Aaa Hoosier Home Healthcare Specialists Inc

The home health agency failed to ensure: the comprehensive assessment included the patient’s current health status (see tag G0528); the comprehensive assessment included a review of all patient medications (see tag G0536); the comprehensive assessment included the assessment of the caregiver’s…

The home health agency failed to ensure: the agency met the needs of the patient as assessed (See G0570); services were provided as directed in the plan of care (See G0572); the plan of care was individualized and included all medications, medical equipment and patient-specific interventions and…

The agency failed to update and revise the comprehensive assessment based on changes in the patient’s condition in 1 of 1 active clinical record reviewed with increased pain resulting in a hold in services.

The agency failed to provide services as directed in the POC in 5 of 5 active clinical records reviewed.

The agency failed to ensure the comprehensive assessment was completed to include an assessment of pertinent information related to the care of the patient in 4 of 5 active clinical records reviewed.

The agency failed to ensure the comprehensive assessment included the assessment of drug interactions in 2 of 5 active clinical records reviewed.

The agency failed to ensure the availability, capability, and ability of the caregiver was included in the comprehensive assessment in 5 of 5 active clinical records reviewed.

The agency failed to ensure the POC was developed to include all the medications, interventions, and measurable goals in 5 of 5 active clinical records reviewed.

The agency failed to provide services only as directed by a physician in 3 of 5 active clinical records reviewed.

The agency failed to provide services as directed in the POC in 3 of 5 active clinical records reviewed.

The agency failed to revise the POC with changes in the patient’s care in 1 of 1 active clinical records reviewed with a tracheostomy (a surgically created hole in the neck and into the airway to assist with breathing).

The agency failed to ensure the HHA provided tasks as directed in the care plan in 3 of 3 active clinical records reviewed with HHA services.

The agency failed to ensure the HHA supervision included the HHA followed the aide care plan in 3 of 3 active clinical records reviewed with HHA services.

The agency failed to ensure the discharge plans were communicated to the physician in 1 of 1 closed clinical record reviewed.

The home health agency failed to ensure: the patient was treated with respect (see tag G0428); the patient was informed in advance of the disciplines to provide service and the frequency of visits (see tag G0434); the discharge was appropriate because the physician responsible for the plan of care…

The home health agency failed to ensure the initial assessment was completed within 48 hours of referral (See G0514), failed to ensure the comprehensive assessment included all pertinent information related to the care of the patient (See G528), failed to ensure the comprehensive assessment…

The home health agency failed to ensure: the agency met the patient needs (See G0570), the plan of care was individualized and followed by all agency staff as directed by the primary care physician (See G0572), the plan of care contained all medications, medical equipment and patient-specific…

The agency failed to ensure the governing body approved the detail of the data collection, failed to evidence the quality assessment and performance improvement (QAPI) program utilized quality indicator data to include OASIS (Outcome and Assessment Information Set) data to identify opportunities…

The home health agency failed to ensure: the home health aide provided services only after successfully completing a competency evaluation (see tag G0768); the home health aide was assigned with appropriate written instructions (see tag G0798); the home health aide provide services that were…

The agency failed to create and implement individualized emergency preparedness plans for each patient in 3 of 4 home visits observed (#1, 2, 3).

The emergency preparedness plan failed to evidence procedures to follow up with on-duty staff and patients to determine services needed if there was an interruption of services due to an emergency in 1 of 1 agency.

The emergency preparedness plan failed to evidence a specific communication plan for 1 of 1 agency.

The agency failed to electronically transmit the completed OASIS (Outcome and Assessment Information Set) assessment to the CMS (Centers for Medicare and Medicaid Services) system within 30 days of the completion of the patient assessment in 4 of 4 active clinical records reviewed with skilled…

The agency failed to implement a discharge planning process that followed agency policy and informed the patient and physician of potential discharge in 1 of 2 closed clinical records reviewed.

The agency failed to ensure the discharge summary content included all necessary information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences to the physician in 2 of 2 closed clinical records reviewed (Patient #6, 7).

The agency failed to ensure each patient received services as written in an individualized plan of care in 3 of 7 records reviewed (Patient #1, 4, 7).

The agency failed to ensure staff followed standard infection control procedures in 2 of 2 home visits with a home health aide (Patient #2, 4).

The agency failed to provide infection control education to staff annually for 12 of 12 skilled professional staff members (Administrative Staff 1, 2, 3; Licensed Practical Nurse 1; Physical Therapy Staff 1, 2, 3, 4, 5, 6, 7; Occupational Therapy Staff 1).

The agency failed to ensure the home health aide (HHA) did not complete any task that they did not demonstrate competency to in 1 of 1 home health aide visit with hoyer (mechanical lift device) used.

The registered nurse (RN) failed to assign tasks appropriately to the home health aide (HHA) in 2 of 2 active clinical records reviewed with HHA services.

The agency failed to ensure the plans of care included the correct address for the home health agency in 7 of 7 clinical records reviewed (Patient #1, 2, 3, 4, 5, 6, 7) and failed to ensure the home health aide (HHA) documented notes accurately and timely in 2 of 4 clinical records reviewed with…

The agency failed to ensure the patient was treated with respect in 1 of 2 home visits with a home health aide (HHA).

The agency failed to ensure all patients were informed of and consented to care and treatments provided in 3 of 5 active records reviewed (Patient #1, 3, 5).

The agency failed to ensure the discharge was appropriate because the measurable goals in the plan of care were achieved and failed to ensure the physician responsible for the home health plan of care agreed that the patient no longer needed home health services in 1 of 1 closed record reviewed…

The agency failed to make efforts to resolve problems presented by the behavior of the caregiver in 1 of 1 patient records discharged for cause (Patient #6).

The agency failed to provide the patient with contact information for other agencies in 1 of 1 patient records discharged for cause (Patient #6).

The agency failed to document the problem and efforts to resolve problems in 1 of 1 patient records discharged for cause (Patient #6).

The registered nurse failed to complete an initial assessment visit within 48 hours of referral in 3 of 4 active clinical records reviewed with a start of care date after the last survey on 5/20/2022. (Patient #3, 4, 5) The findings include: XX.

The agency failed to ensure the comprehensive assessment was completed to include an assessment of pertinent information related to the care of the patient in 4 of 5 active clinical records reviewed.

The nurse failed to ensure all patient medications were reviewed for potential adverse effects and drug interactions in 2 of 4 active records with observation of a home visit (Patient #1, 3).

The agency failed to ensure the availability, capability, and ability of the caregiver was included in the comprehensive assessment in 1 of 5 active clinical records reviewed.

The agency failed to complete a comprehensive assessment within 48 hours of returning home in 1 of 1 active patient records reviewed with a hospitalization (Patient #4).

The agency failed to ensure the plan of care included all required components in 4 of 5 active records reviewed (Patients #1, 2, 3, 4).

The agency failed to ensure services were provided only as ordered by the physician in 2 of 3 active clinical records reviewed with more than 1 certification period.

The agency failed to ensure the plan of care was reviewed by the physician at least every 60 days in 2 of 3 active clinical records reviewed with more than 1 certification period.

The agency failed to alert the physician to changes in the patient’s condition in 4 of 5 active records reviewed (Patient #1, 3, 4, 5).

The agency failed to coordinate patient care in 3 of 3 active records receiving care from another agency (Patient #1, 2, 3).

The nurse failed to provide services only as ordered by the physician in 1 of 1 home visits of a patient with a pressure ulcer and nephrostomy tube (Patient #4).

Physical therapy assistant (PTA) failed to prepare notes accurately and timely in 5 of 7 clinical records reviewed.

The home health aide (HHA) failed to provide services as directed in the plan of care in 2 of 2 active clinical records reviewed with HHA services (Patient #2 and 4).

The agency failed to ensure the home health aide (HHA) was supervised to ensure the aide furnished care that followed the patient’s plan of care in 2 of 2 active clinical records reviewed with home health aide services (Patient #2, 4).

The administration failed to be responsible of the day-to-day operations of the agency to include ensuring agency policies were followed for timeliness of OASIS (Outcome and Assessment Information Set) transmissions to CMS (Centers for Medicare and Medicaid Services) in 4 of 4 active skilled…

The Clinical Manager failed to provide oversight of the referral process in 3 of 4 active clinical records reviewed with a start date after the last survey on 5/20/2022. (Patient #3, 4, 5) The findings include: A review of a policy dated 1/14/2021 titled “Comprehensive Assessment of Patients OASIS…

The agency failed to ensure a written agreement with the consulting organization was established.

The agency failed to ensure medications were stored according to current clinical practice for 1 of 1 agency.

The agency failed to ensure each patient record included all pertinent patient information in 2 of 5 active records reviewed (Patient #1, 4).

The agency failed to ensure a discharge summary was sent to the primary care practitioner within 5 days of discharge in 1 of 2 closed clinical records reviewed.

Citation Corrected on 5/3/2022. Deficiency corrected 05/03/2022

The home health agency failed to ensure all clinical documents were authenticated timely per agency policy for 1 of 3 active clinical records reviewed.

The home health agency failed to ensure a medication review was performed for 3 of 3 active clinical records reviewed.

The home health agency failed to ensure that the plan of care included individualized information including but not limited to safety measures, disciplines/frequencies/treatments, and goals for 3 of 3 active clinical records reviewed.

The home health agency failed to ensure all physician orders were incorporated into the plan of care for 1 of 2 active records where a home visit was conducted.

The home health agency failed to ensure the skilled nurse prepared clinical records accurately and submitted timely for 2 of 2 active clinical records reviewed where a home visit was conducted.

The home health agency failed to evidence the home health aide followed the plan of care for each patient in 1 of 2 active clinical records reviewed who received home health aide services.

The home health agency failed to ensure all employees practiced standard/universal precautions to prevent the transmission of infections (see tag G0682), and maintain a program for identification, prevention, control and investigation of infectious and communicable diseases (see tag G0684).

The home health agency failed to ensure all employees practiced standard/universal precautions to prevent the transmission of infections in 2 of 3 home visits (#1, #2) The findings include: 1. Record review on 4/8/2022, evidenced an agency policy titled, "Contaminated Reusable Materials…

The home health agency failed to maintain a program for identification, prevention, control and investigation of infectious and communicable diseases.

The agency failed to ensure their COVID-19 vaccine policy evidenced contingency plans for staff who were not fully vaccinated for COVID-19. The findings include: Record review on 4/7/2022, evidenced an agency policy titled, "AAA Hoosier Home Healthcare Specialists Mandatory Vaccination Policy"…

The agency failed to provide treatments only as ordered by the physician in 2 of 3 records reviewed receiving physical therapy (#2, #5).

The agency failed to coordinate care with other entities providing services in 2 of 3 records reviewed with a home visit conducted (#1, #2).

The agency failed to ensure patients were provided with a current medication list in 3 of 3 home visits conducted (#1, #2, #3).

The agency failed to ensure recertification comprehensive assessments were completed in its entirety in 2 of 6 active records reviewed.

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

The registered nurse (RN) failed to ensure the aide careplan contained specific timeframe's that tasks were to be completed for 2 of 2 active records reviewed with aide services (#1, 3).

The comprehensive assessment failed to contain information about the current health status for 4 of 6 active records reviewed (#1, 2, 3, 4).

The agency failed to ensure the plan of care (POC) contained all durable medical equipment (DME), measurable goals, medications, and interventions pertinent to the care of the patient for 4 of 5 active records reviewed (#1, 2, 3, 4).

The SN (skilled nurse) failed to complete a physical assessment according to professional standards for 1 of 2 skilled nursing visits observed.

The skilled nurse (SN) failed to follow the plan of care for 1 of 6 active records reviewed (#1).