g 0000 - indiana · that services could resume with no changes to plan of care. the record failed...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

JEFFERSONVILLE, IN 47130

15K093 06/12/2018

ADAPTIVE NURSING AND HEALTHCARE SERVICES INC

702 NORTH SHORE DRIVE, SUITE 103

00

G 0000

Bldg. 00

This survey visit was for a federal home health

recertification and complaint investigation (5

complaints)

The survey was partially extended

Complaint ID IN00219348 unsubstantiated,

insufficient evidence





Complaint ID IN00187949 substantiated, related

federal deficiencies are cited


federal deficiencies are cited

Facility ID # 012872

Medicaid # 201084980

Survey Dates: 6/6/2018 through 6/12/2018

G 0000

G 0454

Bldg. 00

Based on record review and interview, the agency

failed to arrange a safe and appropriate transfer to

another care entity after having determined the

needs of the patient exceeded the agency's

capabilities for 2 (#9 and 11) of 2 patients with

household bed bug infestation.

Findings Include:

1. A 4/23/2018 agency policy titled Bed Bug

G 0454 The Administrator will provide an

in-service to all internal and

external employees by 7/27/2018

on appropriate transfer and

discharge of patients. When a

patient’s care needs change to

require more than intermittent

services or require specialized

services not provided by the

agency, the agency will inform

the patient/representative and the

07/13/2018 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: 2Z5G11 Facility ID: 012872

TITLE

If continuation sheet of 27

(X6) DATE




07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

Policy stated "Bedbugs are spreading rapidly

within the United States. Bed bug researchers

have observed that bed bug reservoirs are

developing among the lower socioeconomic

classes due to the cost of control. People who

require home visits usually have a long list of

economic problems. Bed bug infestations are just

another problem that they cannot afford to deal

with. Consequently, if a few bed bugs become

established in a low income situation it is very

likely that an infestation will develop...When bed

bugs are identified in the home, services will be

placed on hold. Adaptive will offer assistance by

placing a call to the waiver case manager to see if

funding exists for extermination, the MD will also

be notified of the infestation. In the event of

infestation discovery, the administrator or

designee will document 30 days notice that if

proof of extermination is not met or in progress,

then the client will be referred or discharged to

another provider. Adaptive will assist in the

transition. Adaptive will refer the client to the

exterminator as soon as the infestation is

discovered.

2. The clinical record for patient #9 start of care

11/12/2015 was reviewed 6/12/2018. The record

included a plan of care, established by the

physician for the certification period 7/4/16

through 9/1/6, with orders for home health aide

services 4 hours per day, 4-5 days per week to

assist with all ADLs ( activities of daily living)

such as bathing, hair care, dressing, nail care,

incontinence care, meal preparation, light

housekeeping, transfers and medication

reminders.

A. Included in the record was a physician

order to hold services effective 7/8/16 because the

patient was found to have "active bed bugs" in

physician that the home health

plan of care cannot meet the

patient’s needs. The agency will

assist the patient/representative,

physician and case manager in

choosing an alternative

agency/facility by identifying those

entities in the area that may be

able to meet the patient’s needs.

Once the patient/representative

chooses an alternate

agency/facility, the agency will

contact that agency/facility to

facilitate a safe transfer through

communication and transfer

information. The agency will

ensure transfer of patient

information to facilitate continuity

of care. The agency will provide

copies of current plan of care and

medication profile and any other

pertinent patient information to the

receiving agency/facility prior to

services with the new

agency/facility beginning. Agency

staff will maintain coordination with

patient/representative, case

manager and physician throughout

transfer process.

The Administrator/designee will

ensure that orientation of newly

hired clinical staff will include

review of agency transfer and

discharge policy. Agency staff will

be instructed to notify

Administrator/designee of all

service interruptions. The

Administrator/designee will

monitor all service interruptions to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Z5G11 Facility ID: 012872 If continuation sheet of 27




07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

the home. The order dated 7/8/16 was not signed

by the physician until 7/26/16.

B. The clinical record failed to evidence the

agency made contact with the waiver case

manager to arrange for alternative services or

otherwise made arrangements to assist the patient

with extermination as per their policy.

C. The record failed to evidence that

arrangements were made to provide those

necessary services ordered by the physician while

Adaptive had suspended services.

D. A 7/26/16 physician order indicated the

home of patient #9 was cleared of bedbugs and

that services could resume with no changes to

plan of care. The record failed to indicate the

patient's care needs were reassessed following the

time services were on hold.

3. The clinical record for patient #11, start of care

date 1/8/16 was reviewed 6/12/18. The record

included a plan of care established by the


through 3/2/17 with orders for home health aide

services 3 hours per day for 5-7 days per week to

assist with ADLs, hair care, dressing, nail care,

incontinence care, meal prep, light housekeeping,

transfers and medication reminders.


order to hold home health aide services effective

2/5/17 due to client home being currently treated

for bed bugs. The order was not signed by the

physician until 2/28/17.

B. The record failed to evidence the agency

made contact with he waiver case manager to

arrange for alternative services or otherwise made

determine if needs are no longer

able to be met by the agency. If

services are no longer able to be

provided to meet client's needs

then the transfer process will be

initiated. This will begin

immediately and be ongoing. The

Administrator/designee will be

responsible for monitoring these

corrective actions to ensure that

this deficiency is corrected and

will not recur.

Updated policies will be uploaded.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

arrangements to assist the patient with

extermination as per their policy.




Adaptive suspended services.


home of patient #11 had been treated and

re-inspected for bedbugs and care should resume.

The record failed to indicate the patient's care

needs were reassessed following the time services

were on hold.

4. In an interview with the alternate administrator

on 6/12/18 at 1:30 pm, the alternate administrator

acknowledged the care needs outlined in the

plans of care were not met during the time

services were "on hold" due to bed bug

infestation.

G 0514

Bldg. 00


failed to ensure the registered nurse completed an

initial assessment of the patient within 48 hours of

referral for 3 of 11 records reviewed.

Findings Include:

1. The agency's policy titled Comprehensive

Client Assessment dated 3/29/18 stated " The

initial assessment visit must be completed within

48 hours of the referral or within 48 hours of the

patient's return home or on the physician ordered

start of care date."


in-service to all Clinical Managers

regarding all admissions to be

completed within 48 hours of

referral or patient's return home.

Clinical Manager will call MD for

verbal order to assess client for

HHA services, up on receiving

referral. Verbal order to assess

will be obtained, clinical manager

will meet with client within 48

hours of referral or clients return

home to complete initial

assessment. If client meets

requirements and is agreeable to

07/13/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

2. The clinical record for patient #7 was reviewed

6/11/18. A physician referral order dated 3/7/13,

stated "Ok for RN to assess patient in home to

determine need for private duty home health aide

services funded by Medicaid PA (personal

attendant)."

A. A comprehensive nursing visit record

dated 3/13/13 indicated the reason for the visit

was an "admission visit".

B. When interviewed on 6/12/18 at 11:00 a.m.,

the nursing supervisor indicated that the nursing

visit record completed on 3/13/13 was the initial

assessment and it was not completed within 48

hours of the referral date.


6/11/18 and included a physician order dated

2/22/18 which indicated: OK for RN to assess the

client in the home to determine medical necessity

for HHA PA services, funded by medicaid, which

includes personal care, assistance with mobility,

med reminders, meal prep and light housekeeping

etc. If client meets eligibility they will be admitted

for services.

A. The record included a document titled

initial assessment completed by a registered nurse

and dated 3/13/18.


the nursing supervisor indicated that the nursing

visit record completed on 3/13/18 was the initial

assessment and was not completed within 48

hours of the physician referral date.


on 6/11/18, and evidenced a plan of care

established by the physician for the certification

period 5/15/18 to 7/13/18.

services, Clinical Manager will

admit client at that time.

Administrator/designee will

monitor all new referrals going

forward. The

Administrator/designee will audit

100% of all new admissions

clinical records to ensure that

admissions are being completed

with in 48 hour time frame. Once

100% of all admissions within 48

hours of order compliance is

obtained, then will monitor 100%

monthly for 3 months, then 20%

quarterly. Clinical staff that are

not compliant will be re-instructed

within 5 business days.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

A. A referral order dated 4/9/18 was

evidenced for patient #8.

B. An initial comprehensive assessment was

completed on 5/15/18. This was 36 days after the

referral.

G 0536

Bldg. 00

Based on observation, record review, and

interview, the agency failed to perform a review of

all medications the patient was using for 1 ( #2) of

11 records reviewed.

Findings Include :

1. An agency policy titled Comprehensive Client

Assessment dated 3/29/18 stated, "The

comprehensive assessment will include a review

of all medications the client is using. This

assessment will identify potential adverse effects

and drug reactions, including ineffective therapy,

significant side effects, significant drug

interactions, duplicate drug therapt and

non-compliance with therapy."

1. On 6/8/18 at 11:30 a.m., Employee H, a

registered nurse was observed performing

medication reconciliation and med planner set up

at a home visit with patient #2. During the time,

the patient indicated that they took stool

softeners as needed for constipation and had a

bottle of colace 100 mg on a nearby shelf.

2. A review of the patient's medication list

completed as a part of the comprehensive

assessment on admission failed to evidenced

G 0536 The Administrator/ designee will

provide an in-service to all clinical

Managers regarding Medication

Reconciliation, upon admission

and each subsequent visit

thereafter. To include all over the

counter, prescription and PRN/As

needed medications. Clinical

Manager to educate the clients on

importance of all medications

being reported for accurate

medication interaction reports.

100% of charts will be reviewed to

ensure that medications are

current and up to date. Any

deficiencies noted will be

corrected, plan of care and

medication profile will be updated

to contain all current medications

and supplemental order sent to

the physician. 100% of all charts

will be reviewed and updated by

July 27, 2018 by

Administrator/designee.


audit 100% of records until 100%

compliance is met, then 20%

monthly for 3 months then 20%

07/27/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

colace 100 mg and it's ordered frequency. quarterly to ensure medication

compliance is corrected and does

not recur.

G 0572

Bldg. 00

Based on record review, and interview, the home

health agency failed to ensure home health aide

visits were completed as ordered and that care

was delivered in accordace with the plan of care

for of 5 of (#4,5,7,8,9) 11 records reviewed.

Findings Include :

1. An agency policy titled Plan of Treatment,

dated 3/21/12 stated " Medical care shall follow a

written medical plan of care established and

periodically reviewed."

2. An agency policy titled "Home Health Aide

Plan of Care" revision date 8/1/2012 states, " ... 2.

The Care Plan shall be developed ... identify the

duties to be performed such as, but not limited to:

a. personal care. b. ambulation and exercise ..."


6/8/18. The record included a plan of care for the

certification period of 2/15/16 through 4/14/16,

with orders for home health aide services for 1

hour daily 5-6 days per week. The home health

aide failed to follow the plan of care as evidenced

by:

A. Review of the "HHA (home health aide)

Daily Records" indicated the patient was not seen

by the aide 5-6 days per week for 1 hour but

G 0572 The Administrator/designee will

provide re-education to both

internal staff which refers to

Clinical Managers and Program

Managers, and external staff

which refers to hourly caregivers

working in the home, on following

the plan of care/aide care plan as

it is written. This will include a

review of supplemental orders and

when those are necessary. The

in-service will provide re-education

that when a caregiver notifies the

agency that they are working

hours that do not follow the plan of

care or when the client notifies the

agency that they need to alter

their hours being worked. The

Registered Nurse will immediately

or at least prior to the change

being made in the scheduled

hours, obtain a verbal and signed

written physician order to

authorize the change to the plan of

care. This order will be

maintained in the clinical record.

In-service will provide re-education

that plan of care orders must be

followed as written for hours per

day and days per week. In-service

will provide re-education on

07/27/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

instead seen for 2 hours daily on 2/17/16, 2/24/16,

2/25/16, 3/1/16, 3/2/16, 3/9/16, 3/11/16, 3/14/16,

3/16/16, 3/18/16, 3/21/16, 3/23/16, 3/25/16, 3/28/16,

3/30/16, 4/1/16, 4/4/16, 4/6/16, 4/8/16, 4/11/16 and

4/13/16.


the director of nursing acknowledged the home

health aide visits for patient #4 were not

completed in accordance with the plan of care.



certification period 11/8/14 through 1/6/15, with

orders for home health aide services for 3 hours

per day, 5-6 days per week. The home health aide

failed to follow the plan of care as evidenced by:

Review of the "HHA( home health aide) Daily

Records" indicated the patient was not seen 3

hours daily but instead for 4.5 hours on 11/9/15

through 11/12/15, 11/16/15 through 11/20/15,

11/23/15 through 11/25/15, 11/27/16, 11/30/15

through 12/3/15, 12/7/15 through 12/11/15,

12/14/15 through 12/18/15, 12/21/15, 12/22/15,

12/29/15 and 12/30/15. The aide visited only 4

days the week of 11/8/15 through 11/14/15, only 4

days the week of 11/22/15 through 11/28/15 and

only 3 days the week of 11/20 through 11/26/15.



certification period 8/30/15 through 10/28/15. The

plan of care included orders for a gait belt to be

used to assist the patient with ambulation and

also noted in the care plan indicating that the

patient did not get up and walk on his own

without a caregiver, a gait belt, or wheelchair. The

home health aide failed to follow the plan of care

as evidenced by:

following the plan of care regarding

proper use of all DME in the home

and assistance with ADLs as

ordered. Using DME that is in the

home to ensure safe transfers and

ambulation. Providing bathing as

ordered on service plan. In-service

will provide re-education that

services not on the plan of care

cannot be provided, including

transportation is not to be

provided. In-service will provide

re-education on coordination of

care with other service providers,

ensuring that the proper services

are being provided by each service

provider including waiver service

providers. In-service will provide

re-education of properly

documenting services provided.


audit 100% of clinical records until

100% compliance is met, then

20% monthly for 3 months, then

20% quarterly.


address any compliance issues

with plan of care and aide care

plan within 5 business days.


ensure orientation of all newly

hired agency staff includes

education on following the plan of

care/aide care plan as written.

Any changes to the plan of care

will have a supplemental order

obtained prior to the change being





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

A. An agency document titled Incident

Report, dated 10/20/15 evidenced patient #7 fell

while being ambulated by employee A, a home

health aide, while not using the gait belt as

ordered.

B. Found in the record of patient #7 were fax

notifications to the physician dated 9/13/15 - 2

hours missed/ unable to staff, 9/27/15 - 2 hours

missed/ unable to staff, 10/11/15 - 4 hours missed/

unable to staff, 10/18/15 - 5.5 hours missed/

unable to staff, 10/25/15 - 2 hours missed/ unable

to staff.




period 5/15/18 to 7/13/18, start of care 5/15/18. The

patient was to recieve home health aide services 2

hours a day/5 days a week. The home health aide


A. The Aide Care Plan dated 5/15/18, stated

that patient #8 was to receive assist with a bath 5

days a week/ per patient request.

B. The HHA Daily Records dated for 5/24,

5/26, 5/31, 6/5, 6/7 of 2018 failed to evidence

documentation that the home health aide assisted

patient #8 with a bath or that the patient received

a bath.

C. The agency failed to evidence home

health aide visits were conducted on 5/28, 5/30

and 6/8 of 2018.

7. The clinical manager was interviewed on

6/12/18 at 1:30 p.m. and was unable to provide any

additional information regarding patient #8 bath

schedule. The clinical manager stated the 5/23,

made. This order will be


Will upload policy.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

5/30, 6/8 visits were covered by waiver service,

but not with the agency's home health aide.




period 11/1/16 to 12/30/16, start of care 11/12/15.

The patient was to recieve home health aide

sevices 4 hours a day/6-7 days a week. The home

health aide failed to follow the plan of care as

evidenced by:

A. The Aide Care Plan dated 10/27/16, revised

12/9/16, stated that patient #9 was to be assisted

with ambulation 4-5 days/week per patient request

and assisted with a bath-chair/bed bath/tub bath 4

-5 days/week per patient request.

B. The HHA Daily Records dated 11/9, 11/10,

11/11, 11/14, 11/15, 11/16, 11/18, 11/19, 11/20,

11/21, 11/22, 11/23, 11/24, 11/25, 11/26, 11/28,

11/29, 11/30, 12/1, 12/4, 12/6, 12/7, 12/16, 12/18 and

12/26 of 2016 failed to evidence documentation

that the home health aide assisted patient #9 with

ambulation 4-5 days/ week.

C. The HHA Daily Records dated for 11/12,

11/13, 12/18 and 12/26 of 2016 failed to evidence



a bath.

D. The agency failed to evidence HHA Daily

Records for dates 12/10, 12/11, 12/13, 12/14, 12/15,

12/20, 12/21, 12/22, 12/23, 12/25 of 2016.

E. An "HHA [home health aide] Daily Report

Sheet" dated 12/6/16, stated the home health aide

took the patient to 2 different doctor

appointments.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

F. A review of patient #9's plan of care failed

to evidence the home health aide was to transport

the patient to physician appointments.

9. The clinical manager was interviewed on 6/12/18

at 1:30 p.m. regarding home health aide visits not

conducted. The clinical manager was unable to

provide any documentation signed by the patient

or clincian that visits were made and was not able

to provide additional information to evidence

compliance. The clinical manager stated the home

health aide should not have provided

transportation for the patient.

G 0682

Bldg. 00


interview, the agency failed to ensure clinicians

followed recognized infection control procedures

and policies updated to include when to change

gloves while providing care in 1 of 3 home visits

(patient #8).

Findings include:

1. A document titled The Indiana State

Department of Health Nurse Aide Curriculum,

revised 11/19/15, states, " ... Procedure number 33:

Bed bath/perineal care states, that after washing

feet and toes, " ... 19. Change bath water and

gloves, wash hands and use clean gloves and

towel" ... Perineal Care: 23. ... For Females ... 24.

Change water in basin. Wash hands and change

gloves ... 28. Clean anal area from front to back ...

32. Wash hands and change gloves ..."

2. The Centers for Disease Control Standard

G 0682 Administrator has updated the

HHA Comps policy on July 2,

2018 to include changing gloves

and washing hands when going

from dirty to clean during bed

baths. In-service will be provided to

all Clinical staff on standard

precautions/infection control.

Clinical Managers will observe

Home Health Aides using

standard precautions during

supervisory home visits to ensure

standard precautions are being

followed. If aide is found to not be

following standard precautions

properly, they will be re-instructed

at that time. Monitoring will be

on-going during annual

competency evaluations of all

Clinical Staff. The Administrator

or designee will be responsible for

monitoring these corrective

07/13/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

Precautions indicated, "IV. Standard Precautions

... IV.A. Hand Hygiene. IV.A.1. During the

delivery of healthcare, avoid unnecessary

touching of surfaces in close proximity to the

patient to prevent both contamination of clean

hands from environmental surfaces and

transmission of pathogens from contaminated

hands to surfaces ... Perform hand hygiene:

IV.A.3.a. Before having direct contact with

patients. IV.A.3.c. After contact with a patient's

intact skin (e.g., when taking a pulse or blood

pressure or lifting a patient). IV.3.d. If hands will

be moving from a contaminated-body site to a

clean-body site during patient care. IV.A.3.e.

After contact with inanimate objects (including

medical equipment) in the immediate vicinity of

the patient. IV.A.3.f. After removing gloves ... "

3. An agency policy titled "HHA Comps" revised

12/12/17, page 55 Bed Bath, failed to state

changing gloves or washing hands as part of

providing a bed bath.

4. During a home visit for patient #8 on 6/12/18 at

10:15 a.m., the home health aide was observed

providing a bed bath for patient #8. The HHA was

observed washing both legs and feet and then

emptying the dirty water from and refilling both

the soapy and rinse bath basins. The HHA was

then observed washing the patient's back and

posterior and then emptying and refilling both

bath basins. The HHA was then observed

handing the patient two different wash clothes,

one soapy wash cloth and one rinse cloth, and

instructed the patient to clean his/her own

peri-area. The home health aide emptied the water

out of both bath basins, then removed his/ her

gloves, gathered trash in trash bag and took it

outside. The home health aide did not change his/

her gloves (dirty area to clean) or perform hand

actions to ensure this deficiency

is corrected and will not recur. Will

upload updated policy.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

hygiene between proceduresor at any time during

the bed bath.

5. The clinical manager was present during the

home visit and was later interviewed on 6/12/18 at

1:30 p.m. The clinical manager was unable to

provide any additional information.

G 0804

Bldg. 00

Based on record review and interview, the home

health aide failed to notify the registered nurse in

regards to a patients skin impairments in 1 out of

11 records reviewed (patient # 6).

Findings include:


Care Plan" revision date August 1, 2012 states, "

... 4. ... the Home Health Aide shall be oriented by

a Registered Nurse/ therapist, by phone or in

person, to the client's care needs and shall be

updated on modifications or changes in the

client's care. The orientation will include and

specify observations the home health aide is

expected to report and document with parameters

for reporting."

2. An agency policy titled "Job Description" for

the home health aide, revised 4/2/12, stated, " ...

Responsibilities/ essential functions ... 3. Observe

and report any ... significant observations

regarding the client 4. Observe, report, and

document patient status .... "





in-service to Clinical Managers

and Home Health Aides by

7/27/18 regarding skin integrity

and documentation of the Home

Health Aide and report to the

Clinical Manager of that client.

Clinical Manager will document

care coordination communication

with the Home Health Aide

regarding skin integrity issues

under the client record in our

electronic system and print this

out to become part of the clinical

record.


audit 100% of daily visit sheets

weekly until 100% compliance,

then 20% weekly. Clinical

Manager will review all client daily

visit sheets monthly to ensure any

documentation was reported and

followed up with. Currently

employed Home Health Aides

have received the in-service on

Recognizing and Reporting

Abnormal Observations. The

Administrator/designee will ensure

07/27/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

period 11/24/16 to 1/22/17, start of care date of

7/27/16. The patient's diagnoses included

Quadriplegic and depression. The home health

aide failed to notify the registered nurse in regards

to a patients skin impairment as evidenced by:

A weekly visit report sheet dated 12/6/16, signed

by employee D, a home health aide, stated, "Right

upper-side near back extremely red and irritated."

The same report sheet dated 12/7/16 states,

"Under right butt cheek possible bed sore w/ knot

and right upper side red and turning dark in some

spots."

4. On 6/8/17 at 3 p.m., the clinical manager was

unable to evidence documentation that the home

health aide notified the nurse regarding the

patient's skin integrity changes.

all newly hired Home Health Aides

will receive this in-service.

N 0000

Bldg. 00

This survey visit was for a state home health

relicensure and complaint investigation (5

complaints)








state deficiencies are cited


N 0000

State Form Event ID: 2Z5G11 Facility ID: 012872 If continuation sheet of 27




07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

state deficiencies are cited

Facility ID # 012872

Medicaid # 201084980

Survey Dates: 6/6/2018 through 6/12/2018

410 IAC 17-12-1(m)

Home health agency

administration/management

Rule 12 Sec. 1(m) Policies and procedures

shall be written and implemented for the

control of communicable disease in

compliance with applicable federal and state

laws.

N 0470

Bldg. 00


interview, the agency failed to ensure clinicians

followed recognized infection control procedures

and policies updated to include when to change

gloves while providing care in 1 of 3 home visits

(patient #8).

Findings include:

1. A document titled The Indiana State

Department of Health Nurse Aide Curriculum,

revised 11/19/15, states, " ... Procedure number 33:

Bed bath/perineal care states, that after washing

feet and toes, " ... 19. Change bath water and

gloves, wash hands and use clean gloves and

towel" ... Perineal Care: 23. ... For Females ... 24.

Change water in basin. Wash hands and change

gloves ... 28. Clean anal area from front to back ...

32. Wash hands and change gloves ..."

2. The Centers for Disease Control Standard

Precautions indicated, "IV. Standard Precautions

... IV.A. Hand Hygiene. IV.A.1. During the

N 0470 Administrator has updated the

HHA Comps policy on July 2,

2018 to include changing gloves

and washing hands when going

from dirty to clean during bed

baths. In-service will be provided to

all Clinical staff on standard

precautions/infection control.

Clinical Managers will observe

Home Health Aides using

standard precautions during

supervisory home visits to ensure

standard precautions are being

followed. If aide is found to not be

following standard precautions

properly, they will be re-instructed

at that time. Monitoring will be

on-going during annual

competency evaluations of all

Clinical Staff. The Administrator

or designee will be responsible for

monitoring these corrective

actions to ensure this deficiency

is corrected and will not recur. Will

07/13/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

delivery of healthcare, avoid unnecessary

touching of surfaces in close proximity to the

patient to prevent both contamination of clean

hands from environmental surfaces and

transmission of pathogens from contaminated

hands to surfaces ... Perform hand hygiene:

IV.A.3.a. Before having direct contact with

patients. IV.A.3.c. After contact with a patient's

intact skin (e.g., when taking a pulse or blood

pressure or lifting a patient). IV.3.d. If hands will

be moving from a contaminated-body site to a

clean-body site during patient care. IV.A.3.e.

After contact with inanimate objects (including

medical equipment) in the immediate vicinity of

the patient. IV.A.3.f. After removing gloves ... "

3. An agency policy titled "HHA Comps" revised

12/12/17, page 55 Bed Bath, failed to state

changing gloves or washing hands as part of

providing a bed bath.

4. During a home visit for patient #8 on 6/12/18 at

10:15 a.m., the home health aide was observed

providing a bed bath for patient #8. The HHA was

observed washing both legs and feet and then

emptying the dirty water from and refilling both

the soapy and rinse bath basins. The HHA was

then observed washing the patient's back and

posterior and then emptying and refilling both

bath basins. The HHA was then observed

handing the patient two different wash clothes,

one soapy wash cloth and one rinse cloth, and

instructed the patient to clean his/her own

peri-area. The home health aide emptied the water

out of both bath basins, then removed his/ her

gloves, gathered trash in trash bag and took it

outside. The home health aide did not change his/

her gloves (dirty area to clean) or perform hand

hygiene between proceduresor at any time during

the bed bath.

upload updated policy.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

5. The clinical manager was present during the

home visit and was later interviewed on 6/12/18 at

1:30 p.m. The clinical manager was unable to

provide any additional information.

410 IAC 17-12-2(g)

Q A and performance improvement

Rule 12 Sec. 2(g) All personnel providing

services shall maintain effective

communications to assure that their efforts

appropriately complement one another and

support the objectives of the patient's care.

The means of communication and the results

shall be documented in the clinical record or

minutes of case conferences.

N 0484

Bldg. 00

Based on record review and interview, the home

health failed to ensure effective communication

was maintained and documented in the clinical

record in regards to a home health aide identifying

a skin impairment and failed to report it to the

registered nurse in 1 out of 11 records reviewed

(patient # 6).

Findings include:


Care Plan" revision date August 1, 2012 states, "

... 4. ... the Home Health Aide shall be oriented by

a Registered Nurse/ therapist, by phone or in

person, to the client's care needs and shall be

updated on modifications or changes in the

client's care. The orientation will include and

specify observations the home health aide is

expected to report and document with parameters

for reporting."

2. An agency policy titled "Job Description" for

the home health aide, revised 4/2/12, stated, " ...

N 0484 The Administrator will provide an

in-service to Clinical Managers

and Home Health Aides by

7/27/18 regarding skin integrity

and documentation of the Home

Health Aide and report to the

Clinical Manager of that client.

Clinical Manager will document

care coordination communication

with the Home Health Aide

regarding skin integrity issues

under the client record in our

electronic system and print this

out to become part of the clinical

record.

Administrator/designee will audit

100% of daily visit sheets weekly

until 100% compliance, then 20%

weekly. Clinical Manager will

review all client daily visit sheets

monthly to ensure any

documentation was reported and

followed up with. Currently

employed Home Health Aides

07/13/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

Responsibilities/ essential functions ... 3. Observe

and report any ... significant observations

regarding the client 4. Observe, report, and

document patient status .... "




period 11/24/16 to 1/22/17, start of care date of

7/27/16. The patient's diagnoses included

Quadriplegic and depression. The home health

aide failed to notify the registered nurse in regards

to a patients skin impairment as evidenced by:

A weekly visit report sheet dated 12/6/16, signed

by employee D, a home health aide, stated, "Right

upper-side near back extremely red and irritated."

The same report sheet dated 12/7/16 states,

"Under right butt cheek possible bed sore w/ knot

and right upper side red and turning dark in some

spots."

4. On 6/8/17 at 3 p.m., the clinical manager was

unable to evidence documentation that the home

health aide notified the nurse regarding the

patient's skin integrity changes.

have received the in-service on

Recognizing and Reporting

Abnormal Observations. The

Administrator/designee will ensure

all newly hired Home Health Aides

will receive this in-service.

410 IAC 17-13-1(a)

Patient Care

Rule 13 Sec. 1(a) Patients shall be accepted

for care on the basis of a reasonable

expectation that the patient's health needs

can be adequately met by the home health

agency in the patient's place of residence.

N 0520

Bldg. 00


failed to arrange a safe and appropriate transfer to

another care entity after having determined the

needs of the patient exceeded the agency's

N 0520 The Administrator will provide an

in-service to all internal and

external employees by 7/27/2018.

On 7/11/18 the agency's bed bug

policy was updated to reflect that

07/27/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

capabilities for 2 (#9 and 11) of 2 patients with

household bed bug infestation.

Findings Include:

1. A 4/23/2018 agency policy titled Bed Bug

Policy stated "Bedbugs are spreading rapidly

within the United States. Bed bug researchers

have observed that bed bug reservoirs are

developing among the lower socioeconomic

classes due to the cost of control. People who

require home visits usually have a long list of

economic problems. Bed bug infestations are just

another problem that they cannot afford to deal

with. Consequently, if a few bed bugs become

established in a low income situation it is very

likely that an infestation will develop...When bed

bugs are identified in the home, services will be

placed on hold. Adaptive will offer assistance by

placing a call to the waiver case manager to see if

funding exists for extermination, the MD will also

be notified of the infestation. In the event of

infestation discovery, the administrator or

designee will document 30 days notice that if

proof of extermination is not met or in progress,

then the client will be referred or discharged to

another provider. Adaptive will assist in the

transition. Adaptive will refer the client to the

exterminator as soon as the infestation is

discovered.

2. The clinical record for patient #9 start of care

11/12/2015 was reviewed 6/12/2018. The record

included a plan of care, established by the


through 9/1/6, with orders for home health aide

services 4 hours per day, 4-5 days per week to

assist with all ADLs ( activities of daily living)

such as bathing, hair care, dressing, nail care,

incontinence care, meal preparation, light

Adaptive will provide Personal

Protective Equipment and bedbug

education to all staff entering the

home of a known bed bug

infestation. The in-service will

include that services must be

continued as ordered and not

interrupted until the patient can

transferred to another

agency/facility or while the home

is being exterminated. If the

agency is unable to staff, agency

will transfer client to another

agency or facility to ensure their

needs are met. Transfer summary

and current plan of care will be

shared with new accepting

agency/facility. The policy is

uploaded as a supporting

document.


review each newly identified bed

bug infestation going forward to

ensure that the policy is being

followed and the clients needs and

safety as they occur.


ensure that orientation of newly

hired clinical staff will include

review of agency bed bug policy.

This will begin immediately and be

ongoing. The

Administrator/designee will be

responsible for monitoring these

corrective actions to ensure that

this deficiency is corrected and

will not recur.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

housekeeping, transfers and medication

reminders.


order to hold services effective 7/8/16 because the

patient was found to have "active bed bugs" in

the home. The order dated 7/8/16 was not signed

by the physician until 7/26/16.

B. The clinical record failed to evidence the

agency made contact with the waiver case

manager to arrange for alternative services or

otherwise made arrangements to assist the patient

with extermination as per their policy.




Adaptive had suspended services.


home of patient #9 was cleared of bedbugs and

that services could resume with no changes to

plan of care. The record failed to indicate the

patient's care needs were reassessed following the

time services were on hold.

3. The clinical record for patient #11, start of care

date 1/8/16 was reviewed 6/12/18. The record

included a plan of care established by the


through 3/2/17 with orders for home health aide

services 3 hours per day for 5-7 days per week to

assist with ADLs, hair care, dressing, nail care,

incontinence care, meal prep, light housekeeping,

transfers and medication reminders.


order to hold home health aide services effective

2/5/17 due to client home being currently treated

Updated policies will be uploaded.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

for bed bugs. The order was not signed by the

physician until 2/28/17.

B. The record failed to evidence the agency

made contact with he waiver case manager to

arrange for alternative services or otherwise made

arrangements to assist the patient with

extermination as per their policy.




Adaptive suspended services.


home of patient #11 had been treated and

re-inspected for bedbugs and care should resume.

The record failed to indicate the patient's care

needs were reassessed following the time services

were on hold.

4. In an interview with the alternate administrator

on 6/12/18 at 1:30 pm, the alternate administrator

acknowledged the care needs outlined in the

plans of care were not met during the time

services were "on hold" due to bed bug

infestation.

.

410 IAC 17-13-1(a)

Patient Care

Rule 13 Sec. 1(a) Medical care shall follow a


periodically reviewed by the physician,

dentist, chiropractor, optometrist or

podiatrist, as follows:

N 0522

Bldg. 00

Based on record review, and interview, the home

health agency failed to ensure home health aide

N 0522 The Administrator/designee will

provide re-education to both

internal staff which refers to

07/27/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

visits were completed as ordered and that care

was delivered in accordace with the plan of care

for of 5 of (#4,5,7,8,9) 11 records reviewed.

Findings Include :

1. An agency policy titled Plan of Treatment,

dated 3/21/12 stated " Medical care shall follow a


periodically reviewed."


Plan of Care" revision date 8/1/2012 states, " ... 2.

The Care Plan shall be developed ... identify the

duties to be performed such as, but not limited to:

a. personal care. b. ambulation and exercise ..."



certification period of 2/15/16 through 4/14/16,

with orders for home health aide services for 1

hour daily 5-6 days per week. The home health

aide failed to follow the plan of care as evidenced

by:

A. Review of the "HHA (home health aide)

Daily Records" indicated the patient was not seen

by the aide 5-6 days per week for 1 hour but

instead seen for 2 hours daily on 2/17/16, 2/24/16,

2/25/16, 3/1/16, 3/2/16, 3/9/16, 3/11/16, 3/14/16,

3/16/16, 3/18/16, 3/21/16, 3/23/16, 3/25/16, 3/28/16,

3/30/16, 4/1/16, 4/4/16, 4/6/16, 4/8/16, 4/11/16 and

4/13/16.


the director of nursing acknowledged the home

health aide visits for patient #4 were not

completed in accordance with the plan of care.


Clinical Managers and Program

Managers, and external staff

which refers to hourly caregivers

working in the home, on following

the plan of care/aide care plan.

This will include a review of

supplemental orders and when

those are necessary. The

in-service will provide re-education

that when a caregiver notifies the

agency that they are working

hours that do not follow the plan of

care or when the client notifies the

agency that they need to alter

their hours being worked. The

Registered Nurse will immediately

or at least prior to the change

being made in the scheduled

hours, obtain a verbal and signed

written physician order to

authorize the change to the plan of

care. This order will be


In-service will provide re-education

that plan of care orders must be

followed as written for hours per

day and days per week. In-service


following the plan of care with

regarding proper use of all DME in

the home and assistance with

ADLs as ordered. Using DME that

is in the home to ensure safe

transfers and ambulation.

Providing bathing as ordered on

service plan. In-service will provide

re-education that services not on

the plan of care cannot be

provided, including transportation

is not to be provided. In-service





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00


certification period 11/8/14 through 1/6/15, with

orders for home health aide services for 3 hours

per day, 5-6 days per week. The home health aide


Review of the "HHA( home health aide) Daily

Records" indicated the patient was not seen 3

hours daily but instead for 4.5 hours on 11/9/15

through 11/12/15, 11/16/15 through 11/20/15,

11/23/15 through 11/25/15, 11/27/16, 11/30/15

through 12/3/15, 12/7/15 through 12/11/15,

12/14/15 through 12/18/15, 12/21/15, 12/22/15,

12/29/15 and 12/30/15. The aide visited only 4

days the week of 11/8/15 through 11/14/15, only 4

days the week of 11/22/15 through 11/28/15 and

only 3 days the week of 11/20 through 11/26/15.



certification period 8/30/15 through 10/28/15. The

plan of care included orders for a gait belt to be

used to assist the patient with ambulation and

also noted in the care plan indicating that the

patient did not get up and walk on his own

without a caregiver, a gait belt, or wheelchair. The

home health aide failed to follow the plan of care

as evidenced by:

A. An agency document titled Incident

Report, dated 10/20/15 evidenced patient #7 fell

while being ambulated by employee A, a home

health aide, while not using the gait belt as

ordered.

B. Found in the record of patient #7 were fax

notifications to the physician dated 9/13/15 - 2

hours missed/ unable to staff, 9/27/15 - 2 hours

missed/ unable to staff, 10/11/15 - 4 hours missed/

unable to staff, 10/18/15 - 5.5 hours missed/


coordination of care with other

service providers, ensuring that the

proper services are being provided

by each service provider including

waiver service providers.


audit 100% of clinical records until

100% compliance is met, then

20% monthly for 3 months, then

20% quarterly.


address any compliance issues

with plan of care and aide care

plan within 5 business days.


ensure orientation of all newly

hired agency staff includes

education on following the plan of

care/aide care plan as written.

Any changes to the plan of care

will have a supplemental order

obtained prior to the change being

made. This order will be


Will upload policy.





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

unable to staff, 10/25/15 - 2 hours missed/ unable

to staff.




period 5/15/18 to 7/13/18, start of care 5/15/18. The

patient was to recieve home health aide services 2

hours a day/5 days a week. The home health aide


A. The Aide Care Plan dated 5/15/18, stated

that patient #8 was to receive assist with a bath 5

days a week/ per patient request.

B. The HHA Daily Records dated for 5/24,

5/26, 5/31, 6/5, 6/7 of 2018 failed to evidence



a bath.

C. The agency failed to evidence home

health aide visits were conducted on 5/28, 5/30

and 6/8 of 2018.

7. The clinical manager was interviewed on

6/12/18 at 1:30 p.m. and was unable to provide any

additional information regarding patient #8 bath

schedule. The clinical manager stated the 5/23,

5/30, 6/8 visits were covered by waiver service,

but not with the agency's home health aide.




period 11/1/16 to 12/30/16, start of care 11/12/15.

The patient was to recieve home health aide

sevices 4 hours a day/6-7 days a week. The home

health aide failed to follow the plan of care as

evidenced by:





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

A. The Aide Care Plan dated 10/27/16, revised

12/9/16, stated that patient #9 was to be assisted

with ambulation 4-5 days/week per patient request

and assisted with a bath-chair/bed bath/tub bath 4

-5 days/week per patient request.

B. The HHA Daily Records dated 11/9, 11/10,

11/11, 11/14, 11/15, 11/16, 11/18, 11/19, 11/20,

11/21, 11/22, 11/23, 11/24, 11/25, 11/26, 11/28,

11/29, 11/30, 12/1, 12/4, 12/6, 12/7, 12/16, 12/18 and

12/26 of 2016 failed to evidence documentation

that the home health aide assisted patient #9 with

ambulation 4-5 days/ week.

C. The HHA Daily Records dated for 11/12,

11/13, 12/18 and 12/26 of 2016 failed to evidence



a bath.

D. The agency failed to evidence HHA Daily

Records for dates 12/10, 12/11, 12/13, 12/14, 12/15,

12/20, 12/21, 12/22, 12/23, 12/25 of 2016.

E. An "HHA [home health aide] Daily Report

Sheet" dated 12/6/16, stated the home health aide

took the patient to 2 different doctor

appointments.

F. A review of patient #9's plan of care failed

to evidence the home health aide was to transport

the patient to physician appointments.

9. The clinical manager was interviewed on 6/12/18

at 1:30 p.m. regarding home health aide visits not

conducted. The clinical manager was unable to

provide any documentation signed by the patient

or clincian that visits were made and was not able

to provide additional information to evidence

compliance. The clinical manager stated the home





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

health aide should not have provided

transportation for the patient.

410 IAC 17-13-1(a)(1)

Patient Care

Rule 13 Sec. 1(a)(1) As follows, the medical

plan of care shall:

(A) Be developed in consultation with the

home health agency staff.

(B) Include all services to be provided if a

skilled service is being provided.

(B) Cover all pertinent diagnoses.

(C) Include the following:

(i) Mental status.

(ii) Types of services and equipment

required.

(iii) Frequency and duration of visits.

(iv) Prognosis.

(v) Rehabilitation potential.

(vi) Functional limitations.

(vii) Activities permitted.

(viii) Nutritional requirements.

(ix) Medications and treatments.

(x) Any safety measures to protect

against injury.

(xi) Instructions for timely discharge or

referral.

(xii) Therapy modalities specifying length of

treatment.

(xiii) Any other appropriate items.

N 0524

Bldg. 00


interview, the agency failed to ensure the plan of

care was updated/ revised to include all

medications the patient was using for 1 ( #2) of 11

records reviewed.

Findings Include :

1. An agency policy titled Comprehensive Client

N 0524 The Administrator/ designee will

provide an in-service to all clinical

Managers regarding Medication

Reconciliation, upon admission

and each subsequent visit

thereafter. To include all over the

counter, prescription and PRN/As

needed medications. Clinical

Manager to educate the clients on

importance of all medications

07/27/2018 12:00:00AM





07/26/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15K093 06/12/2018



00

Assessment dated 3/29/18 stated, "The

comprehensive assessment will include a review

of all medications the client is using. This

assessment will identify potential adverse effects

and drug reactions, including ineffective therapy,

significant side effects, significant drug

interactions, duplicate drug therapt and

non-compliance with therapy."

1. On 6/8/18 at 11:30 a.m., Employee H, a

registered nurse was observed performing

medication reconciliation and med planner set up

at a home visit with patient #2. During the time,

the patient indicated that they took stool

softeners as needed for constipation and had a

bottle of colace 100 mg on a nearby shelf.

2. A review of the patient's medication list

completed as a part of the comprehensive

assessment on admission failed to evidenced

colace 100 mg and it's ordered frequency.

being reported for accurate

medication interaction reports.

100% of charts will be reviewed to

ensure that medications are

current and up to date. Any

deficiencies noted will be

corrected, plan of care and

medication profile will be updated

to contain all current medications

and supplemental order sent to

the physician. 100% of all charts

will be reviewed and updated by

July 27, 2018 by

Administrator/designee.


audit 100% of records until 100%

compliance is met, then 20%

monthly for 3 months then 20%

quarterly to ensure medication

compliance is corrected and does

not recur.


g 0000 - indiana · that services could resume with no changes to plan of care. the record failed...

Documents