Caretenders Visiting Services of Kentuckiana LLC

The agency failed to individualize a plan of care for 5 of 5 active clinical records reviewed (Patients #1, #2, #3, #4, and #5) and 2 of 3 inactive clinical records reviewed (Patients #7 and #8) Findings Include: 1. A policy titled “Plan of Care (POC), Policy Number: 2.1.007” revised on 12-01-2021…

The agency failed to ensure proper infection control practices were followed for 1 of 1 Registered Nurse (RN) observed providing wound care on a home visit.

The agency failed to ensure the plan of care included all necessary durable medical equipment (DME) for 1 of 1 active record reviewed with a home visit of a nurse providing wound care.

The agency failed to ensure care was coordinated with the nursing home for 1 of 1 inactive clinical record reviewed who transferred to a nursing home.

The agency failed to ensure care was coordinated with Assisted Living Facilities for 1 of 1 home visit in an Assisted Living Facility.

The agency failed to ensure a transfer summary was sent to the physician and the entity assuming care of the patient for 1 of 3 inactive clinical records reviewed.

The agency failed to ensure an emergency preparedness program was in place for the agency (See tag E0001); failed to ensure an emergency plan was in place to include a risk assessment and the inclusion of emerging infectious diseases (tag E0004) the emergency plan included facility -based and…

The agency failed to ensure an initial assessment was completed within 48 hours of a referral (See tag G514); failed to ensure the accuracy and completeness of the comprehensive assessment (see G526); failed to ensure the medication profile was up to date and include all changes in coumadin orders…

The agency failed to identify patient specific needs and failed to address the needs that were identified in the assessments & comprehensive assessment for 3 patients (#1, #4, #5) out of 8 patient records reviewed (see G570); failed to develop individualized plans of care (POC) that included…

The agency failed to ensure administrative and supervisory functions were not delegated to another entity and failed to ensure policies and procedures for 1 of 1 agency.

The home health agency failed to ensure the accuracy and completeness of the comprehensive assessment for 3 (#4, #6, & #8) patients, in a total sample of 8 clinical records reviewed.

The agency failed to develop individualized plans of care (POC) that included patient specific and measurable outcomes and goals for 1 (#4) of a total sample of 8 records reviewed.

The agency failed to ensure discharge orders were implemented 1 of 1 records reviewed (#4) of patients who were hospitalized during a certification period in a sample of 8. Findings include: Review of the clinical record for patient #4 on 4-11-19, evidenced hospital documents from the local…

The agency failed to ensure it implemented an agency quality assurance and performance improvement (QAPI) program to collect data which would enable the agency to take actions aimed at and sustaining performance improvement for 1 of 1 agency.

The Governing Body failed to ensure the governing body discharged its duty to maintain documentation of meeting minutes and all those who participated in regards to the quality improvement program (QAPI) for 2018 & 2019. Findings Include: Review of agency policy provided by the Administrator…

The agency failed to ensure an initial assessment was completed within 48 hours of a referral for 1 (patient #7) of a sample of 8 records reviewed.

The agency failed to ensure the admitting Registered Nurse completed a thorough admission assessment of 1 (patient #6) of 8 patients who was discharged from the hospital with a diagnosis of ascites.

The agency failed to ensure the medication profile was up to date and include all changes in coumadin orders in 1 (#2) out of 8 records reviewed.

The home health agency failed to ensure the resumption of care assessment was completed within 48 hours of the patients return home from hospitalization for 1 (#4), in a total sample of 8 clinical records reviewed.

The agency failed to ensure all pertinent information was included in the plan of care in 5 (# 1, #4, #5, #6 & #8) out of 8 records reviewed.

The agency failed to ensure skilled nursing put all verbal orders in writing and sent to the ordering physician for signature in 1 (#2) out of 8 records reviewed.

The agency failed to ensure the primary care physician was notified and orders obtained in regards to discharge instructions recommending a waffle cushion to prevent further deterioration of a wound for 1 of 1 record review of a patient discharged from a hospital during a certification period in a…

The agency failed to ensure they documented actions aimed at performance improvement, measured its success and tracked performaces to ensure that imporvements were sustained for 1 of 1 agency.

The agency failed to ensure thorough and accurate on-going assessment of patients diet, weight and abdominal girth of 1 (patient #6) out of 8 records reviewed.

The skilled nurses failed to ensure they accurately documented Intravenous medication administered, failed to ensure physician responses and tasks provided were documented within the clinical visit notes/ clinical record in 1 (#2) out of 8 records reviewed.

Communication With Physicians