Pediatric Nursing Specialists of Indiana

The agency failed to maintain a communication plan that included contact information for federal, state, local, and regional entities or other sources of assistance for 77 of the 92 counties served by the agency.

The agency failed to ensure continuity of care by providing pertinent information to another home health agency or facility of their patient to the alternate entity that would be responsible for providing ongoing care for 1 of 1 transfer discharged records reviewed (Patient: #6) and 1 of 1 transfer…

The agency failed to contact and facilitate the safe transfer of their patient to the alternate entity that would be responsible for providing ongoing care for 1 of 1 transfer discharged inactive records reviewed.

The agency's Emergency Preparedness program failed to evidence a testing and training plan or procedure, thereby failing to ensure the effectiveness of the agency's program, in 1 of 1 Emergency Preparedness program reviewed.

Failed to analyze and document their response by completing after-action reports, and failed to revise the agency's Emergency Preparedness program based on the outcome, in 1 of 1 Emergency Preparedness programs reviewed.

The agency failed to ensure the frequency and detail of the data collected in the development of the Qaulity Assurance Performance Improvement(QAPI) program was approved by the agency's governing body in 1 of 1 agency.

The agency failed to initiate Performance Improvements Projects (PIPS) for identified elements, define why elements of a PIP were determined to be a priority and measure the progress for each PIP for the Quality Assessment and Performance Improvement Program (QAPI).

The agency failed to have a Governing Body assume full legal authority and responsibility for the agency's overall management and operation, including its quality assessment and performance improvement program.

The Clinical Manager and the Alternate Clinical Manager failed to ensure one was available upon surveyors' arrival, failed to ensure they were able to travel within a reasonable distance to the office/and or field, failed to ensure they had a set schedule of when they will be at this location on a…

The agency failed to identify correct durable medical equipment in the individualized plan of care in 1 of 3 home visits conducted.

The agency failed to establish a system to measure and track performance elements related high risk, high volume and problem prone areas to ensure improvements were sustained.

The agency failed to have a qualified Administrator and an agency-appointed Governing Body to ensure a qualified Alternate Administrator and/or Clinical Manager was appointed to assume the same responsibilities and obligations as the Administrator during their absence from this agency.

Failed to ensure 15 patients receiving care and services were provided by clinicians who were directly employed by this agency and failed to ensure 2 of 2 service contracts under arrangement were able to provide therapy services that cover the entire state of Indiana.

The agency failed to ensure a discharge summary was written and sent to the primary care physician who is responsible for the patient's care after discharge within 5 business days of the patient's discharge for 1 of 2 discharged record reviews.

The agency failed to ensure comprehensive assessments were conducted in-person by registered nurse (RN) and thereby failed to ensure the comprehensive assessments were complete and based on hands-on, skilled assessments (G0518), failed to ensure the comprehensive assessment accurately reflected the…

The agency failed to ensure that patient's were serviced based on the reasonable expectation the agency could meet patient's medical and nursing needs by failing to ensure each patient received an individualized plan of care, care and services specified as necessary to meet patient-specific needs…

The agency failed to ensure key Administrative positions were actively filled or designees assigned timely when vacancies existed, failed to ensure the integrity of the organizational structure, and failed to ensure all lines of authority were clearly established and current staff were aware of…

The agency failed to ensure comprehensive assessments were conducted in person by a skilled registered nurse and included skilled hands-on physical assessment, and instead utilized telehealth for recertification assessments and resumption of care assessments, in 6 of 6 active clinical records…

The agency failed to ensure the content of the comprehensive accurately reflected the patient's status in 6 of 6 active clinical record reviews (Patients #4, 5, 6, 7, 8, and 10) and 1 of 2 closed record reviews (Patient #3).

The Governing Body failed to assume full responsibility for the agency's overall management and operations related to the provision of skilled nursing services by the registered nurse, in relation to performing comprehensive assessments and supervisory visits via telehealth for 1 of 1 Governing…

The agency failed to ensure a Clinical Manager or Alternate was in place, failed to establish new organizational structure, and failed to disseminate information of changes to remaining staff of same, in 1 of 1 agency surveyed.

The agency failed to discharge a patient when the agency could no longer provide physician ordered services in 1 of 6 active clinical records reviewed.

The agency failed to ensure an accurate and complete assessment was completed to reflect the patient's current health status in 3 of 8 records reviewed.

The agency failed to ensure a thorough review of medication occurred as part of the comprehensive assessment/reassessment to ensure accuracy of the current medication regimen for 1 of 8 clinical records reviewed (Patient #6).

The agency failed to ensure patient-specific interventions were identified in the care plans of 4 of 6 active clinical records reviewed.

The agency failed to ensure services and treatment were included on the Plan of Care and only provided as ordered by a Physician, in 1 of 6 active clinical records reviewed (Patient #7).

The agency failed to ensure the ordering physicians for patients were notified of recertification and resumption of care assessments being performed via telehealth with staff or a family member in 4 of 6 active clinical records review.

The agency failed to ensure skilled nursing supervisory visits identified the nurse being supervised in 5 of 6 active clinical record reviews.

The agency failed to ensure the supervising registered nurse made an on-site visit to the patient's home to observe and assess the aide performing care in 1 of 1 clinical records receiving home health aide services.

The agency failed to ensure the Administrator or their alternate was responsible for the day to day operation of the agency; failed to ensure staff were available during operating hours and for survey activities, failed to ensure comprehensive assessment visits were performed by a registered nurse…

The agency failed to ensure a Clinical Manager or alternate were in place, available during hours operation, and available for survey activities, in 1 of 1 home health agency surveyed.

The agency failed to ensure an Administrator or alternate was in place, available during operating hours, and available for survey activities, in 1 of 1 home health agencies surveyed.

The agency failed to ensure a patient was accorded the opportunity to participate in care planning, as required by agency policy, in relation to the failure of the agency to furnish skilled nursing services, a change in the care to be furnished (See G 434); the agency failed to ensure patient…

The agency failed to maintain on active service only patients for whom the agency could provide skilled nursing visits to meet the patient's needs for 1 of 1 patient whose services were placed on hold, of a total sample of 7 (See G 570); failed to ensure verbal orders were put into writing and sent…

The administrator failed to ensure missed visit notifications to physicians were not performed by an outside entity, employees at the Ohio corporate office, without the administrator having established a contract with the outside agency, without the right to have input, review authority, authority…

The agency failed to ensure policies and procedures were in place in relation to the required documentation for orientation, training, and duties which could be delegated, in the event the agency recruited volunteers for service during an emergency/disaster for 1 of 1 home health agency emergency…

The facility failed to develop a method for sharing information with non-health care providers in relation to the location and general condition of the patients on service during an emergency and/or disaster for 1 of 1 home health agency emergency preparedness plan.

The administrator failed to ensure the home health agency maintained a quality assurance and performance improvement (QAPI) program which objectively demonstrated improvement for 2 out of 2 quality assurance and peformance improvement plans- receipt of original timesheets, and receipt of original…

The administrator failed to ensure the home health agency maintained a quality assurance and performance improvement (QAPI) program which documented the reasons for conducting its performance improvement plans for 2 out of 2 QAPI performance improvement plans.

The agency failed to provide skilled nursing services and at least one other qualified therapeutic service such as physical therapy, occupational therapy; medical social services; speech language pathology; or home health aide; in the patient's place of residence, for 1 of 1 home health agency.

The agency failed to ensure a patient was accorded the opportunity to participate in care planning, as required by agency policy, in relation to the failure of the agency to furnish skilled nursing services, a change in the care to be furnished, for 1 (Patient #6) of 7 patients.

The agency failed to ensure patient rights were accorded, as required by agency policy, to include the provision of the skilled nursing care visits ordered by the physician in the plan of care for 1 (Patient # 6) of 7 patients.

The agency failed to ensure it implemented agency policy to arrange a safe and appropriate transfer to another home health agency when it did not have sufficient skilled nurses to meet the patient's needs for 1 (Patient #6) of 1 patients whose services were placed on temporary hold, of a total…

The agency failed to document an appropriate resolution to a complaint for 1 (Patient # 6) of 13 complaints in the 2018 complaint log.

The agency failed to ensure verbal orders were put into writing and sent to the attending physician for counter-signature for 5 (Patients #1, 2, 3, 4, and 7) of 7 patients whose clinical record was reviewed.

The agency failed to ensure that coordination of care occurred between staff, other care providers, and/or the physician, and was documented in the clinical record for 3 (Patient #3, 4, and 6) of 7 records reviewed.

The administrator failed to ensure the home health agency maintained a quality assurance and performance improvement (QAPI) program which objectively measured the success of 2 out of 2 performance improvement plans, as required by agency policy.

The administrator failed to be responsible for the day to day management and operations of the home health agency in relation to the need to amend 1 of 21 policies reviewed.

The clinical manager failed to ensure coordination of care activities occurred and were documented for 2 (Patient #3 and 6) of 7 patients.

The clinical manager failed to ensure the plan of care was implemented for 1 (Patient #6) of 7 patients.

The agency failed to ensure all entries in a patient's clinical record were accurate for 1 (Patient #6) of 7 clinical records reviewed and failed to ensure the skilled nurse completed visit notes on the day the visits occured and faild to ensure the visit notes were incorporated into the clinical…