Home Sweet Home Health Care LLC

The agency failed to ensure clinical documentation included an electronic signature and date for 1 of 4 active patients with aide-only services (Patient #4). 410 IAC 17-15-1(a)(7) 1. An undated agency policy titled “Clinical Documentation Summary” indicated “Clinical documentation must be: Accurate…

The agency failed to ensure patients were provided with the hours of operation to place a complaint with the department of health for 3 of 4 home visit observations (Patients # 1, 2, and 4). 410 IAC 17-12-3(b)(2)(C) 1. A review of the agency patient admission handbook failed to evidence the hours…

The home health agency failed to ensure medications were accurately assessed for 1 of 2 unskilled home visit observation patients (Patient #3).

The home health agency failed to ensure all medical equipment the patient used in the home was included in the POC for 1 of 2 unskilled home observation patients (Patient #3).

The agency failed to update a plan of care that was consistent with assessment findings for 1 of 1 patient with SN and HHA services who had a home visit observation (Patient #2).

The agency failed to ensure patients were provided with the name and contact information for the Clinical Supervisor for 4 of 4 home visit observations (Patients #1, 2, 3, and 4).

The home health agency failed to ensure HHA supervisory visits were conducted at least every 14 days for 3 of 3 active patients receiving both SN and HHA services (Patient #2, 5, 6).

The agency failed to ensure the RN performed HHA supervisory visit every 60 days for 1 of 4 active patients receiving aide only services (Patient #4).

The registered nurse (RN) failed to ensure the home health aide (HHA) care plan included the frequency for completion of tasks for 1 of 1 records reviewed with skilled nursing and HHA services (Patient #2).

The agency failed to ensure all plans of care included the psychosocial status, nutritional requirements, medications, hospitalization risk, patient and caregiver education, and information related to advanced directives for 5 of 5 active records reviewed (Patient #1, 2, 3, 4, and 5).

The agency failed to ensure home health aide notes were included in the medical record in 1 of 5 active patients receiving home health aide services (Patient #3), with the potential to affect all home health aide patients.

The agency failed to ensure all staff followed standard precautions and infection control for 1 of 1 home visits observed (#4).

The agency failed to ensure office staff followed an infection control plan for the prevention, control, and investigation of office staff infections.

The agency failed to ensure the establishment of skills competency for home health aides (HHA) included evaluation of the home health aide skills while performing required tasks with a patient or pseudo patient for 3 of 3 home health aides whose establishment of skills competency was reviewed.

The agency failed to ensure the home health aide (HHA) followed the plan of care for 1 of 1 home visits observed (#4).

The agency failed to ensure all staff followed infection control policies and practiced standard precautions during a home visit conducted for 1 of 3 patients.

The registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications, to include indications for use in 6 of 8 patient records reviewed.

The agency failed to ensure the plan of care was revised to reflect the most current physician orders for 3 of 8 patient records reviewed.

The agency failed to ensure coordination of care with all agencies delivering care in 2 of 8 patient records reviewed.

The administrator failed to ensure responsibility for day-to-day operations of the agency.

The agency failed to ensure the patient rights included the right to be free from abuse for 1 of 1 admission packet reviewed.

The agency failed to ensure the initial assessment had been completed within 48 hours of referral 4 of seven clinical records reviewed.

The agency failed to ensure a plan of care was kept current and updated with new orders for the certification period for 1 of 7 records reviewed.

The agency failed to ensure the Home Health Aide (HHA) properly documented tasks for 1 of 5 patients receiving HHA services.

The agency failed to complete a discharge summary for 1 of 2 discharge records reviewed.