Ascension at Home

The home health agency failed to ensure patients received all services as outlined in the plan of care (See Tag G436); failed to advise the patient and physician that a discharge for cause was being considered (See Tag G464); failed to make efforts to resolve the problem (See Tag G466); failed to…

The home health agency failed to document the correct date and time verbal orders were received from the physician (See G576); failed to ensure services were provided only as ordered by a physician or allowed practitioner (See G580); failed to ensure the plan of care (POC) was reviewed with the…

The home health agency failed to provide documentation of emergency preparedness (EP) training upon hire for 7 of 7 employee records reviewed who were hired in the past year (Occupational Therapist (OT) 1, Physical Therapist (PT) 1, Registered Nurse (RN) 2, RN 6, Home Health Aide (HHA) 1, HHA 2 and…

The home health agency failed to analyze the after-action response to determine if the Emergency Plan (EP) plan needed revision for the EP activation performed in 2023 for 1 of 1 agency.

The home health agency failed to ensure the governing body approved the frequency and detail of data collection for 1 of 1 agency.

The home health agency failed to ensure all entries in the clinical record were appropriately authenticated, dated, and timed, for 3 of 12 active patient records reviewed (Patient #1, #3, and #10).

The home health agency failed to ensure patients were informed of a delay in the start of therapy services for 2 of 2 records which evidenced a lapse in time for therapy service(s) initiation (Patient #10 and 11).

The home health agency failed to collaborate with the patient and physician regarding possible discharge for cause/ noncompliance for 2 of 2 discharge for cause/noncompliance patient records reviewed (Patient #14 and 16).

The home health agency failed to make efforts to resolve the problems in the patient home for 1 of 2 discharge for cause patient records reviewed (Patient #14).

The home health agency failed to provide the patient and/or representative with contact information for other home health agencies who may be able to provide care for 1 of 2 discharge for cause patient records reviewed (Patient #14).

The home health agency failed to document the efforts made to resolve the problem for 1 of 2 discharge for cause patient records reviewed (Patient #14).

The agency failed to investigate 1 of 1 complaint regarding discharge for cause (Patient #14).

The home health agency failed to ensure a review of all medications the patient was taking for 6 of 7 patients with home visit observations (Patient #1, #2, #3, #4, #5, and #7).

The home health agency failed to document the correct date and time verbal orders were received from the physician for 2 of 12 active records reviewed (Patient #2 and 10).

The home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 7 of 12 active patient records reviewed (Patient #1, #2, #4, #9, #10, #11, and #12).

The home health agency failed to ensure the plan of care (POC) was reviewed with the physician at start of care (SOC) and/or at recertification for 6 of 12 active patient records reviewed (Patient #1, #4, #9, #10, #11, and #12).

The home health agency failed to ensure the physician or allowed practitioner was promptly notified if the need to alter the plan of care (POC) related to discharge for 2 of 5 discharged patient records reviewed (Patient #14 and #16).

The home health agency failed to document collaboration with the patient, caregiver and physician regarding discharge for 2 of 5 discharged patient records reviewed (Patient #14 and 16).

The home health agency failed to ensure the registered nurse (RN) supervised the home health aide (HHA) for 1 of 2 active clinical records reviewed of patients receiving HHA services (Patient #6).

The home health agency failed to provide a valid written contract for 1 of 1 contracted employee (Registered Nurse 6).

The home health agency failed to submit the discharge summary to the physician within 5 days of discharge for 1 or 2 discharge for cause records reviewed (Patient #14).

The agency failed to ensure comprehensive assessments were updated for 2 of 6 patients with observed home visits (Patients #1, 16).

The agency failed to ensure infection control precautions were maintained for 3 of 6 patients with home visit observations (#1, 15, 16).

The agency failed to ensure COVID infection control precautions were followed for 6 of 6 active patient home visit observations (#1, 2, 3, 14, 15, 16).

The Registered Nurse (RN) failed to ensure that home health aide (HHA) care plans contained patient-specific tasks to be performed by the home health aide for 4 of 4 patients reviewed who received HHA services (#3, 8, 10, 15).

The agency failed to ensure the patients were free from neglect, and appropriate referrals were made and documented to address for 1 of 6 active patients with home visit observations (#16).

The agency failed to thoroughly investigate and document complaints for 6 of 6 complaints reviewed (#18, 19, 20, 21, 22, 23).

The agency's Registered Nurse (RN) failed to ensure the comprehensive assessment contained an accurate assessment of the patient's health status for 1 of 6 records with home visits (#1).

The agency failed to ensure comprehensive assessments contained strengths and care preferences identified by the patient for 10 of 10 active skilled nursing patient records reviewed (#1, 3, 5, 6, 8, 10, 14, 15, 16, 17), and 6 of 6 discharged skilled nursing patient records reviewed (#4, 7, 9, 11…

The Registered Nurse (RN) failed to ensure the comprehensive assessment contained a complete review of the patient's medications and medication lists were accurately maintained for 4 of 6 active patients with home visit observations (#1, 2, 3, 14).

The agency failed ensure comprehensive assessments contained the patient's primary caregiver's willingness to provide care for 10 of 10 active skilled nursing patient records reviewed (#1, 3, 5, 6, 8, 10, 14, 15, 16, 17), and 6 of 6 discharged skilled nursing patient records reviewed (#4, 7, 9, 11…

The agency failed to ensure communication took place with all physicians involved in the plan of care for 1 of 10 active patient records reviewed (#2).

The agency failed to ensure coordination of care was completed with any other home health agency providing care to their patients for 2 of 6 active patient records reviewed with home visit observations (#1, 16).

The agency failed to ensure all patients were provided with a copy of a written visit schedule for 6 of 6 active patients with home visit observations (#1, 2, 3, 14, 15, 16).

The agency failed to ensure all patients were provided with a written copy of their current medications for 6 of 6 active patients with home visit observations (#1, 2, 3, 14, 15, 16).

The agency failed to provide the patient with written information regarding treatments to be administered by HHA personnel (information from the patient's plans of care) for 6 of 6 active patients with home visit observations (#1, 2, 3, 14, 15, 16).

The Administrator failed to report to the governing body.

The agency failed to ensure that written agreements were in place (and signed by both parties) that delineated the services each home health agency was to provide for 2 of 2 active patient records reviewed with shared agencies (#1, 16).

The agency failed to ensure all shared patients had one primary home health agency which was delineated in a written agreement between home health agencies for 2 of 2 active patient records reviewed with shared agencies (#1, 16).

The agency failed to ensure a contract was in place with the individual who submits Outcome and Assessment Information Set (OASIS) data therefore, failed to ensure the confidentiality of all patient information in the clinical record including OASIS data.

Failed to ensure the registered nurse (RN) conducted wound care as ordered per the plan of care (See G572); failed to ensure that the plan of care contained all pertinent diagnoses, specific discipline orders, and frequency orders for all staff in the home and failed to ensure the plan of care…

The Registered Nurse failed to ensure that the plan of care contained all pertinent diagnoses, specific discipline orders, and frequency orders for all staff in the home and failed to ensure the plan of care included goals for identified needs and all goals were measurable (See G708); failed to…

The agency failed to ensure human resource responsibilities were not delegated to another agency or organization for 6 of 15 employee records (C, G, I, J, M, O) and skilled supervision for 1 of 1 social worker assistants (G), failed to ensure protected health information was safeguarded due to the…

The agency failed to ensure that agency policies included the use of volunteers or other staffing strategies in its emergency plan.

The agency failed to ensure that the integrated emergency preparedness program demonstrated that the parent agency and its branch had actively participated in the development of the emergency preparedness program that included risk assessments within their areas for 1 of 1 agency.

The agency failed to ensure the encoded OASIS data included a patient's diagnosis for 1 of 17 records reviewed.

The agency failed to ensure the home health aide did not provide services absent of a physicians order in 1 of 5 records reviewed of patient with home health aide services and the registered nurse (RN) conducted wound care as ordered per the plan of care for 1 of 6 records reviewed of patients with…

The Governing Body failed to ensure the Quality Assurance Performance Improvement (QAPI) meetings included only information regarding the surveyed agency and not other sister agencies.

The agency failed to ensure all staff followed infection control policies and standard precautions for 1 of 7 home visits observed (#2).

The agency failed to ensure the aide coincided with the plan of care and the agency failed to ensure the aide careplan was updated for 1 of 5 records reviewed with a home health aide (#4) in a sample of 17 records reviewed.

The agency failed to ensure the Governing Body meetings only included information regarding the surveyed agency and not other sister agencies for 1 of 1 agency.

The agency failed to ensure the confidentiality of patient information and clinical records was maintained for 1 of 1 agency.

The agency failed to ensure the confidentiality of patient information and clinical records was maintained for 1 of 1 agency.

The agency failed to ensure written notification was given to a patient in advance for decreasing or stopping care for 1 of 4 records reviewed where services were decreased or stopped in a sample of 17. (#8) Findings include: The clinical record of patient #8 was reviewed on 9/12/18 and indicated a…

The registered nurse (RN) failed to ensure complete review of medications were completed and maintained for 4 of 17 records reviewed (#5, 7, 11,14).

The agency failed to ensure that the plan of care contained all pertinent diagnoses, specific discipline orders, and frequency orders, and tasks for all staff in the home for 3 of 17 records reviewed (#1, 4, 5) and failed to ensure the plan of care included goals for identified needs and all goals…

The agency failed to ensure the physician notified at he start of care to obtain orders for medical social services to evaluate patient needs, speech therapy services for a patient who was identified as having choking episodes, and to obtain interim orders for wound care until supplies were made…

The agency failed to ensure that the goals on the plan of care were updated for 5 of 17 records reviewed (#3, 7, 11, 12, 15).

The agency failed to complete coordination of care between agency staff, to physicians, and to shared agencies for 6 of 17 records reviewed (#4, 6, 7, 8, 13, 14).

The Registered Nurse failed to ensure that the plan of care contained all pertinent diagnoses, specific discipline orders, and frequency orders for all staff in the home for 3 of 17 records reviewed (#1, 4, 5) and failed to ensure the plan of care included goals for identified needs and all goals…

The registered nurse (RN) failed to provide wound care as ordered per the plan of care for 1 of 6 records reviewed of patients with wounds (#5) in a sample of 17 records reviewed.

The Registered Nurse failed to ensure visiting nurses accurately identified and documented wounds consistently for 3 of 5 wound care records reviewed (#3, 5, 10, ) in a sample of 17 records reviewed.

The agency failed to ensure that medical social service assistant was supervised by a qualified medical social worker holding a Master's degree that is employed or contracted within the surveying agency for 1 of 1 agency.

The agency failed to ensure the home health aide did not provide services absent of a physicians order in 1 of 5 records reviewed of patient with home health aide services in a sample of 17 records reviewed.

The agency failed to disclose a change in the branch name and governing body members to Indiana State Department of Health for 1 of 1 agency.

The adminitrator failed to ensure he/ she reported to the governing body for 1 of 1 agency.

The administrator failed to maintain responsibility for the day to day functions of the agency and failed to ensure authority was known to all staff members for 1 of 1 agency.

The Director of Nursing failed to ensure that the plan of care contained all pertinent diagnoses, specific discipline orders, and frequency orders for all staff in the home for 3 of 17 records reviewed (#1, 4, 5) and failed to ensure the plan of care included goals for identified needs and all…

The agency failed to ensure skilled supervision were not delegated to an outside agency and failed to ensure that the parent agency provides oversight and administrative control over the branch for 1 of 1 agency.

The agency failed to maintain responsibility for the all contracted agreements, ensure contracted agreements were authorized by the administrator, and that the contracts contained the legal name of the surveyed agency for 1 of 1 agency.

The agency failed to ensure the skilled nurse (SN) performed a complete physical assessment per professional standards for 3 of 3 skilled nurse home visits.