Indiana Home Care Plus

The agency failed to evidence the comprehensive assessments were complete and accurately reflected the patient's status, including current health, psychosocial, functional, and cognitive status to ensure the patients needs are being met (See G528); failed to ensure comprehensive assessments…

The agency failed to ensure patients received all care and services according to the written plan of care and that they were not placed on hold due to COVID-19 exposure, positive COVID-19 test in 4 out of 5 interviews conducted (Patients #9, 14, 23, 24), failed to ensure services were not placed on…

The agency failed to develop and maintain documented evidence of a Quality Assessment and Performance Improvement (QAPI) program that involved all agency services; failed to identify, measure, analyze, and track improvement indicators; failed to address the frequency with which measurement and…

The Immediate Jeopardy was not abated by the end of the exit conference on 3/22/2021 at 4:15 PM.

The Case Manager failed to ensure the aide care plan was individualized with patient specific instructions of all duties to be performed (See G798); failed to ensure they provided home health aide services to provide personal care services and not be assigned to a homemaker and failed to ensure all…

The Administrator failed ensure they were responsible for all day to day operations of the parent and branch home health agency in regards to infection control; careplanning, coordination, quality of care; comprehensive assessments; complaints/ grievances; QAPI (quality assessment performance…

The agency failed to ensure they adhere to professional documentation standards; failed to ensure documentation in the patients record were accurate for 3 (Patient #25, 29, 30) out of 3 interviews and focused clinical records reviewed and 1 (Patient #1) out of 1 recertification home visit observed…

The agency failed to ensure all Outcome and Assessment Information Set (OASIS) questions were answered accurately in 5 out 7 records reviewed.

The agency failed to ensure nursing and personal care services were provided according to the written plan of care for 7 of 7 complete records reviewed.

The alternate clinical manager failed to ensure she practiced proper hand hygiene while providing wound care to a patient for 1 of 1 patient's observed receiving wound care services by the agency.

The Case Manager failed to ensure the aide care plan was individualized with patient specific instructions of all duties to be performed for 1 (Patients #1) out of 3 active records reviewed of patient's receiving home health aide only services Findings Include: 1. A review of an agency policy…

The agency failed to ensure patients were informed of changes in care to be furnished in relation to being discharged for 3 out of 3 interviews conducted.

The agency failed to ensure they documented their efforts in describing how complaints were investigated, ensuring no other patients are being affected by the lack of care being provided by staff members for 3 out of 8 complaints reviewed about the lack of care being provided.

The agency failed to ensure they documented the resolution for all complaints 5 of 8 grievances reviewed about the lack of care being provided.

The agency failed to evidence the comprehensive assessments were complete and accurately reflected the patient's status, including current health, psychosocial, functional, and cognitive status to ensure the patients needs are being met in 6 of 9 complete records reviewed.

The agency failed to ensure comprehensive assessments contained patient goals, strengths, and care preferences for 7 of 7 active records reviewed.

The agency failed to ensure the medication list included indications for all PRN/ as needed medications and failed to evidence the location of application of topical medications was correct in 2 out of 7 active records reviewed.

The agency failed to ensure the individualized plan of care was supported by the comprehensive assessment and included all interventions and measurable goals identified by the agency and patient, all durable medical equipment (DME) and supplies, all treatment orders, diet, safety measures…

The agency failed to ensure they had a system in place to accurately reflect outstanding orders in need of signature; failed to ensure their physician order policy specified a time frame of when physician orders must be returned with the date and signature of the ordering physician; failed to…

The agency failed to promptly alert the physician of changes in patient conditions in 6 of 9 complete records reviewed.

The agency failed to ensure they communicated with all physicians involved in the patient's plan of care and documented those efforts within the patients' clinical record for 6 of 6 random sample of focused records reviewed of patients who were to be discharged due to unsigned verbal orders.

The agency failed to coordinate care and delivery with wound care, dialysis, cardiac, and infusion centers to meet the patient's needs in 4 of 4 complete clinical records reviewed of patients receiving outside services.

The skilled nurses failed to appropriately assess patients temperatures, skin impairments, and renal access in 4 (Patients #1, 3, 12, 19) out of 4 active records reviewed of receiving skilled nursing services and failed to ensure all clinicians assess vital signs and pain assessments at each visit…

The agency failed to ensure they provided home health aide services as ordered on the plan of care for 3 (Patients #1, 2, 8) out of 3 active records reviewed of patients receiving home health aide services only.

The agency failed to ensure all home health aides provided hands on personal care as ordered in the plan of care for 2 of 5 records reviewed of patients who were to receive personal care services.

The Administrator failed ensure they were responsible for all day to day operations of the parent and branch home health agency in regards to infection control; care planning, coordination, quality of care; comprehensive assessments; complaints/ grievances; QAPI (quality assessment performance…

The Administrator failed to ensure that a qualified, pre-designated person could act in the absence of the administrator/ clinical manager to assume the same responsibilities and obligations, was knowledgeable to their job title and duties and responsibilities, knowledgeable to the titles and…

The Administrator (also the Clinical Manager) failed to ensure the coordination care and delivery with wound care, dialysis, cardiac, and infusion centers to meet the patient's needs in 4 of 4 complete clinical records reviewed of patients receiving outside services.

The Clinical Manager (also the Administrator) and Alternate Clinical Manager failed to ensure initial and recertification comprehensive assessments were complete and accurately reflected the patient's status, in order to ensure patient needs are completely met in 6 out of 9 complete records…

The Clinical Manager (also the Administrator) failed to ensure patients received all care and services according to the written plan of care and that they were not placed on hold due to COVID-19 exposure, positive COVID-19 test in 4 out of 5 interviews conducted (Patients #9, 14, 23, 24), failed to…

The Clinical Manager (also the Administrator) and Alternate Clinical Manager failed to ensure all nurses appropriately and accurately assess patients according to professional standards for 6 of 9 complete records reviewed.

The agency failed to ensure the comprehensive assessment was updated to include wound assessments and goals in 1 of 2 samples of wounds of 10 records reviewed.

The agency failed to ensure the comprehensive assessment contained descriptions of a patient's wounds and a description of the surrounding tissue of the wounds in 1 of records reviewed of patients with wounds in a sample of 10 records.

The agency failed to ensure the comprehensive assessment contained patient goals or to provide measurable outcomes in of records reviewed.

The agency failed to ensure the plan of care included patient-specific interventions/ treatment orders, measurable outcomes, and education or training to expedite a timely discharge in 3 of 10 records reviewed.

The agency failed to ensure all wound care orders were included on the plan of care in 1 of 2 wound care samples of 10 records reviewed.

The agency failed to ensure the physician was notified of fluctuating blood glucose levels that required the need for parameters on the plan of care in 1 of 10 records reviewed.

The agency failed to ensure the Registered Nurse modified the plan of care to include information in the updated comprehensive assessment in 1 of 10 records reviewed (#4)and failed to ensure the plan of care was modified to include blood glucose parameters in 1 of 2 samples of patients with…

The clinical manager failed to ensure the patient's wounds were consistently assessed in 1 of 2 samples of patients with wounds of 10 records reviewed.

The skilled nurse failed to ensure the physician was notified in order to set parameters for fluctuating blood glucose levels in 1 of 10 records reviewed.

The clinical manager failed to ensure the plans of care was updated in 3 of 10 records reviewed.

The agency failed to develop a policy for wound care in 1 of 1 agency with 1 of 1 branches.

The agency failed to ensure clinical records included goals or measurable outcomes in the plan of care in 3 of 10 records reviewed.