aide reported changes in the patient's condition to the supervising nurse in 1 of 3 clinical records reviewed with home visits conducted, out of a total sample of 9 clinical records reviewed.

The agency failed to ensure the supervising registered nurse ensured home health aide care was complete, safe, effective, and followed the patient's plan of care in 1 of 3 clinical records reviewed with a home visit conducted, out of a total sample of 9 clinical records reviewed.

The agency failed to ensure the patient's clinical records evidenced all interventions, treatments, services, and responses to those interventions in 3 of 3 clinical records reviewed of patients receiving wound care, out of a total sample of 9 clinical records reviewed.

The agency failed to ensure services were not provided absent of a plan of care, failed to ensure plans of care were in place and established with the patient's physician for 1 of 6 active records reviewed (#4).

The home health agency failed to follow infection control guidelines in 1 of 1 home visits (#1) observed with a Registered Nurse (#H) with the potential to spread infection from the open wounds to other parts of the patient's leg.

The agency failed to ensure the Registered Nurse completed a Recertification assessment within the last 5 days of a certification period for 1 of 5 clinical records reviewed (#4) with services over 60 days.

The agency failed to ensure a physical therapist completed vital signs at physical therapy visits for 1 of 1 closed record reviewed with physical therapy services (#5).

The home health agency failed to ensure a home health aides only completed tasks allowed under state law during home visits for 1 of 1 home visit observed (patient #2) with a home health aide (Employee # B) and 1 of 1 active records reviewed with home health aide services (patient #2).