Home Health Crusaders Inc

The home health agency failed to develop and implement an effective discharge planning process based on current federal regulatory requirements (See tag G562); and failed to ensure it sent all necessary medical information to the receiving facility or health care practitioner (See tag G564).

The registered nurse (RN) failed to ensure the patient received all services written on the plan of care, and/or the plan of care was individualized, and included patient-specific measurable outcomes and goals (See tag G572); failed to ensure the patient’s plan of care included 1 or more of the…

The home health agency failed to ensure ongoing interdisciplinary assessment of the patient occurred (See tag G706); failed to ensure the RN provided the patient/caregiver with an education based on the patient's condition/needs (See tag G714); failed to ensure the RN completed clinical notes (See…

The administrator failed to be responsible for all day-to-day operations of the home health agency (See tag G948); and the clinical manager failed to provide oversight of all patient care (See tag G958).

The registered nurse (RN) failed to update/revise the patient’s comprehensive assessment for 3 of 3 records reviewed with patients who experienced a significant change in condition (#1, 3, 4).

The home health agency failed to develop and implement an effective discharge planning process that went into effect 2/21/2020. Findings include: An undated agency policy received 7/19/2022, titled "Patient Discharge from Agency" failed to include a process/procedure on the agency's requirement to…

The home health agency failed to ensure it sent all necessary medical information to the receiving facility or health care practitioner, for 3 of 3 discharged records reviewed (#6, 7, 8).

The registered nurse (RN) failed to ensure the patient received all services written on the plan of care, and/or the plan of care was individualized, and included patient-specific measurable outcomes and goals, for 5 of 5 active clinical records reviewed (#1, 2, 3, 4, 5).

The agency failed to ensure its policies and procedures for COVID-19 Vaccination of Home Health Agency staff included all required elements.

The clinical manager failed to provide oversight of all the agency's clinical patient care, which resulted in an identified immediate jeopardy (IJ), and citation of condition level deficiencies.

The registered nurse (RN) failed to ensure the patient’s medication profile included all medications the patient used, and/or indications, directions/precautions for use, for 4 of 8 clinical records reviewed (#1, 3, 4, 8).

The registered nurse (RN) failed to ensure the patient’s plan of care included 1 or more of the following: all pertinent diagnoses, the patient’s psychosocial status, supplies, and/or equipment required, nutritional requirements, all treatments, safety measures to protect against injury…

The registered nurse failed to administer treatments only as ordered by a physician or nurse practitioner (NP) for 2 of 3 clinical records reviewed with home visits (#1, 3).

The registered nurse failed to inform the patient's relevant physician for 1 of 2 home visits observed with patients who experienced a change condition (#3).

The registered nurse (RN) failed to follow agency policy to ensure the patient’s revised plan of care included a summary of the patient’s condition during the previous certification period, or information concerning the patient’s progress toward the outcomes and goals, for 5 of 5 records reviewed…

The home health agency failed to ensure interdisciplinary assessment occurred for 1 of 1 clinical record reviewed for a patient who experienced a change in condition which required hospitalization (#6).

The home health agency failed to ensure the registered nurse (RN) provided the patient/caregiver with education based on the patient's current condition/needs per the plan of care, for 3 of 4 active records reviewed for patients who had more than 1 skilled nursing visit (#2, 3, 4).

The home health agency failed to ensure the registered nurse (RN) completed the clinical visit note on the day the service was provided, per agency policy, for 4 of 5 records reviewed (#1, 3, 4, 5).

The home health agency failed to ensure the registered nurse (RN) communicated with all physicians for 2 of 2 records reviewed with patients who had more than 1 physician involved in the patient's care (#3, 4).

The administrator failed to be responsible for all day-to-day operations of the home health agency, which resulted in an identified immediate jeopardy (IJ), and citation of condition level deficiencies.

The agency failed to ensure the patient's plan of care was individualized in 1 of 1 patient records reviewed with a home visit (#1).

The agency failed to ensure the registered nurse provided a clear plan of care for the home health aide to follow in 1 of 1 active patient records reviewed receiving home health aide services (#4).

The agency failed to ensure all clinical record entries were legible, clear, complete, and appropriately authenticated in 1 of 1 discharged records reviewed receiving home health aide services (#2) The findings include: Record review on 6/21/2021, evidenced an undated agency document titled…

The agency failed to ensure the individualized plan of care included all services, medications and treatments in 4 of 4 records reviewed.(#1, #2, #3, #4) The findings include: 1. Record review on 6/21/2021, evidenced an undated agency policy titled, "Plan of Care", which stated, " ... POLICY…

The agency failed to coordinate care provided by all disciplines in 1 of 1 patient records reviewed with a home visit (#1).

The home health agency failed to ensure the skilled nurse prepared the clinical notes accurately in 1 of 1 discharged records reviewed receiving home health aide services (#2).

The home health aide failed to provide services as indicated in the aide care plan in 2 of 2 records reviewed receiving home health aide services (#2, #4).

The agency failed to ensure the quality assurance program was capable of showing measurable improvement and measured, analyzed and tracked quality assurance indicators, including adverse patient events, and other aspects of performance that enable the agency to assess processes of care, HHA…

The agency failed to provide the patient and caregiver with a copy of written instructions relating to the patient's care needs for 2 of 2 home observations completed. [patient's 6 and 10] Findings include: 1. Policy #G-2, entitled Emergency Preparedness Plan, undated, was presented by the office…

The agency failed to ensure individualized emergency plans were included as part of the comprehensive assessment in 3 of 4 home visit observations. [# 5, 8, and 11] The findings include: 1. The "EMERGENCY EVACUATION PLAN FOR PATIENTS" policy was provided by Employee C on 8/21/19 at 3:25 p.m.

The agency failed to ensure they electronically submited a completed OASIS (outcome and assessment information set) assessments to the CMS system within 30 days of completing the assessment of the beneficiary for 2 of 10 clinical [#1 and 5 ] records reviewed that required submission of OASIS items…

The agency failed to ensure the initial assessment was completed within 48 hours for 1 of 11 full records reviewed that received skilled services. [9] The findings include: The clinical record for patient #9, was reviewed on 8/21/2019. The record evidenced a referral to the agency dated 7/19/2019…

The Registered Nurse (RN) failed to ensure contents of the comprehensive assessment was accurate for 1 of 11 [#2] records reviewed in a sample of 11 patient records reviewed that received skilled services.

The agency failed to ensure services, procedures and treatments were not provided absence of a physicians order plan of care for 1 of 11 (#5) full records reviewed, the Skilled Nurse visit failed to complete a skin assessment as identified in the signed physician's Plan of Care for 1 of home visit…

The agency failed to provide the patient and caregiver with a copy of the current plan of care for 2 of 4 home observations.

The agency failed to ensure standard infection control practices related to handwashing and glove use were followed during patient care for 2 of 3 home visits observed of skilled nurse care.

The agency failed to ensure an Infection Control Policy was in place to identify, evaluate, and analyze possible root causes of specific infections identified as reported in the 2018 Infection Control Program and to ensure staff followed the policy in regards to reporting infections for 1 of 2…

The agency failed to ensure that skills competencies were completed on live, active patients for 2 of 2 home health aide personnel file review.

The agency failed to ensure all entries in the record were appropriately authenticated in 4 of 11 sample record reviewed [#1, 6, 10, and 11] The findings include: 1. An undated policy titled "Plan of Care," provided by the office manager on 8/22/19 at 7:15 p.m., indicated, but was not limited to…

The agency failed to ensure patients' clinical medical records were protected from destruction for 174 of 174 potentially identified patient's clinical records stored in cardboard boxes on the floor in the medical room storage area.

The agency failed to ensure patient and / or patient representatives was provided Authorization and Agreement for care, and Acknowledgement Forms, Notice of Privacy Rights, the disciplines that would furnish care, the type of care to be provided, the anticipated frequency / duration of visits to be…

The agency failed to notify new patients upon admission of the written policy and procedure for transfer and discharge for 1 of 1 agency reviewed for Patient Rights.

The agency failed to maintain documentation that it did provide a patient a written notice of patient rights in 2 out of 11 records reviewed of a sample of sample of 11. (#2 and 7) Findings include: 1. The clinical record for patient #2, start of care [SOC] 5/07/2019 was reviewed on 8/20/2019 via…

The entity failed to complete a medication review during each skilled nursing visit for 1 of 4 home observations.[10] The findings include: A home observation for patient #10 was completed on 08/21/19 at 1:00 p.m.

The entity failed to complete the comprehensive assessments no later than 5 calendar days after the start of care for 1 of 11 full clinical records reviewed.

The agency failed to include all active health and medical problems on the comprehensive assessment for 1 of 11 clinical records reviewed.

The Registered Nurse (RN) failed to ensure the Comprehensive assessment included patient specific strengths and care preferences in 4 of 11 record sample reviewed [#1, 2, 6, 10] and included individualized and measurable patient goals for 2 of 11 record sample reviewed (#5 and 8).

The entity failed to include start dates for all of the medications the patient is currently taking for 1 of 11 [#10] clinical records reviewed and failed to maintain a current medication profile for 1 of 11 [#6] clinical records reviewed.

The agency failed to complete a recertification assessment within 5 calendar days of the 60-day recertification period for 1 of 11 clinical records reviewed. [#1] Findings include: Policy #E-4, entitled Comprehensive Assessment, undated, was presented by the office manager on 08/22/19 at 7:15 p.m.…

The the plan of care failed to include all transfer and mobility devices and pertinent safety measures and individualized needs of the patient in 2 of 11 [patient 6 and 10], failed to include to include all patient-specific interventions and education, measurable outcomes and goals for risks…

The agency failed to follow their policy and incorporated all orders for therapy into one plan of care for 7 of 10 sample records reviewed that received therapy services [3, 4, 5, 8, 9, and 11] and all orders were recorded in the plan of care for 1 of 11 sample record reviewed [#10]. The findings…

The agency failed to ensure the followed their policy in relation to verbal orders only being accepted only by personnel authorized to do so for 1 of 11 clinical records reviewed.

The home health agency failed to to coordinate the plan of care and all services of all disciplines for 8 of 10 clinical records reviewed with therapy services [1, 3, 4, 6, and 8, 9, 10, 11] for 1 of 1 agency.

The agency failed to provide the patient and caregiver with a current copy of patient medication schedule and instructions that included the medication name, dosage, frequency and instructions for 1 of 4 home observations.

The Interdisciplinary Team failed to reassess a patient's need when it was identified that the primary caregiver was ill and had difficulty caring for the patient for 1 of 3 home visit observations.

The agency failed to ensure that on-site supervisory visits to the patient's home were completed no less frequently than every 14 days for 1 of 4 clinical records reviewed that received the services of a home health aide and a skilled service.

The agency failed to ensure the physical therapist followed the agency's policy and followed the Indiana Code 15-27-1-2(c) in regards to providing direction, oversite, and consulted, with the physical therapist assistant(s) [PTA] who provided the physical therapy [PT] services for 3 of 3 patient…

The agency failed to ensure discharge summaries were prepared and sent to the attending physician in 1 [3] of 3 full record review of closed records.