Total Home Health Services Inc

The agency failed to ensure Outcome and Assessment Information Set (OASIS) accurately reflected the patient’s status at the time of assessment in 1 of 2 active clinical records reviewed with a staged wound and a home visit (Patient #2).

The agency failed to ensure the comprehensive assessment was updated and revised as frequently as the patient’s condition warrants due to a major decline or improvement in patient’s health status in 1 of 2 active clinical records with home visits and wounds (Patients #2).

The agency failed to ensure each patient received the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals for 1 of 1 active records reviewed for a recertified patient.

The agency failed to ensure their staff followed accepted standards of practice for prevention of transmission of infections in 2 of 2 home visits of patients with wounds [RN 2 and RN3]. The findings include: 1. A policy with revised date of 5/27/2024 titled “Infectious Disease Control” indicated…

The agency failed to ensure the RN provided the home health aide (HHA) patient specific instructions and precautions in 1 of 1 active clinical record with home health aide (HHA) service and a home visit (Patient #2).

The agency failed to ensure the rights of the patients including consent in advance of and during treatment in 1 of 1 active clinical record review with a start of care on or after 11/23/2024 (Patient #1).

The agency failed to evidence the discharge was appropriate and the allowed practitioner, responsible for the home health plan of care, agreed that the patient no longer needed the services set forth in the plan of care for 1 of 1 discharged record reviewed for goals met.

The agency failed to ensure a registered nurse conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral for 1 of 1 active records reviewed that included a recertification period.

The comprehensive assessment failed evidence a review of all medications the patient was currently using, to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and or drug interactions, duplicate drug therapy, and noncompliance in…

The agency failed to ensure the individualized plan of care included the types of services, supplies, equipment required, nutritional requirements, medications and treatments, and or safety measures to protect against injury for 6 of 7 active records reviewed.

The agency failed to ensure drugs, services, and treatments were administered only as ordered by a physician in 4 of 4 active clinical records reviewed with a home visits (Patients # 1, 2, 3, and 4).

The agency failed to ensure services were provided based on a physician or allowed practitioner’s verbal orders, or verbal orders were authenticated and dated by the physician or allowed practitioner for 2 of 2 active records reviewed with use of anticoagulants or identified increased risk of…

The agency failed to ensure written instructions outlining an treatments and therapy to be administered by agency personnel in 1 of 1 active clinical record reviewed with a home visit with physical therapy (Patient #4).

The agency failed to ensure their skilled professionals who provide services to patients prepared clinical notes for 4 of 4 [Patient # 1, 2, 4, and 5] active records reviewed with home visits and 1 of 1 [Patient #8] discharged record reviewed for hospitalization.

The agency administrator failed to ensure the agency employed qualified personnel in 1 of 2 home health aide [HHA] files reviewed [HHA 1]. Findings include: The personnel record for HHA#1 failed to evidence an active HHA certification.

The agency failed to ensure the agency adopted and provided services in accordance with current clinical practice guidelines and standards of practice in 1 of 1 active clinical record with a home visit with new wounds assessed (Patient #2).

The agency failed to ensure OASIS data accurately reflected the patient’s status in 1 of 1 discharged patients receiving therapy services only (#12).

The home health agency failed to ensure the plan of care was followed and individualized in 3 of 5 active patient records reviewed receiving wound care (#2, #7, #8).

The agency failed to ensure the clinician performed full documented assessments during visits in 6 of 9 patient records reviewed receiving physical therapy (#2, #4, #5, #6, #7, #11).

The home health agency failed to ensure all entries in the clinical record were complete and appropriately authenticated in 4 of 13 patient records reviewed (#2, #3, #12, #13).

The agency failed to ensure the comprehensive assessment was complete in 1 of 3 active patient records reviewed with surgical wounds (#3).

The home health agency failed to assess and meet the patient's needs in 1 of 2 discharged patient records reviewed receiving wound care (#11).

The agency failed to ensure the individualized plan of care included all services, safety measures, medications and treatments in 6 of 12 records reviewed receiving skilled nursing services (#1, #4, #7, #8, #9, #13).

The agency failed to ensure all medications, services and treatments were administered only as ordered by the physician in 2 of 5 active patient records reviewed receiving wound care (#2, #7).

The agency failed to promptly alert the physician to change in a patient's condition in 2 of 4 records reviewed receiving occupational therapy (#9, #11).

The agency failed to provide the patient with an updated medication schedule in 2 of 9 active patients.

The agency failed to ensure coordination of care between disciplines in 2 of 9 active patients.

The home health aide failed to provide services as indicated in the aide care plan in 2 of 4 records reviewed receiving home health aide services (#1, #8).

The agency failed to ensure the patient's clinical record evidenced all interventions and responses to those interventions in 4 of 9 patient records reviewed receiving physical therapy (#2, #7, #11, #12).

The skilled nurse failed to ensure social services was ordered to meet the patients social needs in 2 of 14 patient record reviews (see G0570); failed to ensure the skilled professionals and home health aide failed to follow the physician orders per the plan of care (see G0572); failed to ensure…

Skilled nurses failed to ensure a pain, skin, and foley catheter assessments were completed and documented (see G0706); failed to ensure the skilled nurse provided the patient/ caregiver with all necessary instructions/ education as indicated per the physician signed plan of care (see G0714)…

The home health agency failed to ensure they had collaboration and cooperation with local and state entities to maintain an integrated response in case of an actual emergency in 1 of 1 home health agency.

The home health agency failed to ensure the skilled nurse completed a comprehensive assessment to include the assessment of all body systems in 1 of 8 active clinical records reviewed, of a total sample of 14 clinical records reviewed.

The home health agency failed to ensure the comprehensive assessment was accurate, in 1 of 8 active clinical records reviewed with skilled nursing services, out of a total of 14 clinical records reviewed.

The agency failed to ensure skill nursing accurately assessed a patient with congestive heart failure upon recertification for 1 of 8 active records reviewed in a sample of 14. (#12) Findings include: Clinical record review on 4/2/19 for patient #12, start of care 1/10/19, certification period…

The home health agency failed to ensure the plan of care was followed by all skilled professionals and home health aides in 8 of 14 clinical records reviewed.

The home health agency failed to ensure a physician order for occupational therapy (OT) services was carried out in a timely manner for 1 of 8 record reviewed (#13) of patients with OT services and failed to ensure wound measurements were performed weekly as ordered for 1 of 9 records reviewed of…

The home health agency failed to ensure all employees followed standard precautions during a home visit, and all employees failed to include patients with infectious diseases on the agency's infection control log in 7 of 14 records reviewed.

The home health agency failed to ensure the home health aide successfully completed their skilled competency prior to being assigned to agency clients in 2 of 4 home health aide personnel records reviewed.

The home health agency failed to ensure all home health aides had 12 hours of in-service training per year, in 2 of 4 home health aide personnel records reviewed.

The skilled nurse directed the home health aide to perform duties on the home health aide care plan that are contraindicated to the patient's current medical status in 1 of 7 clinical records reviewed with home health aide and skilled nursing services, of a total sample of 14 clinical records…

The home health agency failed to ensure all records were appropriately authenticated to include the date, time, credentials and clinician that authored the clinical note in 7 of 14 clinical records reviewed.

The home health agency failed to ensure all clinical records were safeguarded against unauthorized use in 1 of 1 home health agency.

The home health agency failed to ensure patient rights were given to the patient's caregiver in a language that could be understood, in 1 of 8 active records reviewed, from a total sample of 14 records reviewed.

The home health agency failed to ensure the patient's caregiver was given their rights verbally in a language that could be understood in 1 of 8 active records reviewed, of a total sample of 14 records reviewed.

The home health agency failed to ensure all clinical records were safeguarded against unauthorized use in 1 of 1 home health agency.

The home health agency failed to ensure patients knew how to contact the Indiana State Department of Health home hotline number to file an anonymous complaint in 3 of 7 patients interviewed.

The home health agency failed to ensure all patients received an initial assessment within 48 hours of the physician referral in 5 of 14 clinical records reviewed.

The home health agency failed to ensure the skilled nurse completed the comprehensive assessment in full, to include all factors that affected the primary diagnosis, in 1 of 8 active clinical records reviewed with skilled nursing services, out of a total of 14 clinical records reviewed.

The home health agency failed to ensure patients medication lists were current, included prescription and non-prescription medication, and the correct route the patient used in 2 of 14 clinical records reviewed.

The home health agency failed to ensure all services, safety precautions, medications, and supplies were listed on the plan of care in 5 of 14 clinical records reviewed.

The home health agency failed to ensure a physician ordered all treatments and services of agency patients in 4 of 14 clinical records reviewed.

The home health agency failed to ensure the skilled nurse put orders into writing and sent to the physician for signature in 1 of 8 active clinical records, of a total sample of 14 clinical records reviewed.

The home health agency failed to ensure the primary physician reviewed/ revised the plan of care in 1 of 8 active clinical records reviewed, out of a total sample of 14 clinical records reviewed.

The home health agency failed to ensure the physician was notified for a patient's change in needs and/ or significant assessment findings in 6 of 14 clinical records reviewed.

The home health agency failed to ensure the skilled nurse had communication with all physician's involved in the patient's care in relation to the patient's primary diagnosis and care plan in 2 of 8 active clinical records reviewed with skilled nursing, in a total of 14 clinical records reviewed.

The home health agency failed to ensure coordination of care amongst all disciplines and entities that provided care to the patient in 6 of 14 clinical records reviewed.

The skilled nurses failed to ensure a pain, skin, and foley catheter assessments were completed and documented in 4 of 14 clinical records reviewed.

The skilled nurse failed to provide the patient/ caregiver with education on their disease process, and education on the importance of wound care dressing changes, in 7 of 14 clinical records reviewed.

The skilled nursing failed to ensure wound measurements were documented accurately, failed to ensure wound measurements were documented, occupational and physical therapists failed to ensure the clinical notes were completed in their entirety and submitted timely in 6 of 14 clinical records…

The registered nurse (RN) failed to accurately supervise the licensed practical nurse (LPN) to ensure the LPN was following the plan of care in 1 of 1 LPN employed with the home health agency.

This document failed to indicate the physical therapy assistant provided training in bed mobility, stairs training, balance training , transfer training, heat/ ice, and established/ taught HEP.

The home health aide failed to ensure they followed the aide care plan in 1 of 7 clinical records with home health aide services, out of a total sample of 14 clinical records reviewed.

The home health aide failed to ensure they informed the supervising nurse of changes in the patient's condition in 1 of 7 clinical records reviewed with home health aide services, in a total sample of 14 records reviewed.

The home health agency failed to ensure all contracts contained by whom the patients would be accepted, the responsibilities in developing the plan of care, the manner in which services would be controlled, the procedures for submitting clinical notes, and the procedures for payment in 2 of 2…

The agency failed to ensure home health aide and skilled nursing accurately document interventions that were provided in 2 of ** home visits and record reviews.