Pediatric Nursing Specialists of Indiana

The agency failed to ensure it provided Skilled Nursing and/or one other therapeutic service in 1 of 1 agency.

The agency's Emergency Program failed to evidence testing and training as part of their plan, in 1 of 1 Emergency Preparedness program reviewed.

The agency failed to participate in a full-scale exercise that is community-based or conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise in 1 of 1 Emergency Preparedness program reviewed.

The agency failed to ensure the frequency and detail of the data collection in the development of the QAPI program was approved by the agency's governing body in 1 of 1 agency.

The agency failed to ensure Performance Improvements Projects (PIPS) were documented, why they were conducting these projects, and measurable progress with each project in 1 of 1 agency.

The agency failed to have a Governing Body assume full legal authority and responsibility for the agency's overall management and operation, including its quality assessment and performance improvement program.

The Clinical Manager and the Alternate Clinical Manager failed to ensure one was available upon surveyors' arrival, failed to ensure they were able to travel within a reasonable distance to the office/and or field, failed to ensure they had a schedule of when they would be at this location on a…

The agency failed to establish a system to measure and track performance to ensure improvements were sustained.

The Administrator failed to ensure they were available, able to respond to emergencies within a reasonable amount of time, failed to ensure they had a schedule of when they would be at this location on a frequent and consistent basis, and responsible for the day-to-day operations of the home health…

The agency failed to ensure the presumed Alternate Administrator had a schedule of when they would be at this location on a frequent and consistent basis and failed to ensure a qualified Alternate Administrator was appointed to assume the same responsibilities and obligations as the Administrator…

The agency failed to ensure 2 of 2 service contracts under arrangement were able to provide therapy services that cover the entire state of Indiana.

The governing body failed to ensure failed to ensure patients were receiving appropriate home health services (registered nurse not performing in-person comprehensive assessments) (G0942), the acting Administrator failed to be responsible for day to day operations of the agency (G0948), and failed…

The agency failed to ensure comprehensive assessments were conducted in person by a skilled registered nurse and included skilled hands-on physical assessment, and instead utilized telehealth for recertification assessments and resumption of care assessments in 1 of 4 clinical records reviewed…

The agency failed to ensure the content of the comprehensive accurately reflected the patient's status in 1 of 4 clinical record reviews.

The Governing Body failed to assume full responsibility for the agency's overall management and operations related to the provision of skilled nursing services by the registered nurse, in relation to performing comprehensive assessments and supervisory visits via telehealth for 1 of 1 Governing…

The agency failed to discharge patients when the agency could no longer provide physician ordered services in 1 of 4 active clinical records reviewed.

The agency failed to ensure an accurate and complete assessment was completed to reflect the patient's current health status in 1 of 2 records reviewed.

The agency failed to ensure patient-specific interventions were identified in the care plans of 4 of 4 clinical records reviewed.

The agency failed to ensure the ordering physicians for patients were notified of recertification and resumption of care assessments were being performed via telehealth with staff or a family member in 1 of 4 active clinical records review.

The agency failed to ensure skilled nursing supervisory visits identified the nurse being supervised in 1 of 4 active clinical record reviews.

The agency failed to ensure the Administrator or their alternate was responsible for the day to day operation of the agency; failed to ensure staff were available during operating hours and for survey activities, failed to ensure comprehensive assessment visits were performed by a registered nurse…

The agency failed to ensure an Administrator or alternate was in place, available during operating hours, and available for survey activities, in 1 of 1 home health agencies surveyed.

The agency failed to ensure all services in the plan of care were met, with the potential to affect all patients (See G572); failed to ensure all orders were record in the plan of care to ensure staff were working from a current plan of care (See G576); failed to review and revise the plan of care…

The agency failed to ensure administrative and supervisory duties such as scheduling, documentation of missed visits, physician notification, and after hour phone calls were not delegated to a contracted Entity or another agency (See G940); the governing body failed to ensure the Administrator and…

The agency failed to adequately prepare and describe a plan for a surge in Covid-19 among administrative personnel that assume responsibility for two separate licensed agencies during a pandemic for Pediatric Nursing Specialists of Indiana and failed to ensure all employees participated in a…

The agency failed to ensure all services in the plan of care were met for 5 of 7 record reviews, with the potential to affect all patients.

The agency failed to review and revise the plan of care to ensure staff were working from a current plan of care for 3 of 3 home visit observations with the potential to affect all patients.

The agency failed to ensure unvaccinated staff exposed to Covid-19 were allowed to quarantine for 1 of 2 administrative staff.

The agency failed to ensure management information for Pediatric Nursing Specialist of Evansville was disclosed to the state agency for 1 of 1 home health agency.

The agency failed to disclose to the state agency any change in management for the Pediatric Nursing Specialty of Evansville for 1 of 1 home health agency.

The governing body failed to ensure the Administrator and Alternate Administrator were adequately trained, participated in the survey, and able to manage the day-to-day operations for 1 of 1 home health agency.

The Administrator failed to demonstrate distinct boundaries of the Medicaid certified program in relation to any other programs the larger organization has to offer for 1 of 1 home health agency.

The agency failed to offer and provide one other therapeutic service such as physical or occupational therapy, speech-language therapy, medical social services, or home health aide available on a visiting basis in the patient’s home for 4 of 4 interviews.

The facility failed to ensure clinical records were appropriately authenticated, dated, and timed for 5 of 7 records reviewed (Patient 2,3,5,6,7); and failed to update policies that accurately reflect services the agency provides for 1 of 1 admission policy reviewed.

The Governing Body and Administrator failed to appoint a qualified Alternate Administrator to act in the Administrator's absence for 1 of 1 home health agency.

The agency failed to ensure patient/caregivers had current written contact information for the agency administrator to receive complaints for 2 of 5 caregiver interviews.

The agency failed to contact patient caregivers to offer or provide agency therapy services such as physical or occupational therapy and speech-language therapy on a visiting basis in the patient’s home since 2019 for 4 of 4 caregiver interviews.

The agency failed to ensure patients received all services outlined in the plan of care for 5 of 7 record reviews, with the potential to affect all patients.

The agency failed to ensure the medication review addressed compliance, response to drug therapy, adverse drug reactions, duplicate medications, side effects, and drug interactions for 7 of 7 records reviewed with the potential to affect all patients.

The agency failed to ensure all orders were recorded in the plan of care to ensure staff were working from a current plan of care for 3 of 3 home visit observations with the potential to affect all patients.

The agency failed to provide a written schedule that included visit frequency for 3 of 3 home visits with the potential to affect all active patients.

The agency failed to ensure patients or caregivers were provided with a written copy of the patient medication schedule and instructions that includes medication name, dosage, and frequency and which medications will be administered by agency personnel and persons acting on behalf of the agency for…

The agency failed to ensure pertinent instructions specific to patient care needs for 3 of 7 records reviewed.

The agency failed to disclose to the state agency any officer, director, agent, or managing employee specific to Pediatric Nursing Specialist of Evansville for 1 of 1 home health agency.

The agency failed to disclose to the state agency the name and address of any person that was responsible for the management specific to Pediatric Nursing Specialist of Evansville for 1 of 1 home health agency.

The agency failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries for 1 of 1 home health agency.

The administrator failed to provide overall direction and leadership of agency services, failed to ensure the agency met all rules and regulations for recertification, and failed ensure the responsibility for all day-to-day operations for 1 of 1 home health agency.

The agency failed to ensure a person authorized by the governing body was able to assume the administrator role and was available during an emergency pandemic for Pediatric Nursing Specialist of Evansville for 1 of 1 home health agency.

The agency failed to ensure there was a contract with the agent acting on behalf of the Pediatric Nursing Specialist of Indiana to ensure the confidentiality of all patient identifiable information contained in the clinical record and OASIS data, and also that the patient-identifiable OASIS…

The agency failed to perform patient's initial assessment for home care within 48 (forty eight) hours of referral (See G 514); failed to ensure they followed their policy and obtained a past medical history upon referral/ admission to the agency in order to have a full understanding and knowledge…

The agency failed to ensure administrative and supervisory duties such as scheduling, documentation of missed visits, Quality Assurance Performance Improvement (QAPI) were not delegated to another agency and failed to ensure its organizational structure and lines of authority did not include…

The agency failed to conduct an annual evaluation with updates for the emergency preparedness program for 1 of 1 agency.

The agency failed to ensure policies and procedures were in place regarding the use of volunteers or emergency staff that would be available during an emergency for 1 of 1 agencies.

The agency failed to ensure that all employees participated in the table top exercise to test their emergency plan for 1 of 1 agency.

The agency failed to ensure Outcome Assessment and Information Set (OASIS) data were submitted within 30 days of collection for 2 of 2 clinical records reviewed of patients who qualified for OASIS data collection.

The agency failed to ensure their QAPI (Quality Assessment Performance Improvement) program measured, analyzed, and tracked an incident that resulted in an emergency room visit within the agency's QAPI program and failed to evidence complaints were tracked for 1 of 1 agency.

The agency failed to ensure Indiana State Department of Health (ISDH) received information regarding changes in management for 1 of 1 agency.

The agency failed to ensure one other therapeutic service besides skilled nursing was available under arrangement for 1 of 1 agency.

The facility failed to ensure clinical record documents were completed by the visiting clinician for 2 of 7 records (# 2, 4) and appropriately authenticated, dated, and timed for 4 of 7 records reviewed.

The agency failed to ensure patient rights were adhered to and received care as ordered by the physician for 3 of 7 clinical records reviewed.

The agency failed to perform patient's initial assessment for home care within 48 (forty-eight) hours of referral for 2 of 6 patients reviewed for referrals.

The agency failed to ensure they followed their policy and obtained a past medical history upon referral/ admission to the agency in order to have a full understanding and knowledge of a patient's past and current health, psychosocial, functional, and cognitive status when completing a…

The agency failed to follow their policy to ensure recertifications were completed within the last 5 (five) days of every 60 (sixty) day window for 2 of 7 records reviewed.

The agency failed to ensure the discharge assessment document was completed in its entirety for 1 of 1 patient records reviewed for discharge.

The agency failed to ensure the plan of care was revised to reflect verbal orders received during the certification period for 2 of 7 clinical records reviewed.

The agency failed to effectively integrate and coordinate the care provided by an outside agency to assure patients needs were met for 2 of 2 patients with therapy services.

The agency failed to ensure a written schedule was provided to the patient in 1 of 3 home visits.

The agency failed to ensure nursing visits were provided as ordered by the physician in the plan of care for 3 of 7 records reviewed.

The agency failed to ensure the Administrator and Alternate Administrator were adequately trained, participated in the survey, and able to manage the day to day operations for 1 of 1 agency.

The agency failed to ensure the agency policy was followed for incorporating clinical documentation into the clinical record in a timely manner and documents were not created after inquiry for 2 of 7 records reviewed.

The facility failed to complete a discharge summary in its entirety and be sent to the physician and transferring agency within 2 business days of a transfer for 1 of 1 patient records reviewed for discharge.