Visiting Nurse Association of the Wabash Valley in

The agency failed to provide the patient with a copy of the aide POC in the home for 1 of 1 non-skilled patient home visits.

The agency failed to adhere to infection control procedures for 4 of 6 skilled patient home visits.

The agency failed to have a signed POC or a valid verbal POC order including the physician’s name, the date and time of the verbal order, the specific services and treatments authorized, and the name and title of the staff member receiving the order from the primary physician before providing…

The agency failed to ensure staff completed a nursing assessment for 5 of 7 home visit observations with a nurse.

The agency failed to ensure that the patient and their representative were provided with contact information for other community resources and with the names of alternative agencies or providers available to assume care, for 1 of 1 discharge‑for‑cause records reviewed (Patient #1).

The agency failed to investigate medication complaint errors in 5 of 5 medication error complaints completed (see tag G480) that resulted in the death of a patient.

The Registered Nurse failed to ensure the patient received the right medication, route, and failed to follow agency policy to ensure all orders for IV medication contained the medication name, dose, diluent type, and amount, route, frequency, and rate.

The agency failed to ensure the admission packets included the most current transfer and discharge policy for a 15-day notice of discharge for 5 of 5 patients.

The facility failed to ensure plans of care were effectively reviewed and revised for 3 of 18 records reviewed (Patients #2, #5, and #12).

The agency failed to ensure standard infection control precautions were followed for 5 of 5 home visit observations.

The agency staff failed to ensure safe IV medication was provided 1 of 1 closed record review (Patient #1) (RN 2); failed to ensure a complete up-to-date list of current medications were listed on the plan of care, and failed to follow agency policies and expectations for 14 of 14 record reviews…

The Registered Nurse (RN) failed to act as skilled professional to ensure safe medication administration was provided to patients for 1 of 1 closed record review.

The agency failed to investigate care furnished in 5 of 5 medication error complaints reviewed between 02/14/2023-7/12/2023. Findings Include: 1. An undated policy titled, "Patient Rights and Responsibilities" was provided by the Regulatory Director on 07/20/2023 at 9:00 AM.

The agency failed to investigate and document 5 of 5 complaints reviewed involving medication errors.

The agency failed to ensure nursing staff reviewed all current medications and failed to ensure medication reconciliations were performed for 5 of 5 home visit observations.

The agency failed to ensure a complete and up-to-date list of current medications were listed on the plan of care in 14 of 18 record reviews completed.

The agency Registered Nurse (RN) failed to document nursing care and information within the clinical notes for 1 of 1 closed record reviews.

The administrator failed to provide overall direction and leadership of agency services and failed to ensure the agency met all rules and regulations for recertification for 1 of 1 home health agency.

The agency failed to ensure nursing staff received education or nurse competency was evaluated regarding the preparation and administration of undiluted epinephrine or following the five rights of medication administration for 5 of 5 nursing personnel files reviewed.

The agency failed to provide a plan of care that had patient-specific discharge goals with measurable outcomes and patient/caregiver responses for 17 of 17 records reviewed.

The agency failed to alert the physician when changes were made to the administration of a medication for 1 of 7 patient home visit observations.

The nurse failed to accurately document the administration of treatment for 1 of 7 patients observed during home visits.

The Agency failed to communicate the findings of the comprehensive assessment with the physician ensuring a physician directed/established plan of care for 13 of 17 (Patient #1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 14, 15, & 17 clinical records reviewed.

The home health agency failed to ensure all staff followed standard precautions/infection control policies & procedures in 1 of 7 (Patient #4) home visits conducted.

The agency failed to ensure administrative and supervisory functions were not delegated to another entity and failed to ensure policies & procedures were agency specific for 1 of 1 agency.

The agency failed to inform the patient in writing of the extent to which payment for home health services may be expected from federally-funded programs for 17 of 17 clinical records reviewed (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 & 17).