Purposecare of Indiana

The agency failed to maintain a comprehensive emergency preparedness program.

The agency failed to ensure the frequency of visits were met according to the POC (G0572) the plans of care were individualized to include all pertinent all equipment and supplies, treatments, and all safety measures and limitations (G0574), all orders were accepted by authorized personnel and…

The agency failed to electronically transmit the completed OASIS assessments to the CMS (Centers for Medicare & Medicaid Services) system within 30 days of completing the patient assessments in 18 of 18 focused clinical records reviewed.

The agency failed to ensure the transfer/discharge summaries were sent to the receiving healthcare providers 1 of 1 active records reviewed transferred to an in-center acute care facility (Patient: #9), and for 2 of 2 inactive records reviewed, patients transferred to a hospice provider.

The agency failed to provide the patient or caregiver with written instructions regarding the home health services to be provided and the plan of care for 2 of 2 patients (Patients: #1 and 3) during home visits conducted, receiving ongoing continued care.

The agency failed to ensure infection control practices were maintained, including hand hygiene, glove changes, and bag technique, for 2 of 4 home visits.

The agency failed to ensure Home Health Aides (HHAs) were assigned and provided appropriate instruction in 2 of 2 active clinical records reviewed for patients receiving HHA services.

The agency failed to ensure a Resumption of care (ROC) assessment had been authenticated and completed for 1 of 1 clinical records reviewed, with a ROC being completed.

The agency failed to ensure the RN completed the initial assessment to determine home care needs within 48 hours of receiving the referral for 1 of 1 SOC observations.

The agency failed to ensure the RN reconciled all medication with the patient, and the ordering physician in 1 of 1 SOC observed.

The agency failed to ensure the POC contained all of the elements, including mental/cognitive status, psychosocial status, safety, seizure plans, nutritional information, DME and Supplies, discipline orders with frequency and duration, for 4 of 8 active clinical records reviewed (Patient #1, 2, 3…

The agency failed to ensure that verbal orders were authenticated in 3 of 5 active clinical records reviewed for patients admitted in the last 3 months.(Patients: #1, 5, and 9) Findings include: 1. A review of an undated agency policy titled “Physician Orders” indicated but is not limited to, “ ……

The agency failed to ensure coordination of care had been completed with other entities providing services for 3 of 4 active clinical records reviewed.

The agency failed to provide the patient and caregiver in writing with a copy of the visit schedule in 2 of 2 home visits conducted with patients receiving ongoing services.

The agency failed to provide the patient or caregiver with a medication schedule and instructions for 2 of 2 patients (Patients: #1 and 3), during home visits conducted, receiving ongoing continued care.

The agency failed to provide the name and contact information for the clinical manager for 2 of 2 home visits conducted with patients with ongoing needs.

The agency failed to ensure nursing services were provided under RN supervision for 4 of 9 active clinical records reviewed.

The agency failed to ensure RN supervisory visits were completed at least every 14 days for 2 of 2 active clinical records reviewed, with patients receiving skilled services and HHA services.

The agency failed to follow its policy to ensure hired staff were qualified to provide services for 1 of 1 agency.

The agency failed to ensure the RN appropriately and accurately assessed patients according to professional standards for 1 of 1 RN home visits completed.

The clinicians failed to follow the plan of care for 1 of 1 home visits receiving skilled services.

The home health aide failed to follow the aide care plan of care for 1 of 2 home health aide home visits.

The agency failed to ensure ordered care visits were provided according to the written plan of care (See G572); failed to ensure the plan of care was created in conjunction with the ordering physician by having failed to obtain verbal orders before furnishing care, resumption of care, and/or…

The agency failed to ensure all clinical record entries were accurate and failed to review the record for compliance with the EVV documentation policy for 1 of 9 (Patients #4) active records reviewed.

The agency failed to ensure care visits for skilled nursing, therapy and aides were provided according to the written plan of care for 1 of 8 active records and 1 of 2 closed records reviewed.

Based record review, observation, and interview, the agency failed to ensure an effective infection control training/education program was provided, and failed to ensure agency staff demonstrated proper infection control practices when providing wound care and/or personal/hygiene care to patients…

The agency failed to ensure they adhered to patient rights and provide all services as outlined on the patient's plan of care in 1 of 7 active records (Patient #4) and 1 of 3 closed records.

The agency failed to ensure the plan of care was created in conjunction with the ordering physician by having failed to obtain verbal orders after the initial comprehensive assessment, at the time of resumption of care, and at recertification in 6 (Patients #2, 4, 6, 7, 8 and 10) out of 10 clinical…

The agency failed to ensure verbal orders were obtained and documented in the clinical and included signature, date, and time the verbal orders were received from the physician in 5 (Patients 4, 5, 7, 8, 10) of a total sample of 10 active and 1 closed clinical record (Patient #5) reviewed.

The agency failed to ensure the individualized Plan of Care was reviewed and revised by the allowable prescriber who was responsible for the Home Health Plan of Carex, no less frequently than every 60 days from the start of care date in 2 (Patients 4 and 6) of a total sample of 10 clinical records…

The agency failed to ensure home health aides (HHA) provided services per the plan of care in 1 home visit of 2. (Patient #4) 1. A review of an Agency’s policy “Home Health Aide Care Plan C-751”, dated 1/19/17, revealed, “ POLICY CDT 7.1.M.7 A complete and appropriate Care Plan, identifying duties…

The Administrator failed to be responsible for the day to day operation of the home health agency, ensuring patient care plans were collaborated by the staff with the physician every 60 days, failed to obtain verbal orders before furnishing services, failed to ensure services being provided met the…

The agency failed to ensure the emergency plan included a facility-based and community-based risk assessment, utilizing an all-hazards approach patients/ client population at risk (E0006); failed to ensure the emergency plan adequately identified all patients / client population at risk during an…

The Physical Therapist (PT) failed to ensure the contents of the comprehensive assessment was accurate and reflrected a patient's current health status (See Tag G526); the SN (skilled nurse) failed to ensure the comprehensive assessment was complete and reflected a patient's current health status…

The agency failed to ensure a clinical record contained 1 individualized plan of care containing all accurate information that met the needs of a patient (See tag G572); failed to accurately complete the plan of care to include all pertinent diagnoses, ensure the goals were measurable and present…

The agency failed to ensure all staff followed infection control policies and standard precautions (See Tag G682) and the agency failed to ensure that an agency wide infection program included patient and staff infections and communicable infections and that all data was incorporated into the…

The registered nurse (RN) failed to ensure that the aide care plan was individualized with specific, not generic, tasks to be completed and that the aide followed the aide care plan (See Tag G798); and failed to perform supervisory visits of the home health aide (HHA) in the required timeframe (See…

The agency failed to submit OASIS (outcome and assessment information set) within 30 days of assessment completion for 10 of 21 skilled records reviewed (#14, 15, 16, 17, 18, 19, 20, 21, 22, 23).

The Physical Therapist (PT) failed to ensure encoded OASIS date accurately reflected a patient's status at the time of the comprehensive assessment for 1 of 9 active records reviewed (#7), in a sample of 23. Findings include: A current policy titled, "Comprehensive Client Assessment" Policy C-145…

The Physical Therapist (PT) failed to ensure the contents of the comprehensive assessment was accurate and reflrected a patient's current health status for 1 of 9 active records reviewed (#7), in a sample of 23. Findings include: A current policy titled, "Comprehensive Client Assessment" Policy…

The agency failed to ensure that all staff members followed the plan of care for 4 of 9 active records reviewed (#4, 6, 9, 13), and failed to ensure a clinical record contained 1 individualized plan of care containing all accurate information that met the needs of a patient for 1 of 9 active…

The agency failed to ensure skilled nurses (SN) followed supplemental physician orders for 1 of 9 active records reviewed (#13), in a sample of 23. Findings include: The clinical record of patient #13 was reviewed on 3/27/19 and indicated a start of care date of 2/8/19. The record contained a plan…

The agency failed to ensure all staff followed infection control policies and standard precautions for 4 of 4 home visits observed (#1, 2, 3, 4).

The agency failed to ensure an agency wide infection program included patient and staff infections, communicable infections, and all data was incorporated into the agency quality assessment and performance improvement (QAPI) program for 1 of 1 agency.

The registered nurse (RN) failed to ensure that the aide care plan was individualized with specific, not generic, tasks to be completed and that the aide followed the aide care plan for 5 of 8 patients receiving HHA (home health aide) services (#2, 5, 6, 12, 13).

The agency failed to ensure that Governing Body meeting documentation contained; official appointments of administrative staff, bylaw reviews, budget approvals, and quality assessment and performance improvement (QAPI) data for 1 of 1 agency.

The agency failed to ensure patients were given the administrator's name, and contact information in order to recieve complaints during the admission to home health services for 1 of 1 agency.

The agency failed to ensure patient rights information contained the patient's right to access auxiliary aids and language services for 1 of 1 agency.

The agency failed to follow their complaint policy to ensure that the administrator approved all complaint resolutions prior to notifying the complainant of the resolution and failed to ensure the home health complaint log was separated from the home care agency for 1 of 1 agency.

The SN (skilled nurse) failed to ensure the comprehensive assessment was complete and reflected a patient's current health status for 1 of 9 records reviewed (#10 in a sample of 23. Findings include: A current policy titled, "Comprehensive Client Assessment" Policy C-145 stated, "... Purpose...To…

The registered nurse (RN) failed to ensure the comprehensive assessment contained individual patient goals and preferences identified by the patient for 3 of 4 discharged records and 9 of 9 active records (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13), in a total sample of 23. Findings include: 1. An…

The registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications, drug interactions were identified, and medication lists were accurately maintained for 1 of 4 discharged records (#8) and 5 of 9 active records (#2, 3, 4, 5, 9), in a total sample of…

The Registered Nurse (RN) failed to accurately complete the plan of care to include all pertinent diagnoses for 2 of 9 active records reviewed (#5,10), all allergies for 1 of 9 active records reviewed (#2), all durable medical equipment (DME) in the home for 2 of 4 home visits observed (#1, 4) all…

The agency failed to ensure that all orders received by a nurse practitioner or physician assistant was not accepted unless there was a co-signature obtained from the collaborating physician and that the agency policy was written accordingly for 1 of 9 active records reviewed (#5), in a sample of…

The RN (Registered Nurse) failed to ensure communication occurred with all physicians for 1 of 3 skilled home visits observed (#2), in a sample of 23. Findings include: An current agency policy titled "Coordination of Client Services" Policy #C-360 stated "... All personnel furnishing services…

The registered nurse (RN) failed to ensure they coordinated and educated with home health aides (HHA) on proper diets for 2 of 9 active records reviewed (#2, 5) and 1 of 4 discharged records reviewed (#12), in a sample of 23. Findings include: 1. An agency policy dated 2/21/18 titled "Competency…

The agency failed to ensure a written visit schedule was provided for review for 4 of 4 home visits observed (#1, 2, 3, 4).

The agency failed to ensure the patients were given the director of nursing's name, and contact information during the admission to home health services for 1 of 1 agency.

The Skilled Nurse (SN) failed to accurately assess, measure and document wound conditions for 3 of 3 patients with wounds ( # 2, 11, 13).

The Registered Nurse (RN) failed to perform supervisory visits of the home health aide (HHA) in the required timeframe for 1 of 8 records reviewed for home health aide services (#2), in a sample of 23. Findings include: A current agency policy titled ,"Home Health Aide Supervision" Policy # C-340…

The administrator failed to be appointed by the governing body for 1 of 1 agency.

The administrator failed to ensure they were responsibile for the day to day operations of the home health for 1 of 1 agency.

Employee C failed to visualize the heel wound, auscultate anterior lung sounds, or auscultate all 4 quadrants for bowel sounds.

The agency failed to ensure that all documentation was scanned into the electronic medical record (EMR) within a timely manner for 1 of 9 active records reviewed (#4) in a sample of 23. Findings include: 1. A current policy dated 08/18/2017 titled, "Client Discharge Process," Policy C-500…

The Skilled Nurse (SN) failed to provide discharge notice to the patient and family at time of discharge from the agency for 1 of 13 patients reviewed (#11).