Heritage Home Health Services of Indiana LLC

The home health agency failed to develop an emergency preparedness plan, (E0004); failed to ensure the plan included a current facility-based or community-based risk assessment, or strategies for addressing emergency events identified by a risk assessment of the agency (E0006); failed to ensure…

The agency failed to evidence they met all requirements in order to participate in the Medicare Program when they failed to accept and admit patients and provide skilled services since 09/07/2022. The cumulative effect of this systemic problem resulted in the agency being out of compliance with…

The agency failed to ensure their promoted and protected patients' rights when the agency failed to ensure a safe and appropriate transfer to other health care entities when the needs of the patients exceed the agency’s capabilities (G 454) and failed to ensure their patients were provided…

The home health agency failed to evidence failed to evidence they provided necessary medical information pertaining to the patient’s current course of illness and treatment to the receiving health care practitioner and receiving facility, if any, to ensure a safe and effective transition of care…

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity as well as assure that administrative and supervisory functions are not delegated to another agency or organization, (G0940); failed to evidence a governing body or…

The agency failed to ensure they could meet the patient needs at home for 2 of 6 (#4, #5) active patients, from a sample of 8, who went without skilled nursing visits as ordered by the physician, which had the potential to affect all patients (See G0570); the agency failed to ensure the plan of…

The Governing Body failed to develop a COVID- 19 emergency preparedness policies and procedures in relation to staffing strategies during an emergency, e.g. the COVID-19 pandemic, which affected the delivery of services to 8 of 8 patient records reviewed (Patient #4, 5, 9, 10, 11, 12, 13, 14) and…

The home health agency failed to ensure skilled nursing was provided without delay per hospital discharge orders for 1 of 3 records reviewed (#4) from a sample of 8. Findings include: 1. An undated agency policy titled " Physician orders, " Home Care staff will administer care and treatment…

The agency failed to ensure their QAPI (Quality Assessment Performance Improvement) program included agency complaints/ grievance and utilized quality indicator data, including measures derived from OASIS.

The agency failed to ensure it followed accepted standards of practice, including use of standard precautions when practicing bag technique and performing hand hygiene, to prevent the transmission of infections and communicable diseases in 1 of 1 (#3) patients from a sample of 8. Findings included…

The agency failed to ensure policies and procedures created in regards to the pandemic, were signed/ approved by the Governing Body and failed to ensure policies and procedures were reviewed and revised (when needed) to ensure the agency was operating with current professional practices and…

The agency failed to inform the patients in advance of disciplines which would be furnished and frequency in establishing the start of care (SOC) in 2 of 3 active patients (#4, #6) from a sample of 8. Findings include: 1. Review of an undated agency policy titled " Patient Rights," Excel Home…

The home health agency failed ensure skilled nursing initiated care per hospital discharge orders for 1 of 3 records reviewed (#4). from a sample of 8. Findings include: An undated agency policy titled Physician orders, indicated, but was not limited to, "Home Care staff will administer care and…

The agency failed to ensure the comprehensive assessment was complete and accurately reflected the patient's status, including current health, psychosocial, functional, and cognitive status for 3 of 8 reviewed (#5, #7, #4).

The agency failed to ensure comprehensive assessment contained individual patient goals, strengths, and care preferences identified by the patient for 4 of 6 active records (patients 4, 5, 6, 7) from a sample of 8. Findings included: 1. A review of an undated agency policy titled "Comprehensive…

The agency failed to ensure the clinician completed a review of all medications the patient was using in order to identify any potential adverse effects and drug reactions, including ineffective therapy, adverse effects/reactions, side effects, drug interactions, duplicate therapy, and…

The agency failed to ensure the plan of care was individualized and included all correct and pertinent diagnoses and their onset date and status, all supplies and equipment, all treatment orders, diet, safety measures, all medications the patient was taking, accurate medications including…

The agency failed to ensure performance improvement projects (PIP) identified, took/ updated actions and failed to ensure projects initiated in the first quarter of 2020 were followed up on to ensure improvements were achieved and/ or sustained.

The agency failed to ensure clinical notes prepared documented how a patient tolerated procedures in 1 out 2 active records (patient 6) reviewed of a patient receiving wound care in a sample of 8. Finding include: The clinical record of patient #6, start of care 12/11/2020, was reviewed on…

The agency failed to ensure the clinician communicated with the patient's physician(s) to establish plans of care, review medical findings, or discuss changes in condition for 2 of 2 (#5, #7) active patients reviewed in a sample of 8. Findings include: 1. A review of an agency policy, revised…

The Administrator failed to ensure they were responsible for all day to day operations of the agency in regards to ensuring patients are accepted on the basis that the agency can meet their needs, visits are provided per the physician ordered plan of care, the Clinical Manager's inability to…

The agency failed to obtain a physicians order to delay an initial assessment that was not going to be conducted within 48 hours of referral in 1 of 7 records reviewed.

The agency failed to ensure the skilled nurse included consistent wound measurements in the clinical notes in 2 of 7 records reviewed.

The agency failed to ensure the skilled nurse documented consistent wound measurements to indicate improvement of wounds in 2 of 7 records reviewed.