Interim Healthcare of South Bend

Deficiency Corrected 04/15/2022 Deficiency Corrected 04/15/2022

The home health agency failed to ensure the transfer summary included information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences in 1 of 2 transferred patient’s records reviewed (#6).

The agency failed to ensure the patient’s plan of care was individualized, included patient-specific measurable outcomes and goals, and/or the patient received all services indicated on the plan of care, for 4 of 7 clinical records reviewed (#1, 4, 5, 6).

The home health agency failed to ensure all entries into the clinical record were correctly authenticated in 1 of 2 home visits conducted (#4).

The comprehensive assessment failed to include the patient’s current health, psychosocial, functional, and/or cognitive status for 5 of 7 clinical records reviewed (#1, 3, 4, 5, 6).

The registered nurse (RN) failed to ensure the patient’s medication profile included an accurate list of all medications the patient currently used, which included dose, route, frequency, and/or indications for use, for 3 of 7 clinical records reviewed (#1, 3, 5).

The agency failed to ensure the individualized plan of care included all pertinent diagnoses, nutritional requirements, a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors, patient and…

The home health agency failed to ensure physicians were promptly notified of needs that suggested the plan of care should be altered in 1 of 7 clinical records reviewed (#6).

The home health agency failed to ensure patients received a written visit schedule including frequency of visits by home health personnel in 1 of 2 home visits conducted (#4).

The home health agency failed to ensure patients were provided with written medication schedule/instructions in 1 of 2 home visits conducted (#5).

The agency failed to ensure the registered nurse (RN) completed a full physical assessment with complete assessment of lower legs, feet/toes on a patient diagnosed with diabetes, diabetic foot ulcer to (R) heel (open wound due to a combination of factors, such as lack of feeling in the foot, poor…

The home health agency failed to ensure a plan of care for certification period 2/5/2022 - 4/5/2022 included an order from wound clinic M, dated 1/31/22, which indicated wound care was to be provided by the agency 3 times per week to 1 known wound on left foot, and 1 known wound on right heel…

The agency the agency was non-compliant with the 100% COVID-19 vaccination requirement; failed to ensure all employees practiced the use of standard precautions during patient care to prevent the transmission of infections and communicable diseases (See tag G682); failed to ensure all employees…

The home health agency (HHA) failed to employ qualified home health aides; failed to adequately train home health aides; failed to make appropriate HHA patient assignments; failed to assign HHA's to a specific patient by a registered nurse with written care instructions for a home health aide (See…

The registered nurse (RN) failed to ensure the comprehensive assessment was updated and revised (including the administration of the OASIS – outcome and assessment information set) for 3 of 3 records reviewed with patients who experienced a significant change in condition (#3, 5, 10).

The agency failed to develop and implement an effective discharge planning process.

The agency failed to ensure all employees practiced the correct use of standard precautions during patient care to prevent the transmission of infections and communicable diseases for 1 of 6 home visits observed (#10).

The agency was non-compliant with the 100% COVID-19 vaccination requirement; failed to ensure all employees received, at a minimum, the first dose of a multi-dose COVID-19 vaccine, or a one-dose dose COVID-19 vaccine, or was granted (or had a pending request for) exemption, or was identified as…

The agency failed to ensure home health aides were assigned with written patient care instructions prepared by registered nurses in 1 out of 6 clinical records reviewed with home health aides (#6).

The governing body failed to ensure the agency ensured the provision of all home health services occurred in a safe and effective manner.

The home health agency failed to ensure clinical records were secured and protected against unauthorized use in the office setting.

The registered nurse failed to conduct the initial assessment within 48 hours of referral for 3 of 14 records reviewed (#2, 10, 11).

The registered nurse failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the start of care date for 5 of 11 initial comprehensive assessments reviewed (#3, 5, 6, 11, 12).

The registered nurse (RN) failed to ensure the comprehensive reassessment was completed within the last 5 days of every 60-day certification period for 3 of 9 comprehensive reassessments reviewed (#1, 7, 8).

The home health agency failed to ensure all patient care orders were recorded in the plan of care for 1 out of 6 home visits completed (#9).

The agency failed to ensure all drugs, services, and/or treatments were administered only as ordered by a physician for 4 of 14 records reviewed (#1, 2, 5, 8).

The agency failed to ensure the patient’s plan of care was reviewed no less frequently than once every 60 days, for 4 of 9 records reviewed where a recertification/comprehensive reassessment occurred (#1, 6, 7, 8).

The home health agency failed to ensure a revised plan of care reflected current information from an updated comprehensive assessment and contained information concerning the patient's progress toward the measurable outcomes and goals in the plan of care in 2 of 14 records reviewed (#5, 14).

The home health agency failed to ensure communication with all physicians in the plan of care in 2 out of 14 clinical records reviewed (#5, 8).

The home health agency failed to ensure each patient or caregiver received ongoing education and training provided by the home health agency regarding care and services identified in the plan of care to ensure a timely discharge in 8 out of 14 clinical records reviewed (#2, 4, 5, 6, 7, 8, 9, 14).

The home health agency failed to ensure patients received written instruction on any treatments to be administered by home health agency personnel, including therapy services in 5 out of 5 applicable home visits (#1, 2, 7, 9, 10).

The agency failed to ensure home health aides provided only services as ordered and included on the plan of care, and performed by appropriately trained personnel in 5 of 6 patients receiving home health aide services (#5, 6, 7, 8, 14).

The administrator failed to be responsible for all day-to-day operations of the agency.

The agency failed to report to the Indiana Department of Health (IDOH), during any time period prior to this recertification/re-licensure survey, that it operated a branch location (home health agency NN).

The agency failed to ensure the physician was notified when the frequency and/or duration of services ordered in the Plan of Care (POC) were not met in 3 of 9 clinical records reviewed (patients # 3, 5 and 6).

Failed to include homemaker services in the plan of care (POC) in 1 of 9 records reviewed (patient # 3).

The agency failed ensure the the physician was notified when visits were not being made as ordered per the plan of care in 4 of 9 clinical records reviewed (patient # 3, 4, 5,6 ).

The agency failed to ensure the plan of care was revised when a patient's home health frequency changed for 1 of 9 records reviewed.