Pediatric Nursing Specialists of Indiana

The Agency failed to ensure all Governing Body and Administrative staff were knowledgeable in the Federal and State regulations to ensure they met the requirements of a home health agency by employing and furnishing directly or indirectly services other than skilled nursing.

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 91 of the 92 counties served by the agency.

The agency failed to ensure skilled nursing services and at least one other service was provided by direct staff or under an arrangement in 1of 1 stand-alone home health agency.

The agency failed to ensure the Emergency Preparedness program contained a Training and Testing plan or procedure, thereby failing to ensure the program's effectiveness, in 1 of 1 Emergency Preparedness programs reviewed.

The agency failed to conduct Emergency drills/exercises, thereby failed to analyze and document an after- action response, analyze, and utilize the resulting outcomes to revise the agency's Emergency Preparedness program, in 1 of 1 Emergency Preparedness programs reviewed.

The agency failed to ensure the frequency and detail of the data collection in the development of the QAPI program was approved by the agency's governing body.

The agency failed to ensure Performance Improvements Projects (PIPS) were documented, reason for conducting, and measurable progress with each project in 1 of 1 agency.

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 schedule of when they would be at this location on a…

The agency failed to establish a system to measure and track performance to ensure improvements were sustained.

The Governing Body failed to ensure they appointed an appropriate Administrator for this agency.

The Administrator failed to ensure they had a schedule of when they would be at this location on a frequent and consistent basis and failed to ensure they were available, able to respond to emergencies within a reasonable amount of time, and responsible for the day-to-day operations of the home…

The agency failed 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.

The agency 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 skilled nursing services and one other direct or contracted therapeutic service was provided in 1 of 1 home health agency.

The agency failed to ensure comprehensive assessments were conducted in-person by a 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 agency failed 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 same.

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 2 of 2 clinical records reviewed…

The agency failed to ensure the content of the comprehensive assessment accurately reflected the patient's status in 2 of 2 clinical record reviews.

The agency failed to ensure the registered nurse completed a comprehensive assessment after a change in condition occurred in patient status, in 1 of 2 clinical records reviewed (Patient #2).

The agency failed to ensure field staff followed appropriate infection control practices per agency policy while providing patient care in 1 of 2 home visits conducted.

The agency failed to ensure an LPN (Licensed Practical Nurse) adhered to standards of practice when administering medication to a patient, in 1 of 2 clinical records reviewed (Patient #2).

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

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 ensure the comprehensive assessment reflected the patient's current health status in 2 of 2 records reviewed.

The agency failed to ensure the ordering physicians for patients were notified of recertification and resumption of care assessments were being performed via telehealth with staff or a family member in 2 of 2 active clinical record review.

The agency failed to ensure skilled nursing supervisory visits identified the nurse being supervised in 2 of 2 active clinical record reviews.

The agency failed to appoint a willing participant to serve in the role of Administrator, in 1 of 1 home health agency surveyed.

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 and supervisory visits for nursing…

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 staff were following acceptable standards of practice by actively documenting absence of illness or signs/symptoms of COVID-19 for 1 of 1 agency reviewed.

The agency failed to ensure that clinical record entries were legible, clear, and complete for 1 of 2 closed records reviewed.

5. The complete clinical record for Patient 6, SOC 8/16/2011, was reviewed on 7/22/2021 and evidenced the following: A document titled "Plan of Care" for the certification period 5/6/2019-7/4/2019 indicated, but was not limited to, "Orders for Discipline and Treatment SN 9 hours every 30 days ... "…

5. The complete clinical record for Patient 3, SOC 7/28/2017, was reviewed on 7/21/2021 and evidenced the following: A document titled "Plan of Care" for the recertification period 7/7/2021-9/4/2021 indicated, but was not limited to, "Orders for discipline and Treatment PRN SN Hourly 720.00 Hour…

The clinical manager failed to ensure the Plan of Care was followed, implemented, and updated to reflect the services the patient was actively receiving for 3 of 5 active patients reviewed.

The facility failed to ensure that a parent office resided within the agency's service area and/ or had a branch located within service area with contiguous counties.

The agency failed to ensure missed visit reports provided to the physician were specific to include the dates, times, and reasons for missed visits and services for 3 of 4 clinical records reviewed.

The agency failed to ensure patients' needs were met and caregivers were up to date and informed about the care to be furnished and/or of any changes in the care to be furnished for 8 of 14 clinical records reviewed (# 1, 3, 4, 5, 6, 8, 9, and 11) (See G 570); failed to ensure patients received…

The Registered Nurse failed to ensure the plan of care contained specific range in frequency of visits were not large and specific to the patient needs (See G 708) and failed to ensure patients received care as ordered by the physician (See G 710).

The administrator failed to ensure the day to day operations of the agency (See G 948); failed to ensure employees were able to identify who the director of nursing (DON) and alternate director of nursing (ADON) were, made aware of their availability during all operating hours, on and off premises…

The agency failed to ensure Outcome Assessment and Information Sets (OASIS) data were submitted within 30 days of collection for 3 of 3 clinical records reviewed of patients who qualified for OASIS data collection.

The agency failed to ensure patients received care as ordered by the physician for 7 of 14 clinical records reviewed.

The agency failed to ensure the Indiana State Department of Health (ISDH) had been notified for any changes in administration for 1 of 1 agency.

The agency failed to ensure the patient admission booklets contained contact information for the administrator of the agency for 1 of 1 agency.

The agency failed to ensure patients received care as ordered by the physician for 8 of 14 clinical records reviewed.

The agency failed to ensure they arranged a safe and appropriate transfer to other home health agencies due to their inability to provide skilled nurse (SN) coverage for more than 30 days for 3 of 14 clinical records reviewed.

The agency failed to ensure the plan of care contained specific range in frequency of visits were not large and specific to the patient needs for 13 of 14 clinical records reviewed.

The agency failed to ensure a physician was notified of missed visits/ the agencies inabililty to provide services for 1 of 1 physician interview in a sample of 14 clinical records reviewed.

The agency failed to ensure patients' caregivers were informed about the agency's inability to provide staff for physician ordered hours/ visits for 7 of 14 clinical records reviewed.

The Registered Nurse failed to ensure the plan of care contained specific range in frequency of visits were not large and specific to the patient needs for 13 of 14 clinical records reviewed.

Skilled nursing failed to ensure patients received care as ordered by the physician for 7 of 14 clinical records reviewed.

The administrator failed to ensure the day to day operations of the agency.

The agency failed to ensure employees were able to identify who the director of nursing (DON) and alternate director of nursing (ADON) were, made aware of their availability during all operating hours, on and off premises for 1 of 1 agency.

The director of nursing (DON) and alternate director of nursing (ADON) failed to ensure coordination of patient care between the agency and caregivers for 6 of 14 clinical records reviewed.

The director of nursing (DON) and the alternate director of nursing (ADON) failed to ensure the patient needs were met per the plan of care for 8 of 14 clinical records reviewed.

The agency failed to ensure all required documents were in the patient records within 14 days for 2 of 14 clinical records reviewed.