Pediatric Infant & Family Personal Care Special

The home health agency failed to ensure the quality assurance and performance improvement (QAPI) program focused on patients’ hospitalizations rate of 29% in October 2025, 7% in November 2025, and 7% in December 2025. Findings include: A Patient Hospitalization Sheet indicated Patient #16 was…

The home health agency failed to ensure: the comprehensive assessment reflected patients’ health/psychosocial/cognitive status (see G0528); the comprehensive assessment included patients’ strengths/goals (see G0530); the comprehensive assessment included review of medication (see G0536); the…

The home health agency failed to ensure: skilled services were provided as ordered (See G0572); the plan of care included all required information / elements for the treatment of the patient (See G0574); all orders were recorded in the plan of care (See G0576); verbal orders were written and…

The home health agency failed to evidence they had a QAPI program that measured, analyzed, and tracked quality indicators (G0642); utilized data to identify opportunities for improvement (G0644); improvement activities focused on high risk or problem prone areas (G0646); performance improvement…

The agency failed to ensure patients’ comprehensive assessment included an individualized emergency plan in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7).

The agency failed to ensure emergency preparedness training was completed and documented for new and at least every 2 years for existing staff for 1 of 1 RN, 4 of 4 Home Health Aides, 2 of 2 LPN’s, 1 of 1 Physical Therapist, and 1 of 1 Alternate Director of Nursing personnel records reviewed (RN 2…

The agency failed to ensure Outcome and Assessment Information Set (OASIS) was submitted within 30 days of completing the assessment of the patient in 2 of 4 home visits conducted (Patient #1,# 3).

The agency failed to ensure the Outcome and Assessment Information Set (OASIS) data accurately reflected patients documented status at the time of the comprehensive assessment in 2 of 6 active clinical records reviewed who had OASIS data submitted to Centers for Medicare/Medicaid Services (CMS)…

The agency failed to ensure each patient received the home health services that were written in the individualized plan of care that identified patient specific measurable outcomes and goals in 3 of 4 active clinical records reviewed with wound care (Patient #1 and #3).

The agency failed to evidence home health aides had written patient care instructions prepared by a RN in 1 of 1 active clinical record reviewed with a ventilator (Patient #3), and in 1 of 2 active clinical records reviewed with a home health aide only (Patient #4).

The agency failed to ensure the content of the comprehensive assessment accurately reflected the patient’s status and failed to include the patient’s current health, psychosocial, functional and cognitive status in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7).

The agency failed to ensure the comprehensive assessment included patients’ strengths and goals and progress towards goals identified by measurable outcomes in 3 of 5 active clinical records reviewed with wound care (Patient #1, #3, #6).

The agency failed to ensure the comprehensive assessment included a review of all medications taken by the patient in order to identify significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy in 1 of 1 active clinical records reviewed with a ventilator (Patient…

The agency failed to ensure the comprehensive assessment included an assessment of patient’s primary caregiver, including their willingness and ability to provide care and availability, in 1 of 1 active clinical record reviewed with a feeding tube (Patient #1), in 1 of 1 active clinical record…

The agency failed to ensure the comprehensive assessment included incorporation of the Outcome and Assessment Information Set (OASIS) items to include clinical record items, demographics, patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory…

The agency failed to ensure the plan of care included all medications and treatments, safety measures to protect against injury, patient and caregiver education and training to facilitate timely discharge, and measurable outcomes and goals identified by the agency and the patient in 7 of 7 active…

The agency failed to ensure all orders were recorded in the plan of care in 1 of 1 active clinical records reviewed with a feeding tube (Patient #1).

The agency failed to ensure physician verbal orders were documented, signed and dated in the patient’s clinical record in 7 of 7 active clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7).

The agency failed to ensure physician orders were integrated to ensure the coordination of all services and interventions provided to the patient in 1 of 1 active clinical record reviewed with a feeding tube (Patient #1).

The agency failed to coordinate care delivery to meet the patient’s needs in 1 of 2 active clinical records reviewed that attended wound clinic (Patient #6).

The agency failed to ensure each patient received the services and treatments ordered in the plan of care for 2 of 2 clinical records reviewed where a tracheostomy (an incision in the neck to open a direct airway) was present.

The agency failed to ensure the plan of care was individualized and included complete medication orders and orders for discipline and treatment for 6 of 7 clinical records reviewed.

The home health agency failed to ensure medications and treatments were carried out according to the physician orders for 4 of 7 clinical records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition in 2 of 2 patients with a tracheostomy (an opening created in the neck to help someone breathe).

The home health agency failed to ensure the skilled nurse (SN) prepared clinical notes to document on all pertinent tasks as identified in the plan of care and policy for 6 of 7 clinical records reviewed.

The home health agency failed to ensure all employees practiced standard/universal precautions in 2 of 2 home visits observed.

The home health agency failed to follow infection control guidelines in 1 of 1 home visits (#10) observed with a Registered Nurse (#O).

The agency failed to ensure the comprehensive assessment identified and included an assessment of a patient with wounds and IV 1 of 6 records reviewed (#10).

The skilled nurses failed to ensure a complete assessments were provided per professional standards and per the plan of care for 1 of 2 active clinical records reviewed (#10) of patients admitted after 12/10/18 and 1 of 3 discharged (#14 ) records reviewed with skilled nursing services.

The agency failed to ensure the patient's medical and nursing needs were met in his or her place of residence for 4 of 8 records reviewed (#1, #2, #5, #8) and for 1 of 3 active clinical records reviewed with home health aides in a sample of 8 (#1) (See G 570); failed to ensure treatment and…

The agency failed to develop, implement, evaluate and maintain an effective, ongoing, HHA - wide, data driven Quality Assurance Performance Program (QAPI) (G 640); failed to ensure the quality assurance program was capable of showing measurable improvement and must measure, analyze and track…

The home health agency failed to follow infection control guidelines in 1 of 1 home visits observed with a Registered Nurse and 1 of 2 home visits observed with a Licensed Practical Nurse (see G 682) and failed to evidence the infection control program was a part of the quality assurance program…

The Registered Nurse/ Case Manager failed to ensure the plans of care contained all durable equipment needed (see G 708); failed to ensure treatment and services were provided per the physician ordered plan of care for 4 of 8 clinical records reviewed (see G 710); and failed to ensure the skilled…

The agency failed to ensure treatment and services were provided per the physician ordered plan of care for 4 of 8 clinical records reviewed (#1,#2, #5, #8) and for 1 of 3 active clinical records reviewed with home health aides in a sample of 8 (#1).

The home health agency failed to follow infection control guidelines in 1 of 1 home visits (#6) observed with a Registered Nurse (#O) and 1 of 2 home visits (#2) observed with a Licensed Practical Nurse (#B).

The agency failed to evidence the infection control program was a part of the quality assurance program for 1 of 1 agency.

The governing body failed to ensure the quality assurance program had been developed, implemented, evaluated and maintained and ensured an effective, ongoing, HHA wide, data-driven quality assurance program for 1 of 1 agency.

The agency failed to ensure clinical records reviewed included entries which were accurate, authentic, and complete for 6 of 8 records reviewed (#1, #2, #4, #5, #6, #8).

The agency failed to accord all patients the right to receive all services in the plan of care for 4 of 8 patients whose clinical records were reviewed (Patients #1, #2, #5, #8).

The agency failed to ensure patients were advised about the purpose of Indiana State Department of Health hotline number for 8 of 8 clinical records reviewed (#1 - #8).

The agency failed to follow agency policy to ensure a registered nurse performed an initial assessment within 48 hours of referral for 1 of 8 patients whose clinical records were reviewed (#2).

The agency failed to ensure a patient's vital signs were obtained and documented upon admission for 1 of 8 records reviewed.

The agency failed to ensure the plans of care contained all durable equipment needed for 3 of 8 records reviewed (#2, #4, #8).

The agency failed to follow their policy by notifying the patient and physician in advance of discharge planning and failed to provide discharge documents to the patient and/ or patient's representative, and the patient's physician for 1 of 2 closed records reviewed (#2).

The Registered Nurse/ Case Manager failed to ensure the plans of care contained all durable equipment needed for 3 of 8 records reviewed (#2, #4, #8) for 3 of 8 records reviewed (#2, #4, #8).

The skilled nurse failed to ensure treatment and services were provided per the physician ordered plan of care for 4 of 8 clinical records reviewed (#1,#2, #5, #8) with skilled nursing services.

The agency failed to ensure the skilled professional services participated in a quality assurance program for 1 of 1 agency reviewed.

The agency failed to ensure treatment and services were provided per the physician ordered plan of care for 1 of 3 active clinical records reviewed with home health aides in a sample of 8 (#1).

The agency failed to ensure the RN made and documented an aide supervisory visit every 14 days with 2 of 3 active clinical records with home health aide services (#1, #5).

The agency failed to ensure the clinical record included a completed discharge summary for 1 of 2 closed records reviewed (#2).