Accentcare Home Health of Indiana

The home health agency failed to develop and maintain a comprehensive emergency preparedness plan which included a documented, facility-based and community-based risk assessment utilizing an all-hazards approach and included strategies for addressing emergency events identified by the risk…

The home health agency failed to ensure: the plan of care was reviewed by the physician, individualized and followed by all agency staff (See tag G0572); the plan of care included all required information / elements for the treatment of the patient (See tag G0574); services and treatment were…

The quality assurance and performance improvement (QAPI) program failed to measure, analyze and track quality indicators and other aspects of performance that enable the agency to assess processes of care, agency services and operations (see tag G642); to monitor the effectiveness and safety of…

The skilled professional failed to ensure the following: failed to provide the services as indicated in the plan of care (See tag G0710); failed to provide the patient and caregiver education (See tag G0714); failed to prepare clinical notes (See tag G0716); failed to communicate with the physician…

The home health agency failed to ensure the organization and management of the home health agency as follows: the administrator failed to maintain the day to day operations of the agency (see tag G0948), the administrator failed to ensure the clinical manager was available during all home health…

The agency failed to develop and maintain a comprehensive emergency preparedness plan which included strategies for addressing emergency events identified by the risk assessment.

The agency failed to develop and maintain an emergency preparedness plan which included a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency.

The home health agency failed to ensure individual emergency preparedness plans prepared during the comprehensive assessment included specific patient care information and evacuation location plans in 12 of 17 clinical records reviewed (#1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 15, 16).

The agency failed to develop and maintain an emergency preparedness communication plan which included names and contact information for staff and patients' physicians.

The agency failed to develop and maintain an emergency preparedness communication plan which included contact information for State and regional emergency preparedness staff and other sources of assistance.

The agency failed to develop and maintain an emergency preparedness communication plan which included an alternate means for communicating with agency staff and Federal, State, tribal, regional, and local emergency management agencies.

The agency failed to develop and maintain an emergency preparedness communication plan which included a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care and a means for…

The agency failed to participate in a full-scale community-based or facility-based exercise every 2 years to test the emergency plan.

The home health agency failed to ensure the discharge summary included post-discharge goals of care and treatment preferences in * of 5 discharge records reviewed (#15, 16).

The home health agency failed to ensure the patient received all services as ordered on the plan of care, and/or had an individualized plan of care which included patient-specific, measurable goals and outcomes, and/or was reviewed and signed by a doctor for 11 of 17 clinical records reviewed (#2…

The agency failed to ensure conformance with physician orders in 1 of 3 home visits conducted with a registered nurse (RN).

The home health agency failed to measure, analyze, and track quality indicators, including adverse events, that enable the agency to assess processes of care, agency services, and operations.

The home health agency failed to ensure the detail of the data collections was approved by the governing body.

The agency failed to ensure the performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventive actions.

The agency failed to document the reasons for conducting the performance improvement projects and the measurable progress achieved.

The agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections in 2 of 4 home visits with the registered nurse (RN).

The agency failed to maintain a program for the surveillance, identification, prevention, control, and investigation of infections.

The agency failed to ensure the clinical record entries were accurate and complete to include a title of the author in 2 of 5 closed clinical records reviewed.

The agency failed to provide written notice of patient’s rights and responsibilities which were understandable to patients with limited English proficiency in 1 of 5 discharge records reviewed (#15).

The agency failed to ensure complaints made by the patient were investigated in 5 of 6 clinical records reviewed with a patient complaint.

The agency failed to document the resolution of the complaint in 4 of 5 clinical records reviewed with patient complaints entered on the agency complaint log.

The home health agency failed to ensure the initial assessment was conducted within 48 hours of referral, within 48 hours of patient’s return home, or on the physician ordered start of care date in 2 of 12 active clinical records reviewed (#2, 10).

The agency failed to ensure the comprehensive assessment included a complete physical assessment in 5 of 12 active clinical records reviewed.

The home health agency failed to ensure the comprehensive assessment included a review of all patients medications, and failed to ensure the medication review identified potential adverse effects and drug reactions, including significant drug interactions and duplicative drug therapy in 8 of 17…

The home health agency failed to complete an updated comprehensive assessment in 1 of 1 clinical records reviewed in which there was a significant change in condition (#4).

The home health agency failed to ensure the plan of care included, all pertinent diagnoses, types of services, supplies, and equipment needed, frequency and duration of visits to be made, nutritional requirements, all medications and treatments, a description of the patient’s risk for…

The home health agency failed to ensure treatments were administered only as ordered by a physician in 5 of 8 active clinical records reviewed with a wound or catheter (#3, 7, 8, 9,12).

The agency failed to ensure the plan of care was reviewed and revised by the physician who is responsible for the home health plan of care in 1 of 5 discharge records reviewed (#16).

The home health agency failed to ensure the physician was promptly notified of changes in the patient’s condition that suggest outcomes are not being achieved and/or the plan of care should be revised in 5 of 10 clinical records reviewed receiving wound care services (#4, 7, 9, 14, 17).

The agency failed to ensure the plan of care was revised to reflect the patient’s current status in 2 of 8 active clinical records reviewed with wounds.

The agency failed to ensure the integration of orders from all physicians involved in the patient’s care into the plan of care to assure coordination of all services and interventions provided to the patient in 1 of 8 active clinical records reviewed with wounds.

The agency failed to ensure coordination of care by all disciplines in 2 of 2 clinical records reviewed with dialysis treatment (#1, 5), 3 of 9 active clinical records reviewed with physical therapy services (#6, 11, 12), and 1 of 5 closed clinical records reviewed.

The agency failed to ensure the patient received appropriate discharge teaching in 1 of 5 discharged records reviewed (#13).

The home health agency failed to ensure a written schedule was provided to patients in 6 of 7 home visits conducted (#1, 2, 3, 4, 6, 7).

The home health agency failed to ensure patients were provided written medication schedule/instructions in 3 of 7 home visits conducted (#2, 6, 7).

The home health agency failed to ensure patients received in writing any treatments to be administered by personnel and personnel acting on behalf of the home health agency in 3 of 7 home visits conducted (#2, 6, 7).

The home health agency failed to ensure patients received the name and contact information for the clinical manager in writing in 3 of 7 home visits conducted (#2, 6, 7).

The agency failed to ensure the performance improvement activities focused on high risk, high volume, or problem-prone areas.

The agency failed to ensure the performance improvement activities considered incidence, prevalence, and severity of problems.

The agency failed to ensure the performance improvement activities lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of the patients.

The agency failed to take actions aimed at performance improvement, and, after implementing those actions, the agency must measure its success and track performance to ensure improvements are sustained.

The skilled professional failed to provide services as ordered in the plan of care in 5 of 8 active clinical records reviewed with wounds (#1, 6, 7, 8, 10), 1 of 2 active clinical records reviewed with urinary catheters (a plastic tube inserted into the bladder to drain urine from the body) (#12)…

The registered nurse (RN) failed to provide education to the patient in 1 of 8 active clinical records reviewed with a diagnosis of diabetes (a chronic condition which affects the way the body processes blood sugar).

The home health agency failed to ensure skilled professionals accurately and completely prepared clinical notes in 13 of 17 clinical records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 14, 15, 16).

The home health agency failed to ensure clinicians communicated with all physicians involved in the plan of care, related to the current plan of care in 4 of 8 active clinical records reviewed with wounds.

The agency failed to ensure skilled professionals participated in the QAPI (quality assurance performance improvement) program.

The registered nurse (RN) failed to supervise the licensed practical nurse (LPN) in 1 of 4 clinical records reviewed with a LPN.

The administrator failed to be responsible for the day-to-day operations of the agency.

The administrator failed to ensure the clinical manager was available during all operating hours.

The agency failed to ensure the clinical manager provided oversight for the patient and personnel assignments.

The clinical manager failed to provide oversight of coordination of care.

The clinical manager failed to assure the implementation of the plan of care.

The agency failed to ensure all services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice in 1 of 7 clinical records reviewed with home visit conducted (#1).

The agency failed to ensure all interventions, treatments, and responses to interventions were documented in the patient’s clinical record in 1 of 7 clinical records reviewed with a home visit conducted (#3) The findings include: Record review on 5/17/2022 evidenced an agency policy titled…

The home health agency failed to ensure a completed discharge summary was sent to the physician within 5 business days of the patient’s discharge in 2 of 5 discharge records reviewed (#13, 16) and failed to ensure a completed transfer summary was sent to the physician within 2 business days of…

The home health agency failed to ensure the plan of care was followed to meet the individualized needs of the patient for 1 of 2 patients who reviewed skilled nursing, from a total sample of 3 clinical records reviewed.

The home health agency failed to ensure each patient received the administrator contact information and business phone number for 1 of 2 home visits conducted, from a total sample of 3 clinical records reviewed.

The home health agency failed to ensure each patient was advised of the state toll free home health hotline, for 1 of 2 patients who recieved a home visit.

The administrator failed to provide information for a medical social worker to ensure the patient's needs were met in 1 of 2 patient records reviewed, who received home visits.

The agency failed to include the supplies and equipment required, and all safety measures required to individualize the patient's plan of care for 1 of 2 patients that received a home visit, from a total sample of 3 clinical records reviewed.

The home health agency failed to ensure the drugs and treatments administered to all patients were only as ordered by a physician for 2 of 2 patients who received a home visit, from a total of 3 clinical records reviewed.

The home health agency failed to ensure all outside services being provided to the patient was integrated into the patient's clinical plan of care for 1 of 2 patients who recieved a home visit.

The home health agency failed to ensure the medical plan of care was individualized to include all medications and indications that were prescribed as needed in 3 of 3 clinical records reviewed.

The home health agency failed to ensure all employees used standard precautions to prevent the transmission of infections and communicable diseases for 1 of 1 home visits.

The Administrator failed to provide contact information for other agencies or providers who would be able to provide care to 1 of 2 discharged patients.

The agency failed to ensure patient care was furnished appropriately as ordered on the plan of care in 1 of 2 discharged patients.

The administrator failed to ensure all complaints were documented with a resolution in 1 of 2 discharged records which contained complaints.

The home health agency failed to be responsible for the management of the after hours on-call services to ensure appropriate agency staff was on-call 24 hours a day, 7 days a week for 1 of 1 home health agency.

The home health agency failed to ensure the plan of care was followed in 2 of 7 clinical records reviewed.

The home health agency failed to ensure a review of all the patient's current medications to identify potential adverse effects and drug interactions was conducted in 1 of 7 clinical records reviewed.

The home health agency failed to ensure the skilled nurse obtained a physician's wound care order prior to wound care being provided in 1 of 5 records reviewed with wound care in a total sample of 7 records.

The home health agency failed to promptly alert the physician of changes in the patient's condition in 3 of 7 clinical records reviewed.

The skilled nurse failed to communicate changes/updates with the patient's condition to all physicians providing care in 2 of 7 records reviewed (#5, #7).

The skilled nurse (SN) failed to ensure the plan of care was followed in 2 of 7 clinical records reviewed.