Anchor Home Health Care

The home health agency failed to ensure: the plan of care was individualized to meet the patient needs (see tag G0570), the plan of care was individualized with specific, measurable goals, and followed by all agency staff as directed by the primary care physician (see tag G0572), the plan of care…

The agency failed to ensure each patient had an individualized emergency preparedness plan in 2 of 2 records reviewed of patients with a home visit, not receiving skilled nursing services (Patient #3, 4).

The agency failed to ensure each patient received services written in an individualized plan of care with patient-specific, measurable goals in 5 of 12 records reviewed receiving skilled nursing services (Patient #4, 5, 7, 8, 13).

The agency failed to provide the patient and caregiver with a copy of written instructions in one of five active patient records with home visits (Patient #6).

The agency nursing staff failed to follow acceptable standards of practice to prevent the transmission of infection during the provision of care in two of five active patient records with home visits (Registered nurse [RN] 2 and RN 3).

The agency failed to assign tasks appropriately to the home health aide in 1 of 2 active clinical records reviewed with home health aide (HHA) services.

The agency failed to ensure all clinical record entries were legible, clear, complete and appropriately authenticated in 5 of 12 records reviewed receiving skilled nursing or therapy services (Patient #4, 5, 6, 7, 10).

The agency failed to evidence patient care was free from verbal, mental, and physical abuse in one of five active patients with home visit observations (Patient #6).

The agency failed to evidence the physician was consulted for the purpose of discharge prior discharge for 1 of 4 discharge records reviewed (Patient #11) The record for Patient #11 reviewed on 4/25/24 included a Plan of Care dated 1/27/24 – 3/26/2024 which indicated Skilled Nursing orders 1 to 2…

The agency failed to document the existence and resolution of a complaint in one of five active patient records with home visits (Patient #6).

The agency failed to conduct an initial assessment visit within 48 hours of referral in two out of nine active patient records reviewed (Patient # 6, 7).

The comprehensive assessment failed to accurately reflect the patient’s health status in two of nine active records reviewed (Patient #6, 7).

The agency failed to include a review of all medications to identify potential adverse effects, significant drug reactions, duplicate drug therapy, and noncompliance with drug therapy in 3 out of 9 active records (Patient #6, 7, 9).

The comprehensive assessment failed to accurately reflect the patient’s primary caregiver’s willingness, availability nor their ability to provide care in one of five home visit patients (Patient #6).

The agency failed to ensure the comprehensive assessment was performed in the last 5 days of every 60-day episode in 1 of 1 active records reviewed receiving LPN (Licensed Professional Nurse) services (Patient #8).

The agency failed to ensure the plan of care included all required components in 7 of 9 active records reviewed (Patient #3, 4, 5, 6, 7, 8, 9).

The agency failed to implement services and treatments administered as ordered by a physician in four out of nine active records reviewed (Patient #3, 6, 7, 9).

The agency failed to ensure the physician reviewed the plan of care at least every 60 days in 1 of 7 active clinical records reviewed with more than 1 certification period.

The agency failed to promptly alert the physician to any changes in the patient’s condition or needs in three of nine active patient records reviewed (Patient #5, 6, 7) Findings include: A review of the plan of care for certification period 3/9/2024 to 5/7/2024 indicated the nurse was to assess…

The agency failed to provide a revised plan of care that reflects current information from the patient’s updated comprehensive assessment and contain information concerning the patient’s progress towards goals in two of five active patient records with wounds (Patient #4, 6).

The agency failed to ensure that the patient and his/her caregiver receive ongoing education and training as appropriate to plan of care in two of five active patient records with home visits (Patient #6, 7).

The agency failed to provide the patient and caregiver a copy of written instructions including visit schedule and frequency of visits in three of five home visit patients (Patient #4 and 6).

The agency failed to provide the patient and caregiver in writing a calendar of the visit schedule for 1 of 1 home visit conducted with the home health aide.

The agency’s skilled professionals failed to provide services that are ordered by the physician as indicated in the plan of care in one of five active patient records with home visits (Patient #6) Findings include: The clinical record of Patient #6’s plan of care (POC) evidenced a specified wound…

The agency failed to ensure skilled professionals prepared complete and accurate visit notes in 2 of 2 records reviewed of patients with a home visit, not receiving skilled nursing services (Patient #3, 4).

The home health aide (HHA) failed to provide services as directed in the plan of care in 1 of 2 active clinical records reviewed with home health aide (HHA) services.

The agency failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice in two of five active patient records with home visits (Patient #5, 6).

The agency failed to ensure the clinical record included all interventions and responses to those interventions in 1 of 1 active records receiving physical therapy services only (Patient #4).

The agency failed to ensure the patient’s clinical record included progress toward goals in 1 of 1 active records receiving physical therapy services only (Patient #4).

The agency failed to ensure each patient received the treatments and services as prescribed on the individualized plan of care for 9 of 17 clinical records reviewed.

The agency failed to ensure the plan of care was reviewed and revised for each patient in 4 of 17 clinical records reviewed (#2, #6, #11, #15).

The agency failed to ensure Standard Precautions were followed by every employee during 3 of 7 home visits.

The agency failed to ensure the skilled professional performed complete assessments in 2 of 4 records reviewed receiving IV therapy (#2, #11).

The registered nurse failed to provide complete patient care instructions for the home health aide in 1 of 2 records reviewed receiving home health aide services (#14).

The home health agency failed to ensure all entries in the clinical record were complete and appropriately authenticated in 5 of 17 clinical records reviewed (#1, #3, #4, #11, #17).

The agency failed to ensure the identified goals on the plan of care were achieved prior to discharge in 1 of 5 closed records, in a total sample of 17 clinical records reviewed.

The agency failed to provide the patient with contact information for other agencies who may be able to provide care in 1 of 1 discharged patient records receiving home health aide services (#14).

The agency failed to ensure the comprehensive assessment included the patient's current health status in 1 of 3 patient records with an active wound (#4).

The agency failed to ensure a medication review was performed to identify high-risk medications for 1 of 3 patients receiving wound care treatments, from a total sample of 17 clinical records reviewed.

The agency failed to ensure the individualized plan of care included all services, safety measures, medications and treatments in 11 of 17 records reviewed (#1, #2, #3, #4, #6, #7, #8, #9, #12, #13, #15).

The agency failed to ensure all drugs and treatments were administered as ordered by the physician for 2 of 12 active records, in a total sample of 17 clinical records reviewed.

The agency failed to ensure changes to the plan of care were communicated to the physician in 2 of 3 records of patients with a feeding tube or foley catheter [a tube placed to drain the bladder] (#13, #17).

The agency failed to ensure the physician involved with the plan of care was notified of point of care lab testing for each patient in 1 of 2 pediatric patients, from a total sample of 17 records reviewed.

The home health agency failed to coordinate care with other entities providing services to the patient in 3 of 7 clinical records reviewed with a home visit conducted (#2, #4, #7).

The agency failed to ensure patients were provided a written schedule of visits in 6 of 7 home visits conducted (#1, #2, #3, #4, #7, #8).

The agency failed to ensure patients were provided a current written patient medication list in 6 of 7 home visits performed (#1, #2, #3, #4, #7, #8).

The home health aide failed to provide services included in the plan of care in 1 of 2 records receiving home health aide services (#14).

The agency failed to ensure the patient's clinical record evidenced all interventions and responses to those interventions in 4 of 5 patient records receiving physical therapy (#3, #8, #13, #17).

The agency failed to ensure a complete discharge summary was sent to the physician within 5 business days after discharge, and a complete transfer summary was sent to the physician within 2 business days of transfer for 3 of 7 records reviewed of patients who were discharged or transferred (#13…

The home health agency failed to ensure: a patient was treated with dignity (see tag G0428), failed to ensure patient rights were accorded to include the provision of all services ordered by the physician (see tag G0436), failed to maintain confidential clinical records by failing to secure…

The home health agency failed to ensure: all initial assessments were performed by the registered nurse within 48 hours of the initial physician referral (see tag G0514), the physical therapist completed the initial assessment within 48 hours of the initial physician referral (see tag G0516), a…

The home health agency failed to ensure: all the patients medical and nursing needs were met in their place of residence for 1 of 7 (#8) records reviewed with a peripheral inserted central catheter (PICC), 1 of 1 active record (#9) reviewed on a patient on hold for respite nursing, 1 of 8 active…

The home health agency failed to ensure all employees practiced standard/universal precautions (See G0682); failed to maintain a program for identification, prevention, control and investigation of infectious and communicable diseases specific to care and services provided in the home setting (See…

The home health agency failed to ensure: skilled nursing completed on-going assessments of the patients condition (see tag G0706); the skilled nurse provided the patient / caregiver with the required education as ordered by the primary care physician per the medical plan of care (see tag G0714)…

The home health agency failed to ensure that all staff members were aware of administrative control and the lines of authority in 1 of 1 home health agency (See G0940); failed to ensure the agency's public information was correct, failed to keep staff informed of administrative chain of command…

The home health agency failed to ensure all records were accurate and included all assessments and interventions in 3 of 25 clinical records reviewed.

The agency failed to ensure that an emergency preparedness communication plan included all current patient names and patient physicians for all districts/ territories that the agency provided services to for 1 of 1 agency reviewed.

The agency failed to ensure OASIS data had been transmitted within 30 days of completing an assessment in 3 of 10 clinical records reviewed ( #7, #8, #9 ) of patients that received skilled services and required comprehensive assessments.

The agency failed to ensure recertification assessments were complete and accurate for 3 of 14 active records reviewed (#9, #18, #21) of patients who were recertified for an additional 60 days by a Registered Nurse.

The home health agency failed to ensure the plan of care was followed and visit frequencies were individualized to the patient's needs in 4 of 7 closed records (#1, #2, #7, #14) and 12 of 18 active records (#3, #5, #9, #12, #13, #16, #17, #18, #19, #21, #24, #25) reviewed.

The home health agency failed to conform with physician orders in 1 of 3 active records (#5) reviewed of patients on blood thinners and 1 of 2 records (#25) reviewed of patients receiving TPN (total parental nutrition) through a (PICC) peripheral inserted central catheter.

The home health agency failed to ensure that the quality assurance program include all patient infections, data for patients with tracheostomies, patients with wounds, and take actions that resulted in improvements in performance with use of objective measures in 1 of 1 home health agency.

The home health agency failed to ensure all employees practiced standard/universal precautions in 8 of 9 home visits observed.

The home health agency failed to maintain a program for identification, prevention, control and investigation of infectious and communicable diseases specific to care and services provided in the home setting in 1 of 1 home health agency.

The agency failed to ensure education was provided to a patient practicing unconventional infection control methods related to reuse of a single use suprapubic catheter for 1 of 4 patients reviewed with a suprapubic catheter (#3).

The home health agency failed to ensure the registered nurse placed indications on PRN [as needed] tasks on the home health aide care plan, failed to ensure the home health aide care plans were in the patients home folders, failed to ensure the home health aide completed tasks per the home health…

The home health agency failed to ensure the registered nurse ensured the home health aide was following the aide care plan established by the registered nurse for 2 of 8 clinical records reviewed with home health aide services.

The home health agency failed to ensure their new agency location was approved by CMS [Centers for Medicaid/Medicare] prior to operating from the new location in 1 of 1 home health agency.

The home health agency failed to ensure all clinical records were clear, complete, legible, signed, dated, and appropriately authenticated, in 11 of 25 clinical records reviewed.

The home health agency failed to maintain confidential clinical records by disclosing personal health information in the patient's home in 1 of 9 (#25) home visits made and by failing to secure clinical records (Pt #38) in 1 of 1 field staff observed walking into the office in 1 of 1 home health…

The agency failed to ensure the patient was treated with dignity for 1 of 3 home health aide (HHA) visits observed (patient #11 with Employee F, HHA).

The agency failed to ensure patient rights were accorded to include the provision of all services ordered by the physician for 1 of 8 records (#11) reviewed with home health aide services.

The home health agency failed to maintain confidential clinical records by failing to secure clinical records in 1 of 1 field staff observed walking into the office in 1 of 1 home health agency.

The home health agency failed to ensure the patient was notified of changes in charges for skilled nursing services in 1 of 2 active records reviewed (#17) of patients with billing concerns.

The home health agency failed to ensure all patients/patient caregivers were aware of how to contact or how to access the number to contact the Indiana State Department of Health (ISDH) home health hotline in 6 of 9 patients/ patient caregivers interviewed.

Based record review and interview, the agency failed to investigate complaints reported by patients and/ or their caregivers regarding the lack of treatment or care that was to be furnished for 3 of 12 complaints investigated (#2, #9, #25).

The agency failed to ensure they documented the existence and resolution of complaints by patients and/ or their representatives in 3 of 12 complaints investigated.

The home health agency failed to ensure all initial assessments were performed by the registered nurse within 48 hours of the initial referral, in 2 of 10 records reviewed (#14, #25) with start of care assessments.

The home health agency failed to ensure the initial assessment was performed by the physical therapist within 48 hours of the initial referral, in 1 of 1 active record (#23) reviewed of a patient receiving only physical therapy services.

The home health agency failed to ensure the comprehensive assessment was completed in full to include assessment of all body systems, psychosocial status, functional status and cognitive status, in 3 of 10 start of care assessments reviewed.

The home health agency failed to ensure a review of the patient's current medications to include drug interactions was conducted during the comprehensive assessment in 7 of 25 clinical records reviewed.

The agency failed to ensure resumption of care assessments were complete and accurate for 1 of 2 records reviewed of patients who had services resumed after being hospitalized.

The home health agency failed to ensure accurate comprehensive assessment occurred at discharge in 2 of 7 discharge records reviewed.

The home health agency failed to ensure the plan of care contained all safety precautions, dme [durable medical equipment]/ supplies, and medications for their patients in 1 of 7 closed records (#4) and 5 of 18 active records (#5, #16, #18, #20, #25) reviewed.

The home health agency failed to ensure they recorded interim physician orders in the plan of care in 1 of 3 active clinical records (#5) of patients on blood thinners.

The home health agency failed to ensure treatments, medications, and nutrition changes were not performed absent of a physician's order in 3 of 7 closed records (#1, #2, #7) and 4 of 18 active records (#16, #17, #22, #25) reviewed.

The home health agency failed to ensure the primary care physician reviewed and signed the plan of care every 60 days in 2 of 7 closed record (#7, #14) and 6 of 18 active records (#9, #18, #20, #22, #23, #25) reviewed.

The home health agency failed to ensure they promptly alerted the physician to changes in the patient's condition in 9 of 18 active clinical records reviewed (#3, #5, #8, #11, #17, #21, #22, #23, #25) and 1 of 7 closed (#2) records reviewed.

The home health agency failed to ensure the primary care physician was notified of the patient's discharge from home health services in 2 of 7 clinical discharge records reviewed.

The agency failed to ensure communication with all physicians involved with the plans of care for 1 of 3 records reviewed (#8) of patients taking blood thinners.

The home health agency failed to integrate physician orders in the plan of care in 1 of 3 clinical records reviewed (#5) of patients taking blood thinners.

The home health agency failed to coordinate care amongst the different disciplines/ entities that provided care to the patient in 1 of 1 record reviewed (#21) of a patient receiving services by a LPN (licensed practical nurse)/ 2 of 4 records (#21, #25) reviewed of patients receiving wound care, 4…

The home health agency failed to ensure there was ongoing assessments of the patients condition in 2 of 7 closed records (#1, #7) and 2 of 16 active records (#17, #22) reviewed of patients with skilled nursing services.

The home health agency failed to ensure the skilled nurse provided the required education to the patient / caregiver as ordered per the plan of care in 3 of 23 clinical records reviewed with skilled nurse services.

The home health agency failed to ensure skilled nursing visit notes contained education provided, patient responses, and incidents/ concerns reported by the patient/ patient representative in 2 of 23 clinical records with skilled nursing services.

The home health agency failed to ensure the registered nurse (RN) supervised the licensed practical nurse (LPN) to ensure the LPN was following the medical plan of care in 1 of 1 clinical record reviewed with LPN nursing services, out of a total of 25 clinical records reviewed.

The home health agency failed to ensure the home health aide was supervised every 14 days in 1 of 7 home health aides with skilled services.

The administrator failed to ensure the agency's public information was correct, failed to keep staff informed of administrative chain of command, and failed to ensure he/she was abreast in all aspects of the agency, including the status of all patients when providing documents to review during a…

The clinical manager failed to provide oversight of all patient care services and personnel to include making patient and personnel assignments for 1 of 1 agency.

The director of nursing failed to ensure coordination of care amongst the different disciplines / entities that provided care to the patient in 6 of 25 clinical records reviewed.

The Diector of Nursing failed to ensure accepted clinical standards of practice orders were in place related to flushing of a central line after medication administration for 1 of 4 patients reviewed with IV (intravenous) access (patient #3), out of a total sample of 25 clinical records reviewed.

The home health agency failed to ensure all assessments, clinical notes, physician orders, and plans of care were received and/or completed in 1 of 25 clinical records reviewed.

The home health agency failed to ensure a discharge summary was sent to the primary care physician within 5 business days of the patient's discharge in 4 of 7 discharged records reviewed.