Summit Home Care

The agency failed to evidence the Governing Body delineated the agency’s QAPI program from a separate entity’s QAPI program (G0942), employ qualified personnel for the Alternate Director of Nursing position (G0952), failed to inform Entity 3, a state department of health, about the relocation of…

The agency failed to ensure the agency’s QAPI program was delineated from other agency’s QAPI programs for 1 of 1 home health agency QAPI program.

The agency failed to ensure the budget was exclusive to the agency to meet the patients' needs for 1 of 1 home health agency.

The agency failed to ensure the patients received information regarding the correct state toll free hot line for 7 of 7 patient admission packets reviewed during home visits.

The agency failed to ensure the patients had an initial evaluation 48 hours after a referral or hospitalization for 3 of 5 active clinical records with patients who transferred or discharged from the agency and were readmitted (Patients #4, #5, and #19).

The agency failed to ensure all necessary elements including diagnoses, HHA interventions, all physicians were included in the POC, and DME for 10 of 12 active clinical records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #11).

The agency failed to ensure the physician was notified when a patient was hospitalized for 6 of 6 active clinical records reviewed with patients being hospitalized and failed to notify the physician a patient was being discharged.

The Administrator failed to ensure a qualified individual was in the position of Alternate Director of Nursing for 1 of 1 Alternate DON.

The agency failed to ensure they notified Entity 3, a state health department of a change in location of their branch location for 1 of 1 agency branches.

The agency failed to ensure the contents of the clinical record included coordination notes with other entities providing services for 5 of 11 records reviewed with patients receiving outside services.

The agency failed to ensure the discharge/transfer summary contained all the necessary elements and were sent to the physician for a patient transferred or discharged from the agency for 5 of 5 active clinical records reviewed (Patients #4, #5, #11, #12, and #19) and 2 of 5 inactive clinical…

The agency failed to ensure the comprehensive emergency preparedness program met all requirements to meet the health, safety, and security needs of their staff and patient population for 1 of 1 agency (E0001); failed to ensure an Emergency Preparedness Plan was in place and reviewed every 2 years…

The agency failed to use measurable indicators to improve outcomes, patient safety, and quality of care (G 642); failed to use data derived from OASIS (Outcome and Assessment Information Set) assessments to monitor services and quality of care and failed to obtain governing body approval for the…

The agency failed to ensure staff implemented infection prevention measures, including hand hygiene, while providing patient care in 2 of 7 home visit observations (G682) and failed to ensure their Covid-19 Vaccine Mandate policy and procedures were implemented from December 29, 2021 through a…

The agency failed to ensure staff implemented infection prevention measures, including hand hygiene, while providing patient care in 2 (Home health aide # 1 and physical therapy assistant #1) of 7 home visits observations.

The agency failed to ensure their Covid-19 Vaccine Mandate policy and procedures were implemented from December 29, 2021 through a period of 6 months, during a pandemic, and failed to ensure that the agency met the Covid-19 Vaccine Mandate at 100% compliance for 1 of 1 agency, with the potential of…

The agency failed to conduct an initial assessment within 48 hours of discharge in 1 of 7 home visits conducted with a record review (Patient #11).

The comprehensive assessment failed to contain all information about the current health status for 8 of 17 records reviewed (Patient's #4, 5, 9, 10, 12, 13, 14, and 17).

The agency failed to notify the physician of not completing the SOC (start of care) assessment/treatment when it was ordered by the physician in 1 patient of 17 record reviews (Patient #11).

The agency failed to maintain competency evaluations for 1 of 1 Home Health Aide personnel file reviewed (Employee home health aide #1).

The agency failed to ensure the comprehensive assessments were complete and accurately reflected the patient’s health status to ensure the patients’ needs were being met in 2 of 8 records reviewed.

The agency failed to ensure the plan of care was established/reviewed in conjunction with the attending physician for 7 of 8 records reviewed.

The agency failed to notify the Indiana Department of Health of a change in ownership for 1 of 1 change in ownership.

The governing body failed to exercise its responsibility for the agency's management by having failed to amend policies with the name of an outside agency [entity D] to the agency name for 1of 6 policies reviewed.

The agency failed to ensure patients received and had an understanding of Patient Rights for 5 of 8 active and discharged patients.

The agency failed to ensure patients understood and had received in writing, the phone number and the name of the Administrator in 7 of 8 active and discharged clinical records.

Ncy failed to ensure Outcome and Assessment Information Set (OASIS) privacy notice and rights were provided to patients/caregivers at the start of care and failed to ensure education of OASIS rights was documented in 5 (Patients # 1, 5, 6, 7, and 8) of 5 patients who had received skilled care, out…

The agency failed to document services and care including the frequency of visits, ensuring the patients and family/caregivers were consulted and consented to planned services and care in 5 of 8 active and discharged clinical records.

The agency failed to advise patients/families in writing of expected payment for services from Medicare, and of possible charges for services that may not be covered by insurance at the time of admission in 5 of 8 active and discharged clinical records.

The agency failed to ensure the initial assessment visit was completed either within 48 hours of a referral, discharge from a facility, or to obtained a physician-ordered start of care date for 2 of 8 clinical records reviewed.

The agency failed to ensure services were provided only upon a physician's order in 7 of 8 clinical records reviewed.

The agency failed to ensure the individualized plan of care was reviewed and revised in conjunction with the ordering physician as frequently as the patient's condition or needs warranted in 4 of 8 patient record reviews.

The agency failed to ensure coordination of care occurred between interdisciplinary team members and the attending physician, in order to meet the changing needs of the patient in 3 (Patients #3, 5, and 6) of 8 patient's whose clinical record was reviewed.

Clinicians failed to document all pertinent data and completely assess patients receiving skilled services, and failed to ensure all clinicians discussed among the team members regarding changes in the patient’s health status for 1 of 8 records reviewed (Patient #2).

The skilled clinicians failed to communicate with the attending physician involved in the plan of care related to the adequacy of the current plan of care for 1 of 8 patients (Patient #3) Findings include: A review of the clinical record of Patient #3 on 12/1/21, contained a plan of care for a…

The Administrator failed to execute all of their responsibilities for the day-to-day operations of the home health agency, for 1 of 1 Administrator.

The agency failed to develop and implement COVID- 19 emergency preparedness policies and procedures which addressed staffing strategies during a COVID- 19 emergency.

The agency failed to ensure all Outcome and Assessment Information Set (OASIS) questions were answered accurately for 12 of 17 records reviewed (#1, 3, 4, 5, 7, 8, 9, 12, 13, 14, 15, 17).

The agency failed to ensure all staff followed infection control policies and standard precautions for 4 of 7 home visit observations (#1, 2, 3, 7).

The Registered Nurse failed to ensure the home health aide (HHA) care plan was individualized with specific timeframe's the tasks were to be completed for 3 of 3 records reviewed with HHA services (#2, 3, 12).

The comprehensive assessment failed to contain all information about the current health status for 6 of 17 records reviewed (# 2, 4, 5, 7, 12) Findings include: 1. An undated agency policy titled "comprehensive client assessment," Policy C-145 stated "POLICY: A thorough, well-organized…

The agency failed to ensure comprehensive assessment contained individual patient goals, strengths and care preferences identified by the patient for 17 of 17 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17) Findings include: 1. An undated agency job description titled…

The registered nurse (RN) failed to ensure that as needed (PRN) medications contained indications for their use and medication interactions were sent to the physician for 13 of 17 records reviewed (#3, 4, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17).

The agency failed to ensure the plan of care (POC) included all measurable goals based on the needs of the comprehensive assessment, all durable medical equipment (DME) and supplies, all treatment orders, diet, safety measures, diagnosis, and correct frequency for 16 of 17 records reviewed (1, 2…

The Registered nurse (RN) failed to ensure the patient was provided a medication list written in plain language that did not use medical abbreviations in 4 of 17 records reviewed (#3, 12, 14, 16).

The RN (registered nurse) failed to assess and provide patient care according to professional standards for 3 of 4 skilled nurse observations (#1, 2, 7).

The Skilled nurse (SN) failed to provide services as ordered by the physician for 1 of 16 records reviewed with nursing services (#9).

The skilled nurse (SN) failed to measure wounds weekly for 2 of 5 records reviewed reviewed of patients with wounds (#1, 4).

The home health aide (HHA) failed to follow the plan of care for 1 of 3 records with home health aide (HHA) services (#12).