Together Homecare of Fort Wayne LLC

The home health agency failed to ensure infection control precautions were performed related to bag technique for 1 of 2 home visit observations of RNs (RN 2).

The home health agency failed to ensure patients received all services as ordered in the POC for 2 of 5 active patient records reviewed (Patient #2, 4).

The home health agency failed to ensure the skilled nurse completed an assessment with an accurate representation of the patient's current status (See G528), failed to ensure the comprehensive assessment included a medication review to identify potential medication issues requiring physician input…

The home health agency failed to ensure the medical care provided was established in consultation with the attending physician, and within an individualized written plan of care (See G572), failed to ensure the plan of care was individualized and included all pertinent diagnoses and accurate…

The agency failed to ensure the medical care provided was established in consultation with the attending physician, and within an individualized written plan of care in 1 of 3 active pediatric records reviewed (Patient #4).

The agency failed to ensure staff used proper hand hygiene (handwashing or use of alcohol based hand rub) to prevent the spread of infection in 1 of 2 skilled nurse home visit observations (Registered nurse (RN) 2, and with the potential to affect all patients in which RN 2 provided direct care or…

The home health agency failed to ensure patient's personal health information was stored in a locked, secure area in 1 of 1 home health agency.

The agency failed to ensure Patients were free of abuse, in 1 of 1 one complaint / incident reviewed of registered nurse (RN), (RN 1), with the potential to affect all patients in which RN provided care.

The agency failed to ensure the skilled nurse completed an assessment with an accurate representation of the patient's current status in 1of 2 patients with a comprehensive assessment, following a hospitalization (Patient # 6), with the potential to affect all patients.

The agency failed to ensure the comprehensive assessment included a medication review to identify potential medication issues requiring physician input in 2 of 6 (Patients #2, #5) active records reviewed, with the potential to affect all patients.

The agency failed to ensure a recertification comprehensive assessment was conducted during the last 5 days of every 60 days, in 1 of 3 active pediatric records reviewed (Patient #4).

The agency failed to ensure the plan of care was individualized and included all pertinent diagnoses and accurate medications for 4 of 7 patient records reviewed (Patient #3, 4, 5, 7).

The agency failed to notify the physician of changes in the patient need for services for 1 of 1 discharged patient records reviewed (Patient #3).

The agency failed to ensure the licensed practical nurse (LPN) completed an assessment, as part of the interdisciplinary team, with an accurate representation of the patient's status in 2 of 4 (Patients #5, 6) active patients who received LPN care, with the potential to affect all patients…

The agency failed to provide services, ordered by the physician and as indicated within the plan of care for 1 of 6 records reviewed (Patient # 6) with skilled nurse services.

The registered nurse (RN) failed to supervise the care provided by the licensed practical nurse (LPN) for 1 of 6 active records reviewed (Patient # 5).

The agency failed to ensure a comprehensive re-assessments were completed in the home by a registered nurse for 1 of 2 skilled patients reviewed (Patient #7).

The agency failed to coordinate care for 1 of 2 patients reviewed with orders for skilled nursing care (Patient #1).

The registered nurse (RN) failed to ensure the home health aide (HHA) care plan was patient specific for 1 of 4 clinical records reviewed with orders for HHA care services (Patient #2).

The agency failed to ensure the clinician's documentation included the actual time and duration of a service in 1 of 3 home visits observations conducted (Registered Nurse #2).

The agency failed to ensure staff were qualified or competent to complete the assigned tasks in 1 of 3 home visit observations (Registered Nurse (RN) #1).

The agency failed to ensure nursing staff updated and revised plans of care and medication profiles for patient #4 since March post hospitalization (See G 536); and the agency failed to ensure nursing staff was notified of patient fall in order to perform a comprehensive reassessment due to a…

The agency failed to ensure blood pressure not within parameter on the plan of care, were reported to physician and failed to ensure the range of services were individualized to meet the patients' care needs and failed to provide the full approved PA hours (See G572); failed to ensure the…

The clinical manager failed to ensure the home health aides were not assigned to administer medications for 1 of 3 home visits (See G960); clinical manager failed to ensure patients who were hospitalized discharge medications were adequately reviewed and patients knowledge assessed to ensure…

The agency failed to ensure nursing staff was notified of patient fall in order to perform a comprehensive reassessment due to a patient's change of condition in 1 of 2 (#4) record reviewed.

The agency failed to ensure blood pressure not within parameter on the plan of care, were reported to physician (#4) and failed to ensure the range of services were individualized to meet the patients' care needs and failed to provide the full approved PA hours for 7 of 10 clinical records reviewed…

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

The agency failed to follow their policy by failing to investigate complaints that were documented in the patient's logging report for 3 of 10 clinical records reviewed.

The agency failed to ensure the complaint log evidenced the existence of patient complaints and the agency's resolution for 3 of 10 clinical records reviewed.

The agency failed to ensure the registered nurse (RN) reviewed and updated the patient's medication profile to include adding, changing, and discontinuing medications post hospitalization resulting in an inaccurate medication profile since March 13, 2019, for 1 of 2 clinical records reviewed.

The agency failed to ensure the registered nurse (RN) updated the patient's medication list on the plan of care to include adding, changing, and discontinuing medications post hospitalization resulting in an inaccurate medication list since March 13, 2019, for 1 of 2 clinical records reviewed (#4).

The agency failed to ensure the physician was notified of a patient's fall and in a change of condition in 1 of 2 (#4) records reviewed.

The agency failed to coordinate with a Registered Nurse in regards to a patient's fall in 1 of 2 (#4) record reviewed.

The assistant director of nursing (ADON) failed to ensure notification to the routine registered nurse (RN) that patient # 4 had fallen, so that an in-depth assessment would be completed (#4) for 1 of 1 record reviewed of a patient who had fallen.

The agency failed to ensure the home health aides (HHA) were not assigned to administer medications for 1 of 3 home visits (#2).

The director of nursing (DON) failed to ensure the home health aides (HHA) were not assigned to administer medications for 1 of 3 home visits (#2).

The clinical manager failed to ensure patients who were hospitalized discharge medications were adequately reviewed and patients knowledge assessed to ensure patients were aware and understood changes/ additions/ deletions of medications and primary care physician be made aware of any…

The clinical manager failed to ensure the plan of care was updated to include all patient medications for 1 of 10 clinical records reviewed.

The agency failed to ensure agreements or contracts were in place to establish overall responsibility for the provision of care for 6 of 6 patients receiving other home health services from other entities.

The agency failed to ensure they established which agency was primarily responsible for 6 of 6 patients receiving other home health services from other entities.