G 0000 - in

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

01/09/2020PRINTED:

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

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

HOBART, IN 46342

15K030 12/04/2019

HOMEPOINTE HEALTHCARE

426 CENTER STREET

00

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This visit was a Federal Recertification and State

Licensure survey of a home health agency.

Survey Dates: 11/26, 11/27, 12/2, 12/3, and 12/4/19

Facility ID: IN006663

Active Patients: 26

Discharged Patients: 4

This deficiency report reflects State Findings cited

in accordance with 410 IAC 17. Refer to State

Form for additional State Findings.

Quality Review completed on 12/17/19 CS

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484.50(e)(1)(i)(A)

Treatment or care

(i)(A) Treatment or care that is (or fails to be)

furnished, is furnished inconsistently, or is

furnished inappropriately; and

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Based on record review and interview, the home

health agency failed to investigate complaints for

care not performed made by the patient's

representative in 1 of 7 clinical records reviewed.

(#1)

The findings include:

Review of an agency policy, revised 12/2/17, titled

"Notice of Rights Including Complaint Grievance

Procedure" stated, "... HomePointe HealthCare will

investigate complaints made by a client, the

G 0480 Customer Concern/Grievance form

was completed by the Clinical

Care Manager (CCM) who received

the text message. See attached

Client Grievance, document #1. A

follow up phone call was made to

the parent and a resolution was

discussed. CCMs were

re-educated on agency procedure

for handling all complaints,

including a review of the policy -

Notice of Rights Including

12/12/2019 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: H5IC11 Facility ID: 006663

TITLE

If continuation sheet Page 1 of 39

(X6) DATE




01/09/2020PRINTED:

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client's representative (if any), the client's

caregivers and family regarding care or treatment

that is (or fails to be) furnished, furnished

inconsistently or furnished inappropriately. ..."

Clinical record review for patient #1, start of care

5/23/18, evidenced an agency document titled

"HomePointe HealthCare Nursing Flow Sheet

Shift Assessment" dated and signed by the

skilled nurse on 11/21/19. This document stated,

"... [patient's caregiver] upset [and] yelling

(verbally abusive) to this nurse stating that I had

unplugged secondary vent [ventilator]. ..."

Review of an agency document titled, "Customer

Concern / Grievance Tracking Log" dated for

fiscal year 2020 failed to include a grievance from

the patient's family.

During an interview on 12/2/19 at 2:27 p.m.,

employee C indicated she received a text via

phone on 11/21/19 at 10:41 a.m. from the skilled

nurse regarding the patient's caregiver was upset

the patient's back-up ventilator was unplugged.

Employee C indicated she called to speak with the

skilled nurse about the patient's caregiver

complaint but did not speak to the patient's

caregiver. Employee C indicated there was no

documented investigation of the caregiver's

complaint.

17-12-3(c)(1)(A)

Complaint Grievance Procedure

(C-380), see attached document

#2.

All CCM personnel were retrained

and in-serviced on the policy and

procedure for receiving concerns

or grievances. In discussion with

staff, the Director will ensure that

all grievances are filed as

appropriate.

Director will monitor all grievances

and resolutions by adding this

topic to the weekly meeting

agenda with the CCMs. Director

will ensure that all grievances will

be tracked and will have a

resolution and or plan addressed.

484.50(e)(1)(ii)

Document complaint and resolution

(ii) Document both the existence of the

complaint and the resolution of the complaint;

and

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health agency failed to document the existence G 0484 Customer Concern/Grievance form

was completed by the Clinical 12/12/2019 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 2 of 39




01/09/2020PRINTED:

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and resolution of a complaint in 1 of 7 clinical

records reviewed. (#1)


Review of an agency policy, revised 12/2/17, titled

"Notice of Rights Including Complaint Grievance

Procedure" stated, "... HomePointe HealthCare will

document the existence of all complaints.

Documentation will include the investigation,

actions taken, and the resolution/outcome. ... All

complaints will be tracked and documentation will

be placed in a confidential "Complaint" file. ..."





skilled nurse on 11/21/19. This document stated,

"... [patient's caregiver] upset [and] yelling

(verbally abusive) to this nurse stating that I had

unplugged secondary vent [ventilator]. ..."

Review of an agency document titled "Customer

Concern / Grievance Tracking Log" dated for

fiscal year 2020 failed to include a grievance from

the patient's family.


employee C, clinical care manager, indicated she

received a text via phone on 11/21/19 at 10:41 a.m.

from the skilled nurse regarding the patient's

caregiver was upset the patient's back-up

ventilator was unplugged. Employee C indicated

there was no documentation of the caregiver's

complaint and resolution.

17-12-3(c)(2)

Care Manager (CCM) who received

the text message. See attached

Client Grievance form, document

#1. A follow up phone call was

made to the parent and a

resolution was discussed. CCMs

were re-educated on agency

procedure for handling all

complaints, including a review of

the policy - Notice of Rights

Including Complaint Grievance

Procedure (C-380), see attached

document #2.

Director will monitor all grievances

and resolutions by adding this

topic to the weekly meeting

agenda with the CCMs. Director

will ensure that all grievances will

be tracked and will have a

resolution and or plan addressed.

Director will monitor 100%

concerns and resolutions by

adding this topic to the weekly

meeting agenda with the CCMs.





01/09/2020PRINTED:

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OMB NO. 0938-039




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484.55(c)(1)

Health, psychosocial, functional, cognition

The patient's current health, psychosocial,

functional, and cognitive status;

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health agency failed to ensure the comprehensive

assessment reflected the patient's current health

status in 2 of 5 active clinical records with a

feeding tube (#3, #4) and 1 of 2 (#4) active clinical

records with a wound in a total sample of 7 clinical

records.


1. Review of an agency policy, revised 12/12/17,

titled "Client Comprehensive Assessment"

stated, "... Comprehensive assessments will

accurately reflect and include a minimum of the

following client information: ... Current health,

psychosocial, functional, and cognitive status ...

Nutritional status is assessed. ... Comprehensive

assessments must be updated and revised ... as

frequently as the client's condition warrants ... but

not less frequently then [sic] the last five (5) days

of every sixty (60) days beginning with the start of

care date ..."

2. Review of an agency policy dated August 2002

titled "Assessment/Staging of Pressure Ulcers"

stated, "... In assessing the pressure ulcer, the

following parameters should be addressed

consistently. Site, stage of ulcer, and size of ulcer

... Drainage amount, color, and odor ... Condition

of surrounding tissue. ..."

3. Clinical record review for patient #3, start of

care 5/22/18, evidenced an agency document titled

"Pediatric Admission Assessment" dated 5/22/18

which indicated the patient had a feeding tube but

failed to evidence the assessment of the

G 0528 The CCMs who complete the

comprehensive assessments were

re-trained on ensuring that the

comprehensive assessments

reflect the client’s current health

status. The CCMs will now

include documentation of

assessment that were identified

during survey as missing areas;

nutritional status (feeding type,

amount, frequency, and water

flushes) and skin integrity

including wound assessment

(location, size, color, drainage,

odor, edema, surrounding skin

appearance and staging per

NPUAP Assessment Tool and

dressing condition, if applicable).

CCMs were in-serviced on agency

policy, including the

comprehensive assessment

content, see attachment

document Client Comprehensive

Assessment (C-145) #3.

Nursing staff was also

re-educated/in-serviced on

documentation expectations of

nutritional status and wound

assessment. The Skin Integrity

Alteration Nursing Care Plan

(NCP) has been updated to reflect

any condition in skin changes and

to report this to the CCMs. Also

included were standards for

documentation of impaired skin

integrity: location, size, color,

12/31/2019 12:00:00AM





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nutritional status to include the amount and

frequency of the tube feeding and water flushes.


care 12/15/09, evidenced an agency document

titled "Recert/Follow-Up Assessment OASIS D"

dated 6/25/19 which indicated the patient had a

stage 1 pressure ulcer (a sore affecting the upper

layer of the skin) behind the left ear. The

document failed to assess the wound to include

size, color, drainage, odor and surrounding skin.

Review of an agency document titled

"Recert/Follow-Up Assessment OASIS D" dated

10/23/19 evidenced the patient had a stage 2

pressure ulcer (a sore involving partial thickness

skin loss) to the left ear. The document failed to

assess the wound to include size, color, odor and

drainage.

Review of agency documents titled


6/25/19, 8/26/19 and 10/23/19 indicated the patient

had a jejunostomy (a feeding tube surgically

created through the abdomen and into the small

intestine) but failed to evidence the assessment of

the nutritional assessment to include the amount

and frequency of the tube feeding and water

flushes.

5. During an interview on 12/2/19 at 2:18 p.m.,

employee C indicated the comprehensive

assessment should include the amount and

frequency of tube feedings.

6. During an interview on 12/3/19 at 9:45 a.m., the

clinical supervisor indicated wounds should be

assessed to include during the comprehensive

assessment.

17-14-1(a)(1)(B)

drainage, (amount and color),

odor, edema, surrounding skin

appearance and staging per

attached NPUAP Assessment

Tool as appropriate. The in-service

instructs to include documentation

of wound care as ordered:

appearance of old dressing

removed, technique, cleaned with,

irrigated with, packed with,

dressing applied and client

tolerance of procedure, see

attached documents Skin Integrity

Alteration NCP #4 and NPUAP

Staging System #5. This NCP will

now be present in all client charts

and will be utilized as a guide

when documenting on the

presence of wounds for daily and

comprehensive assessments.

100% of comprehensive

assessments will be audited by

the Director until 100%

compliance of proper

documentation on comprehensive

assessments is achieved.

Retraining will occur for any item

found out of compliance. The Skin

Integrity NCP will be added to the

client charts by the CCMs and the

Director will audit to ensure that

100% of client’s charts have the

NCP present.

CCMs are responsible for proper

documentation of the assessment

items to be contained in client

comprehensive assessments and

for completing the revised NCP for

Skin Integrity in their client’s

charts. The Director will oversee





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completion of the audits of

comprehensive assessments and

for the presence of the Skin

Integrity Alteration NCP in the

client charts.

484.60(a)(1)

Plan of care

Each patient must receive the home health

services that are written in an individualized

plan of care that identifies patient-specific

measurable outcomes and goals, and which

is established, periodically reviewed, and

signed by a doctor of medicine, osteopathy,

or podiatry acting within the scope of his or

her state license, certification, or registration.

If a physician refers a patient under a plan of

care that cannot be completed until after an

evaluation visit, the physician is consulted to

approve additions or modifications to the

original plan.

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health agency failed to provide services as

specified in the individualized plan of care in 5 of 7

clinical records reviewed. (#2, #4, #5, #6, #7)


1. Review of an agency policy revised 1/11/18

titled "Client Plan of Care" stated, "... Each client

must receive the home health services that are

written in an individualized Plan of Care ..."

2. Review of an agency policy dated August 2002

titled "Assessment/Staging of Pressure Ulcers"

stated, "... In assessing the pressure ulcer, the

following parameters should be addressed

consistently. Site, stage of ulcer, and size of ulcer

... Drainage amount, color, and odor ... Condition

of surrounding tissue. ..."

G 0572 The CCMs were re-trained on the

content that must be included in

the client’s Individualized Plan of

Care (POC). This included

re-education of the Client Plan of

Care (C-580) policy, see attached

document #6.

The Director in conjunction with

the CCMs will review and update

100% of active client POCs to

ensure that they are current,

individualized to the client and

accurate. They will review the

POCs to ensure that skilled care

frequency is appropriate and

reflects the client’s needs. CCMs

will also ensure that wound care

and nutrition orders are complete.

PCPs will be consulted and if

12/31/2019 12:00:00AM





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"Home Health Certification and Plan of Care" for

certification period 9/28/19 - 11/26/19 signed by

the physician stated, "... Skilled Nursing 4-10

hours/day, 2-5 days/week for the next 60 days. ..."

Week 2 evidenced skilled nursing care was

provided 1 day.

Week 9 evidenced skilled nursing care was

provided 1 day.

During an interview on 12/4/19 at 9:57 a.m., the

clinical supervisor indicated the plan of care was

not followed for skilled nursing frequency.

During an interview on 12/4/10 at 9:59 a.m.,

employee D indicated the nurse was on vacation

during week 2 and there was no other nurse to

provide skilled nursing care as ordered on the

plan of care. Employee D also indicated during

week 9 there was no nurse to provide skilled

nursing care as ordered on the plan of care.



titled "Home Health Certification and Plan of

Care" for certification period 10/27/19 - 12/25/19

and signed by the physician on 11/6/19 which

stated, "... Orders for Discipline and Treatments ...

Skilled hourly nursing 4-10 hours a day, 3-6 days a

week x 60 days ... Assessment, Temp

[temperature], Pulse, Respirations a minimum of

every shift ..."



Shift Assessment" dated 11/9/19 indicated a

needed the POC will be updated

to reflect the clarification orders

received by the PCP.

(1) When the frequency of the

audited clients POCs are

determined to be too broad the

frequency will be reviewed with the

PCP and parent. The POC will be

narrowed, when appropriate, to

better reflect the client’s needs

and staffing frequency more

specifically. For circumstances

when the agency has a call off

from staff or is unable to meet the

staffing needs for a date(s), the

Staffing Coordinator will contact all

available trained staff to attempt to

meet the client’s needs/orders. If

the agency is unable to fulfill the

frequency orders the parent is

contacted and a plan is

discussed. If orders cannot be

met, the PCP will be contacted

and a Missed Visit Note will be

completed, see attached

document Missed Visit Note #7.

Lastly, for clients that have

minimum staffing and it has been

determined by the client and/or

family that they would like to

continue with HPHC instead of

being assisted in finding another

agency, a note indicating this

conversation will be kept on file.

This situation will be discussed

with the PCP and addressed in

the Physician Summary section of

the POC. HPHC will continue with

staffing efforts to fulfill staffing

needs for clients that are currently





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wound to the left ear but failed to include an

assessment of the area to include signs and

symptoms of infection such as color, odor,

drainage of the wound.


clinical supervisor indicated the nurse was to

complete a full head-to-toe assessment at every

visit to include an assessment of any wounds.




certification period 9/23/19 - 11/21/19 and signed

by the physician on 9/24/19 which indicated the

patient was to receive skilled nursing services 2

-14 hours a day, 1 - 2 days a week until discharge

on 10/17/19. During week 2 of the certification

period, the clinical record failed to evidence the

patient received skilled nursing services.

During an interview on 12/3/19 at 2:33 p.m., the

clinical supervisor indicated there was no skilled

nursing visits completed during week 2 of the

certification period because there was no nurse to

replace the previous nurse who had quit.




certification period 7/6/19 - 9/4/19 and signed by

the physician on 7/15/19 which stated, "... Orders

for Discipline and Treatments ... Skilled nursing

visits 3 [times] week for 4 weeks ... Assessment,

temp, pulse, respirations, weight every visit. ..."

This document indicated the patient was 3 months

old and had a diagnosis of feeding difficulties.

Record review of agency documents titled "Skilled

Nursing Visit (7 weeks to 2 years)" dated 7/8/19

minimally staffed.

(2) Nursing staff were re-educated

through a mandatory in-service

and test (see attached documents

#8a Staff Survey Follow Up Letter,

#8c Skin Integrity Alteration NCP

and #8d NPUAP Staging System

and #8e Hand Hygiene and

Wound Assessment In-service

Test) regarding documenting each

shift, as appropriate, wound

assessment and wound care as

part of their complete head to toe

assessment. Nurses are to refer

to the revised Skin Integrity

Alteration NCP that has been

updated to reflect the notification

of CCM with any condition in skin

changes and the standard for

documentation of impaired skin

integrity when present: location,

size, color, drainage, (amount and

color), odor, edema, surrounding

skin appearance and staging per

attached NPUAP Assessment

Tool as appropriate. The NCP also

includes instruction to document

wound care as ordered:

appearance of old dressing

removed, technique, cleaned with,

irrigated with, packed with,

dressing applied and client

tolerance of procedure, see

attached documents Skin Integrity

Alteration NCP #4 and NPUAP

Staging System #5. The NCP will

be present in all client charts and

will guide nursing staff when

documenting on the presence of

wounds during their head to toe





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and 7/9/19 failed to evidence the patient's

nutritional assessment included amount and

frequency of feedings. The documents on 7/12/19,

7/15/19, 7/19/19, 7/23/19, 7/29/19, 7/31/19 and

8/1/19 failed to evidence the patient's nutritional

assessment included the type of feeding the

patient received and the amount and frequency of

feedings.


employee D indicated the assessment indicated in

the plan of care was a complete head-to-toe

assessment and should include the type of

feeding and the amount and frequency of the

feedings.

7. Clinical record review of patient #5, start of care



certification period 10/26/19 - 12/24/19 signed and

dated by the physician on 10/25/19 stated, "...

Orders for Discipline and Treatments (Specify

Amount/Frequency/Duration)

Assessments/Vitals: Assessment, Temp, Pulse,

and Respirations a minimum of every shift and

PRN [as needed] for a change in status ... Wound

care to buttocks as ordered by Wound Clinic:

Daily and PRN for soiled dressing, dressing

changes to right buttock. Cleanse wound with

saline [wound cleanser] daily, apply Medihoney

[ointment for wound healing], cover with

non-stick dressing (telfa) and dry gauze/pad, per

mom's discretion. Apply Hydrocolloid [substance

which forms a gel in the presence of liquid]

dressing, (in place of Medihoney, when available)

may leave on for up to one week but change PRN

for soiling or coming off ..."

Record review of agency documents titled


Shift Assessment" dated 10/30/19, 11/01/19,

assessments. Specifically, for

clients #4 and #5 mentioned in the

survey, the nurses on the cases

were counseled on their

documentation and how to

correctly document wounds and

wound care in the future. They will

be audited to ensure continued

compliance.

(3) A documentation concern was

discovered with client #7, which

was a visit case. The agency visit

note does not prompt all areas of

assessment. The CCMs perform

the visits and were educated on

ensuring that they document a

complete head to toe

assessment. The visit note is to

include documentation of all

services ordered. This would

include, but is not limited to, the

type of feeding, amount and

frequency.

Director and CCMs will continue to

discuss client needs as it relates

to staffing. This will be discussed

weekly at HPHC meetings.

Director and CCMs will perform

audits to ensure that 100% of

client POC’s contain all stated

contents per policy. Audits will

also include checking of flow

sheets and visit notes (as

applicable) to ensure that the

nurses are documenting on all

services/treatments ordered in the

POC. POCs will be corrected as

appropriate and nurses out of

compliance will be re-educated.

The CCMs will work with the PCP





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11/06/19, 11/08/19, 11/11/19, and 11/13/19 failed to

evidence the wound was assessed to include

color, odor, drainage and surrounding tissue and

wound care was performed as ordered in the plan

of care.

Record review of agency documents titled


Shift Assessment" dated 11/04/19, 11/05/19,

11/12/19, and 11/14/19 failed to evidence wound

care was performed as ordered on the plan of care.


Employee D indicated the wound should be

completely assessed at every visit to include

color, odor, drainage and size.


clinical supervisor indicated wound care was not

performed as ordered on the plan of care and

wound care was an area the agency needed to

focus on.

17-13-1(a)

on any clarifications to the POC.

The CCMs are also responsible for

working with the nursing staff that

fell out of compliance in the areas

noted during the survey. The

Director will audit 100% of POCs

to ensure that the frequency is

appropriate and not too broad. The

Director will ensure and participate

in weekly flowsheet audits. 100%

of staff is responsible for

completing the in-service and

testing. This will be tracked and

followed up for compliance by the

Administrative Assistant.

484.60(a)(2)(i-xvi)

Plan of care must include the following

The individualized plan of care must include

the following:

(i) All pertinent diagnoses;

(ii) The patient's mental, psychosocial, and

cognitive status;

(iii) The types of services, supplies, and

equipment required;

(iv) The frequency and duration of visits to be

made;

(v) Prognosis;

(vi) Rehabilitation potential;

(vii) Functional limitations;

(viii) Activities permitted;

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(ix) Nutritional requirements;

(x) All medications and treatments;

(xi) Safety measures to protect against

injury;

(xii) A description of the patient's risk for

emergency department visits and hospital

re-admission, and all necessary interventions

to address the underlying risk factors.

(xiii) Patient and caregiver education and

training to facilitate timely discharge;

(xiv) Patient-specific interventions and

education; measurable outcomes and goals

identified by the HHA and the patient;

(xv) Information related to any advanced

directives; and

(xvi) Any additional items the HHA or

physician may choose to include.


health agency failed to ensure the plan of care

was individualized and complete to include

frequency and duration of visits, all medications

including indications for use for medications

taken as needed and where medication is to be

applied, safety precautions, nutritional

requirements and patient/caregiver education for

their patients in 7 of 7 clinical records reviewed.

(#1, #2, #3, #4, #5, #6, #7)



titled "Client Plan of Care" stated, "... The

individualized Plan of Care must specify the care

and services necessary to meet the client specific

needs as identified in the comprehensive

assessment ... The Plan of Care shall be completed

in full to include: ... Type(s) of services, supplies,

and equipment required ... Nutritional

requirements ... All medications and treatments ...

Safety measures to protect against injury ... Client

G 0574 POCs will be corrected by the

CCMs to meet the individualized

needs of our clients. Special

attention will be given to feeding

and water flush orders to include

the route; NPO status if indicated;

aspiration and other safety

precautions/measures; to specify

waiver respite hours to be

provided; indication for how

oxygen is delivered; how

suctioning is being performed and

patient/caregiver education. PRN

medications are also being

clarified to ensure that those

medications that have the same or

similar indication, have better

instruction on when each is to be

given. PCPs will be consulted and

the POC will be updated to reflect

the clarification orders and sent for

signature. The Director will audit

100% of POCs to ensure that the

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and caregiver education and training to facilitate a

timely discharge ... Client specific interventions

and education; measurable outcomes and goals

identified by the agency and the client."




certification period 11/12/19 - 1/10/20 which

stated, "... Nutritional Requirements: Isosource 1.5

cal/oz [type of formula, 1.5 calories per ounce]

Bolus Feeding 275 ml [milliliters] 4 [times] daily

...Suction trach [tracheostomy, a surgically

created hole in the neck into the trachea to

provide an airway] PRN [as needed] ... " This

document failed to evidence the route the formula

feeding was to be administered and failed to

provide individualized indications on when to

suction the patient's tracheostomy as needed.

Record review evidenced an agency document


dated 11/7/19 which indicated the patient was

NPO [nothing by mouth.] The plan of care failed

to evidence the patient's NPO status.


employee C indicated the route the formula was to

be administered and the patient's NPO status

should be included on the plan of care.



"Comprehensive Assessment" dated 11/25/19

which indicated the patient was NPO.

Record review of an agency document titled


certification period 9/28/19 - 11/26/19 failed to

evidence the patient's NPO status.

noted concerns have been

addressed and the POC has been

individualized.

100% of client POCs will be

audited for compliance of this

standard. Going forward the

Director will perform random POC

audits of 10% of current census.

The CCMs are responsible for

working with the PCP to

update/clarify the POCs as

indicated. Clarification orders will

be sent for signature. The Director

will audit 100% of POCs to ensure

that they contain the appropriate

content.





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employee D indicated the patient's NPO status

should be included on the plan of care.




certification period 11/14/19 - 1/12/20 which

stated, "... HHA [home health aide] and nurse

respite hours scheduled per parent request. ...

Suction PRN ... Oxygen 1-4 LPM [liters per minute]

PRN to keep sats [saturation] [greater than] 91%

..."

Review of an agency document titled "Service

Agreement / Notice of Rights" dated 7/11/19

indicated the patient was to receive 40 hours a

month of home health aide services and 60 hours

a month of respite nursing services. The plan of

care failed to evidence the individualized amount

of home health aide and respite nursing services

to be provided to the patient.


employee D indicated the plan of care did not

include the specific hours for the home health aide

and respite nursing services.


employee C indicated she was unsure how oxygen

was to be administered but that maybe it was by

mask. She indicated how the oxygen was to be

administered should be included on the plan of

care.









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which stated, "... Oxygen PRN to keep sats

[greater] than 90% ..."



10/23/19 indicated the patient was NPO and

nutrition was given through a jejunostomy [type

of feeding tube surgically inserted through the

patient's abdomen into the small intestines.] The

plan of care failed to evidence the patient's NPO

status and aspiration precautions as a safety

measure.


employee C indicated oxygen was delivered via

the patient's tracheostomy. Employee C also

indicated the plan of care should include how the

oxygen was to be delivered, the patient's NPO

status and aspiration precautions as a safety

measure.





by the physician on 9/24/19 which stated, "...

Peptamin ... [type of feeding tube formula] Give

300 mL [milliliters] ... followed by at least 60 mL

water in 3 feeds daily ... Neosporin Ointment

[antibiotic] ... small amount TOP [topical] BID

[twice daily] PRN skin breakdown Cortef Cream

[reduces inflammation] ... small amount topical

BID PRN skin breakdown Tinactin Cream

[antifungal cream] ... small amount topical BID

PRN skin breakdown Desonate Cream [reduces

inflammation] ... small amount topical BID until

skin clears PRN skin breakdown ...


employee D indicated the plan of care was not





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individualized to include where the topical

medications were to be applied as needed.


clinical supervisor indicated the plan of care was

not individualized to include the route of

administration of the formula and water. The

clinical supervisor indicated the feeding tube

formula and water was to be administered through

the patient's g-tube [a type of feeding tube.]




certification period 7/6/19 - 9/4/19 which failed to

evidence patient/caregiver education

individualized for the patient.


employee D indicated there was not

patient/caregiver education on the plan of care

but indicated it should be.

8. During an interview on 12/4/19 at 10:12 a.m.,

employee C indicated the plan of care should

include individualized indications on when to

suction the patient and the route suctioning

should be performed. At 10:25 a.m., employee C

indicated if there is a feeding tube, aspiration

precautions should be provided and included in

the plan of care.





stated " ...Nutritional Requirements ... 1 carton

Boost High Protein [nutritional formula] bolus

[method of liquid feeding] GB [Gastrostomy

button, surgically placed tube to access stomach





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for feeding, hydration, and medication] 3x [three

times] daily. ..."



Shift Assessment" evidenced aspiration

precautions were indicated on documents dated

10/29/19, 10/30/19, 10/31/19, 11/01/19, 11/04/19,

11/05/19, 11/06/19, 11/07/19, 11/08/19, 11/11/19,

11/12/19, 11/13/19, and 11/14/19. The plan of care

failed to evidence aspiration precaution as a

safety measure.

17-13-1(a)(1)(D)(iii)

17-13-1(a)(1)(D)(viii)

17-13-1(a)(1)(D)( ix)

17-13-1(a)(1)(D)(x)

17-13-1(a)(1)(D)(xiii)

484.60(a)(3)

All orders recorded in plan of care

All patient care orders, including verbal

orders, must be recorded in the plan of care.

G 0576

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health agency failed to ensure all orders were

recorded in the plan of care in 2 of 7 clinical

records reviewed. (#4, #7)


1. Review of an agency policy revised 3/4/19 titled

"Physician Orders" stated, "... Medications,

services, and treatments are administered only as

ordered by a physician. The orders may be

initiated via telephone, verbally, or in writing ... All

client care orders, including verbal orders, must be

recorded in the plan of care. ...


care 7/6/19, evidenced a document titled

G 0576 100% of orders received will be

reviewed to ensure accuracy of the

POC. If an omission, change or

addition is discovered, the PCP

will be contacted and clarification

orders will be sent as indicated.

This would include, but is not

limited to; vital signs, weight,

respiratory status assessments,

wound care, nutritional status

assessments that may include

feeding technique and education.

This was corrected for client #4.

As new orders are received by the

agency, the CCMs will incorporate

them into the clients POC. CCMs

were re-educated with any hospital

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"Inpatient Consult to Case Management" which

stated, "... Home Health skilled nursing for,

monitoring of weight, resp [respiratory] status,

mom's feeding technique, and educate mom on

baby's well being. ..." This document indicated it

was signed by the physician on 6/26/19.

Review of an agency document titled "Home

Health Certification and Plan of Care" for

certification period 7/6/19 - 9/4/19 and signed by

the physician on 7/15/19 stated, "... Assessment,

temp [temperature], pulse, respirations, weight

every visit. ..." The plan of care failed to

incorporate the order for the assessment of mom's

feeding technique and parent education as

indicated in the physician order.


employee D indicated the plan of care did not

incorporate the order to assess mom's feeding

technique and parent education.




dated 10/23/19 which evidenced the patient had a

stage 2 pressure ulcer (a sore involving partial

thickness skin loss) to the left ear.

Review of an agency agency document titled

"Physician Order" dated 10/25/19 and signed by

the physician stated, "... Continue mepilex foam

[type of wound dressing] to [left] ear for 2

[weeks]. May use medihoney [type of wound

ointment] as needed if wound reopens. ..."

Review of an agency document titled "Home

Health Certification and Plan of Care" for


by the physician on 11/6/19 failed to evidence the

discharge orders or discharge

instructions received, to include

those noted orders on the POC.

Director will perform audits of

100% of the current census for

next 3 months then 10% of current

census thereafter for continued

compliance.

CCMs are responsible for ensuring

the accuracy and inclusion of all

POC orders given. The Director

will be responsible for performing

audits to ensure that all orders are

included on the client POCs.





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wound care order for mepilex foam dressing to the

left ear was incorporated in the plan of care.


clinical supervisor indicated the mepilex foam

dressing was not incorporated in the plan of care

but that it should have been added.

17-14-1(a)(1)(C)

484.60(b)

Conformance with physician orders

Standard: Conformance with physician

orders.

G 0578

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health agency failed to ensure conformance with

physician orders in 1 of 2 records with wounds in

a total sample of 7 clinical records reviewed. (#4)


Review of an agency policy revised 1/11/18 titled

"Services Provided" stated, "... Skilled

professionals will assume responsibility for, but

not restricted to the following: ... Providing

services that are ordered by the physician ..."


12/15/19, evidenced an agency agency document

titled "Physician Order" dated 10/25/19 and

signed by the physician stated, "... Continue

mepilex foam [type of wound dressing] to [left] ear

for 2 [weeks]. May use medihoney [type of wound

ointment] as needed if wound reopens. ..."

Review of agency documents titled "HomePointe

HealthCare Nursing Flow Sheet Shift

Assessment" dated 10/27/19, 10/28/19, 10/29/19,

10/30/19, 10/31/19, 11/2/19, 11/4/19 and 11/8/19

failed to evidence the mepilex foam dressing was

G 0578 The Director in conjunction with

the CCMs are reviewing and

updating 100% of active client

POCs to ensure that they are

current and accurate and reflect all

physician orders (including wound

care orders). Staff were educated

through an in-service and

instructed to follow physician

orders and document each shift on

wound care and wound

assessment (see attached

documents #8a Staff Survey

Follow up Letter, #8c Skin

Integrity Alteration NCP, #8d

NPUAP Staging System and #8e

Hand Hygiene and Wound

Assessment In-service Test). Also

as a reference, the revised NCP

for Skin Integrity Alteration,

document# 4 and #5 will be

present in all client charts to guide

nursing staff on wound

assessment and care

documentation and following

physician orders for care.

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applied as ordered to the left ear.


clinical supervisor indicated the agency did not

provide wound care as ordered by the physician.

17-14-1(a)(1)(H)

CCMs will perform nursing flow

sheet documentation audits on

100% of clients with wounds to

ensure compliance. If nurses fall

out of compliance they will be

re-educated in a timely manner to

make proper adjustments to their

documentation. Once compliance

is reached, CCMs will continue to

perform random audits. The

Director will oversee that this

takes place.

CCMs are responsible for

performing nursing flow sheet

documentation audits for wound

compliance and to follow up with

staff that falls out of compliance.

The Director will oversee that the

audits take place. 100% of staff

will complete the in-service and

document properly on their daily

client documentation. The

Administrative Assistant will track

that all mandatory in-service

testing is received and will alert

the CCM of any nursing staff

member out of compliance.

484.60(c)(1)

Promptly alert relevant physician of changes

The HHA must promptly alert the relevant

physician(s) to any changes in the patient's

condition or needs that suggest that

outcomes are not being achieved and/or that

the plan of care should be altered.

G 0590

Bldg. 00


health agency failed to promptly alert the

physician of changes in the patient's status in 2 of

7 clinical records reviewed. (#4, #5)

G 0590 100% of POCs will be reviewed

and if parameters are indicated,

the PCP was contacted to

discuss. Clarification orders were

sent as needed. The nursing staff

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1. Record review of an agency policy revised

1/11/18 titled "Skilled Nursing Services" stated,

"... The Registered Nurse: ... Informs the physician

and other medical personnel of changes in the

client condition and needs. ..."


care 12/15/09, evidenced agency documents titled


Shift Assessment" which indicated the patient's

respiration rate was 39 breaths per minute on

10/31/19, 43 breaths per minute on 11/2/19 and 44

breaths per minute on 11/4/19. The documents

failed to evidence the physician was notified of

the elevated respiration rate.


employee C indicated the patient's respiration rate

was a change in the patient's status that should

have been reported to the physician. 3. Clinical

record review of patient #5 evidenced agency

documents titled "HomePointe HealthCare

Nursing Flow Sheet Shift Assessment" dated

11/04/19, 11/05/19, 11/07/19, 11/11/19, 11/12/19,

and 11/13/19 which revealed the patient had an

elevated heart rate greater than 120 beats per

minute. These documents failed to indicate the

physician was notified of patients change in

status related to the elevated heart rate.

During an interview on 12/04/19, at 10:47 a.m.,

employee D indicated the physician should have

been notified of the change in the patient's

condition related to the elevated heart rate.

Record review evidenced an agency document

titled "HomePointe HealthCare Nursing Flow

Sheet Shift Assessment" dated 11/06/19 which

involved were contacted by the

CCM regarding their

documentation and were

re-educated on when to call the

physician regarding variances in

vital signs. All nursing staff were

also in-serviced via Survey Follow

up Letter, see attached document

#8 on appropriately contacting the

PCP and or the CCM for a change

in client condition that would

include vital sign variances

(elevated respiration or heart rate).

CCMs will perform random audits

of nursing documentation to

ensure that when clients have a

noted change in condition, the

PCP or the CCM is contacted.

Re-education of staff will take

place as needed.

Staff is responsible for alerting the

PCP or the CCM for a client

change in condition. The CCMs,

when contacted regarding the

change in condition, is to alert the

relevant physician as appropriate.

The CCMs are responsible for

auditing flowsheets for any change

in condition and to see that the

appropriate steps have been

taken. If a nurse is identified as

being out of compliance, then one

on one education will occur. The

Director is responsible to oversee

that the audits take place in a

timely manner.





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revealed the patient had elevated respirations

greater than 30 breaths per minute. The document

failed to indicate the physician was notified of the

patient's change in status related to the elevated

respirations.

During an interview on 12/04/19, at 10:47 a.m.,

employee D indicated the physician should have

been notified of the patient's change in condition

related to elevated respirations.

17-13-1(a)(2)

17-13-1(d)

484.60(d)(4)

Coordinate care delivery

Coordinate care delivery to meet the patient's

needs, and involve the patient, representative

(if any), and caregiver(s), as appropriate, in

the coordination of care activities.

G 0608

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health agency failed to coordinate care with the

therapy agency in 2 of 2 clinical records receiving

therapy services out of a total of 7 clinical records

reviewed. (#2, #3)


1. Review of an agency document revised 1/11/18

titled "Coordination of Client Care" stated, "All

personnel furnishing services will assure that their

efforts are coordinated effectively and support the

objectives outlined in ... the plan of care. ... To

integrate services (whether services are provided

directly or under arrangement), to assure the

identification of client needs and factors that

could affect client safety and treatment

effectiveness and the coordination of care

provided by all disciplines. ... Care conferences

will be held as necessary to establish interchange,

G 0608 Clients that receive therapy will be

identified. Integration of therapy

and coordination will be performed

on those clients. The CCMs will

continue to fax the POC as part of

care coordination. They will also

receive an update on therapy

outcomes via the agency

therapist, nurse or parent a

minimum of every sixty days.

Therapy type, frequency and

outcomes will be included in the

Physician Summary section of the

POC.

CCMs will identify 100% of clients

that receive therapy and will

perform care coordination through

report from nursing, or parent, or

through verbal contact with outside

therapy entities and will document

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reporting, and coordinated evaluation between all

disciplines involved in the client's care. ..."



"Comprehensive Assessment" dated 9/23/19

stated, "Other Agencies Involved with Care: ...

Therapy: [entity A] ..." This document failed to

evidence what therapy services the patient

received and frequency of services.


employee D indicated the nurses went with the

patient to outpatient therapy but was unsure what

therapy services the patient received and the

frequency of services. Employee D also indicated

there is no coordination of care with the agency to

include the type of services and frequency and

schedule of the services received.

3. During an interview on 12/2/19 at 10:55 a.m. at

the home of patient #3, the patient's mother

indicated the patient received physical and

occupational therapy services from entity B. The

clinical record failed to evidence coordination of

care with the agency providing therapy services.


employee C indicated the clinical record failed to

evidence care coordination with the agency

providing the physical and occupational therapy

services.

17-12-2(g)

the coordination that takes place.

The Director will monitor this

activity via POC audits and

through our internal QAPI program

on a quarterly basis.

CCMs will identify cases that

receive therapy and will perform

and document care coordination

as indicated. The Director will

perform audits to ensure that care

coordination is taking place.

484.70(a)

Infection Prevention

Standard: Infection Prevention.

The HHA must follow accepted standards of

practice, including the use of standard

G 0682

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precautions, to prevent the transmission of

infections and communicable diseases.

Based on observation, record review, and

interview, the home health agency failed to ensure

all employees followed acceptable standards of

practice to prevent the transmission of infection

including the use of standard precautions in 2 of 3

home visits. (#1, #2)



titled "Infection Prevention" stated, "Agency will

observe the recommended precautions for home

care as identified by the Centers for Disease

Control and Prevention (CDC). ... Standard

precautions apply to blood, all body fluids,

secretions, excretions, non-intact skin, and

mucous membranes. All are to be treated as a

potential source of infection regardless of whether

the client has a communicable disease. Hands are

washed ... immediately after gloves are removed

..."

2. During an observation of care at the home of

patient #1 on 11/27/19 at 10:12 a.m., employee F,

licensed practical nurse (LPN), was observed

wearing gloves as she suctioned the patient's

tracheostomy [a surgical opening in the neck to

the trachea creating an airway.] At 10:13 a.m. the

nurse removed the gloves from her hands, threw

them in the trash, and then applied new gloves to

her hands. The nurse then removed the patient's

dressing from the tracheostomy site, removed her

gloves from her hands, and threw the dressing

and gloves in the trash. At 10:15 a.m. the nurse

applied new gloves to her hands and suctioned

the patient's tracheostomy. At 10:18 a.m. the nurse

removed the gloves from her hands, applied new

gloves and removed the tracheostomy collar [a

G 0682 Mandatory, detailed education,

was given to staff on Hand

Hygiene via in-service and testing,

see attached documents #8 Staff

Survey Follow up Letter, #8a

Clean Hands Flyer CDC, #8b

Nursing Hand Hygiene, #8e Hand

Hygiene and Wound Assessment

In-service Test. The in-service will

be completed by all staff by

12-31-19. The two identified staff

that did not perform hand hygiene

appropriately during the survey

process, were re-trained on our

policy and protocol and prepared a

written statement on ways they

could ensure compliance with our

policy, see attached #9 Hand

Hygiene Write Up from Nurses.

For continued compliance, CCMs

will observe employees perform

hand hygiene at supervisory visits

and promptly correct any actions

performed against policy. At a

minimum, the Hands and Glove

Hygiene Competency (see

attached document #10 Hand and

Glove Hygiene Competency) will

continue to be demonstrated by

100% of employees, upon hire and

every year during our annual

training sessions, with an

emphasis on hand hygiene

between gloving.

The CCMs will be responsible for

ensuring continued compliance

throughout the year.

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device used to secure the tracheostomy tube in

place.] At 10:20 a.m. the nurse removed the gloves

from her hands, applied new gloves, removed the

inner cannula [a plastic tube that creates a

passageway from the trachea to the outside of the

body on the neck] from the tracheostomy and

then inserted the new inner cannula into the

tracheostomy. At 10:22 a.m. the nurse removed

the gloves from her hands and applied new

gloves.

3. During an observation of care at the home of

patient #2 on 11/27/19 at 1:19 p.m., employee G,

registered nurse (RN), was observed wearing

gloves as she suctioned the patient's

tracheostomy. The nurse was observed to then

remove her gloves and place on the patient's bed.

The nurse then applied new gloves and suctioned

the patient's tracheostomy. At 1:25 p.m., the nurse

was observed suctioning the patient's

tracheostomy with gloved hands, and then the

nurse removed the glove from her right hand and

applied a new glove and removed the patient's

tracheostomy dressing. The nurse removed the

glove from her right hand, applied a new glove to

her right hand and suctioned the patient's

tracheostomy. At 1:26 p.m., the nurse removed the

glove from her right hand, applied a new glove to

her right hand and removed the tracheostomy ties

from the patient's neck. At 1:29 p.m., the nurse

removed the glove from her right hand, applied a

new glove to her right hand and suctioned the

patient's tracheostomy. At 1:30 p.m., the nurse


new glove to her right hand and suctioned the

patient's tracheostomy. At 1:35 p.m., the nurse


new glove to her right hand and then cleaned

around the tracheostomy site. At 1:36 p.m., the

nurse removed the glove from her right hand,





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applied a new glove to her right hand and

suctioned the patient's tracheostomy. At 1:40

p.m., the nurse removed gloves from both hands,

applied new gloves and picked up new

tracheostomy tube. At 1:45 p.m., the nurse applied

gloves from the tracheostomy kit over her gloved

hands and inserted the new tracheostomy tube

into the tracheostomy. At 1:52 p.m., the nurse

removed both pairs of gloves from both hands,

applied new gloves and suctioned the

tracheostomy. At 2:03 p.m., the nurse was

observed washing the patient's upper body when

she removed the glove from her right hand,

applied a new glove to her right hand and

suctioned the patient's tracheostomy.

4. During an interview on 11/27/19 at 4:15 p.m., the

clinical supervisor indicated staff should wash

their hands after removing gloves and before

applying new gloves.

17-12-1(m)

484.70(b)(1)(2)

Infection control

Standard: Control.

The HHA must maintain a coordinated

agency-wide program for the surveillance,

identification, prevention, control, and

investigation of infectious and communicable

diseases that is an integral part of the HHA's

quality assessment and performance

improvement (QAPI) program. The infection

control program must include:

(1) A method for identifying infectious and

communicable disease problems; and

(2) A plan for the appropriate actions that are

expected to result in improvement and

G 0684

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disease prevention.


health agency failed to maintain a program for

identification, prevention, control, and

investigation of infectious and communicable

diseases specific to care and services provided in

the home setting in 1 of 7 clinical records

reviewed. (#4)



"Infection Surveillance" stated "Agency will

establish a continuous data monitoring and

collecting system to detect infections or identify

changes in infection trends. ... Client infections to

be reported while the client is receiving services

from the agency. ... Data regarding infections may

be obtained from a number of sources including

home visits, verbal orders for antibiotics or culture

and sensitivity orders, laboratory reports and

interviews with staff. ... "




Shift Assessment" dated 9/6/19 indicated the

patient was noted to have eye drainage and the

patient's caregiver sent a picture of the patient's

eyes to the physician. An agency document titled


Shift Assessment" dated 9/9/19 indicated the

patient was receiving antibiotic eye drops for an

eye infection.


clinical supervisor indicated there was no

infection report completed and no data collected

regarding this infection.

G 0684 HPHC has consistently utilized an

Infection Reporting Form (as part

of our QAPI program) that tracks

and documents active infections of

clients and employees, see

attached document #11 Infection

Reporting form. We were

accepting Physician orders and

Medication Notation Notes for

antibiotics that included a

diagnosis as an alternative for staff

completing a “formal” report. Upon

survey, it was determined that

practice would not be acceptable

and it was discovered that a

tracking log would be a more

effective way to maintain and

analyze the infection control data.

As of 12-11-19 we are no longer

accepting orders or notations for

infection reports, we are now only

accepting the Infection Reporting

form. Staff was educated on this

via the in-service; refer to

document #8 Staff Survey Follow

up Letter. In addition, an Infection

Control Data Log was created and

implemented as of 12-6-19, see

document #12 Infection Control

Tracking Log Client and #13

Infection Control Tracking Log

Employee. All Infection Reporting

forms will be tracked on this log

as they come in.

Staff is diligent in notifying the

CCMs of an infection with

themselves and/or their client.

This practice will be continued.

The log and its occurrences will be

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analyzed each time a new report

is added to the log. It will also be

further discussed and analyzed at

our quarterly QAPI meetings.

CCMs will continue to audit

nursing documentation to ensure

that the Infection Reporting forms

are being properly utilized.

As per our QAPI process, the

designated CCM is responsible for

managing the Infection Control

program and receives all Infection

Control Reporting forms. The CCM

will log all the reports on the

provided tracking logs and will

analyze the data each time the log

is updated. The Director will

oversee the infection control

program and audit the data a

minimum of quarterly.

484.110(a)(4)

Contact information for the patient

Contact information for the patient, the

patient's representative (if any), and the

patient's primary caregiver(s);

G 1018

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health agency failed to ensure the clinical record

contained the contact information for the patient /

patient's primary caregiver in 1 of 3 home visits.

(#3)



"Clinical Records & [and] Medical Record

Retention" stated, "... Clinical records will contain

pertinent past and current finding in accordance

with accepted professional standards including,

but not limited to: ... Contact information for client,

G 1018 For the client indicated on the

survey report, the POC was

properly updated to reflect both

the residence address and the

primary place of care address.

This is the only client the agency

has that received care outside of

the residence.

If this situation should occur

again, the entire administrative

staff is aware that the POC needs

to reflect the address of the

residence and the address in

which care will take place, if

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client representative, and primary caregiver(s) ...

Plan of Care with appropriate identifying

information ..."

When attempting to arrange a home visit for

observation of care at the home of patient #3, the

agency failed to indicate the patient received care

at another residence than that which was listed on

the patient's plan of care.


employee C indicated the address listed on the

plan of care was not the address where the patient

received services from the agency staff.


patient's caregiver indicated the address listed on

the plan of care was incorrect.


clinical supervisor indicated the address where

the patient received care should be included in the

plan of care. The clinical supervisor indicated the

address listed on the plan of care would be

corrected to contain the correct address for the

patient.

17-15-1(a)(1)

different.

The primary CCM is responsible

for ensuring that the correct

address information (residence

and delivery of care) is noted on

the POC. The Director will oversee

that this is done each time the

circumstances warrant.

484.110(b)

Authentication

Standard: Authentication.

All entries must be legible, clear, complete,

and appropriately authenticated, dated, and

timed. Authentication must include a

signature and a title (occupation), or a

secured computer entry by a unique

identifier, of a primary author who has

reviewed and approved the entry.

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Based on record review and interview, the home G 1024 All staff were in-serviced on 12/31/2019 12:00:00AM





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health agency failed to ensure all entries in the

clinical record were complete and appropriately

authenticated, dated, and timed to include a

signature and title in 1 of 7 clinical records

reviewed. (#3)



titled "Clinical Records & [and] Medical Record

Retention" stated, "... All documentation must be

legible, clear, complete, and appropriately

authenticated, dated and timed. Authentication

must include a signature and title (occupation), or

secured computer entry by a unique identifier, of a

primary author who has reviewed and approved

the entry. ... "





skilled nurse on 11/20/19 for time in at 8:00 a.m.

and time out at 6:00 p.m.. The record evidenced an

agency document titled "Home Health Aide Daily

Record" dated and signed by the home health

aide on 11/20/19 for time in at 8:00 a.m. and time

out at 6:00 p.m..


clinical supervisor indicated the date on the home

health aide note was incorrect. She indicated the

home health aide was at the patient's home on

11/19/19.

Record review of agency documents titled "Home

Health Aide Daily Record" dated 11/4/19, 11/5/19,

11/15/19, 11/20/19, 11/22/19, 11/25/19 and 11/26/19

failed to evidence the staff's title.

providing accurate date and times

on their documentation, see

attached document #8 Staff

Survey Follow Up Letter. Staff

was instructed that all entries

must be legible, clear, complete,

dated and timed. Authentication

must include the staff signature

and title. For HPHC, an employee

number associated to that

employee is also included on their

documentation.

If a discrepancy in date and or

time is noted on the

documentation, the staff person

and client will be notified to obtain

the correct information. The

documentation will then be

corrected appropriately.

This deficiency is not

systemic but was cited on one

staff member who is newer to the

agency. This employee was

re-educated individually and will

be monitored weekly.

100% of her charting will be

audited until compliance is met

and maintained.

CCM is responsible for auditing

this staff’s documentation for

continued compliance.





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clinical supervisor indicated the home health aide

visit notes should include the staff's title.

17-15-1(a)(7)

N 0000

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This visit was a State Licensure survey of a home

health agency.

Survey dates: 11/26, 11/27, 12/2, 12/3, and 12/4/19

Facility ID: IN006663

Active Patients: 26

Discharged Patients: 4

N 0000

410 IAC 17-12-1(a)

Home health agency

administration/management

Rule 12 Sec. 1(a) Organization, services

furnished, administrative control, and lines of

authority for the delegation of responsibility

down to the patient care level shall be:

(1) clearly set forth in writing; and

(2) readily identifiable.

N 0440

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health agency failed to ensure clear lines of

authority were readily identifiable and delineated

down to the patient level in 1 of 1 agency.



"Organization Chart" failed to indicate the

delegation of responsibility down to the patient

level. The document also failed to identify the

N 0440 HomePointe HealthCare (HPHC)

has always had “clients” on our

organizational charts. During an

earlier survey at a different location

with a different surveyor, we were

told by that surveyor that “clients”

should not be on our

organizational charts. As a result,

we took off “clients”. Fast forward

to this survey, the surveyor stated

that we should have clients on our

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specific disciplines of staff that were included in

the organization chart and the names of the staff

at each position.

During an interview at the entrance conference on

11/26/19 at 11:10 a.m., employee C indicated that

she was the clinical supervisor and that employee

D was the alternate clinical supervisor.


administrator indicated that employee B was the

clinical supervisor and employee C was the

alternate clinical supervisor.

organizational charts and were

subsequently cited.

Please see attached Hobart

HPHC Organization Chart,

document #14, that includes the

names of employees associated

with their positions. Please note

that the term “staff” was also

spelled out to define who staff is

“RN, LPN HHA”

HPHC will maintain organizational

charts that reflect the positions

with names associated with that

position and will define who “staff”

is.

Administrator will oversee that the

organizational chart is current and

maintained as is.

410 IAC 17-12-1(c)(6)

Home health agency


Rule 12 Sec. 1(c)(6) The administrator, who

may also be the supervising physician or

registered nurse required by subsection (d),

shall do the following:

(6) Ensure that the home health agency

meets all rules and regulations for licensure.

N 0449

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Based on record review and interview, the

administration failed to ensure organization and

the lines of authority for the delegation of

responsibility down to the patient level was clear

and readily identifiable in 1 of 1 home health

agency.


The administrator failed to ensure clear lines of

authority were readily identifiable and delineated

down to the patient level. See tag N0440.

N 0449 HomePointe HealthCare (HPHC)

has always had “clients” on our

organizational charts. During an

earlier survey at a different location

with a different surveyor, we were

told by that surveyor that “clients”

should not be on our

organizational charts. As a result,

we took off “clients”. Fast forward

to this survey, the surveyor stated

that we should have clients on our

organizational charts and were

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The administrator failed to ensure personnel

records included documentation of orientation

and receipt of job description for current position.

See tag N0458.

The administrator failed to ensure all employees

with direct patient contact had a physical

examination prior to direct patient contact that

indicated that the employee was free from

infectious and communicable disease. See tag

N0462.

The administrator failed to provide patients with a

15 day discharge notice. See tag N0488.

subsequently cited.

Please see attached Hobart

HPHC Organization Chart,

document #14, that includes the

names of employees associated

with their positions. Please note

that the term “staff” was also

spelled out to define who staff is

“RN, LPN HHA”

Administrator, Alternate

Administrator, Clinical Supervisor

and Alternate Clinical Supervisor

are all appointed by the Governing

Body on an annual basis. HPHC

did have a policy statement and

sign off for the Alternate

Administrator and Alternate

Director of Nursing job

responsibilities per attached Alt

Admin and DON Policy and Sign

Off, document #15. This was

signed off on prior to this survey

but we failed to provide this

documentation to the surveyor.

The Alternate Director of Nursing

title is now Alternate Clinical

Supervisor; this was revised as

reflected in document #16.

Additionally, a job description and

orientation checklist were created,

completed and signed for the

positions of Alternate


and Alternate Clinical Supervisor,

see attached documents #17, 18

and 19.

Clinical Supervisor, Alternate

Clinical Supervisor, and Alternate

Administrator were all oriented to

their job duties and signed their





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respective job descriptions.


Clinical Supervisor and Alternate

Administrator were all orientated

to their job responsibilities.

HPHC will maintain organizational

charts that reflect the positions

with names associated with that

position and will define who “staff”

is.

Job descriptions and

corresponding orientation

checklists were created and will

be applied and completed as

needed.

The CCM’s will follow the policy

and process for all discharge

clients. As part of our ongoing

Process Improvement Plan for

QAPI, the Director will oversee

compliance with 100% of audits

for discharge clients.

Administrator will oversee that the

organizational chart is current and

maintained as is.

The Administrator will be

responsible for ensure that any

future hires for these positions will

have their job descriptions signed

and have proof of orientation to

their roles.

The CCM’s and Director will

ensure 100% compliance for all

future discharges.

410 IAC 17-12-1(f)

Home health agency


Rule 12 Sec. 1(f) Personnel practices for

employees shall be supported by written

N 0458

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policies. All employees caring for patients in

Indiana shall be subject to Indiana licensure,

certification, or registration required to

perform the respective service. Personnel

records of employees who deliver home

health services shall be kept current and

shall include documentation of orientation to

the job, including the following:

(1) Receipt of job description.

(2) Qualifications.

(3) A copy of limited criminal history

pursuant to IC 16-27-2.

(4) A copy of current license, certification,

or registration.

(5) Annual performance evaluations.


health agency failed to ensure personnel records

included documentation of orientation and receipt

of job description for current position in 1 of 9

personnel records reviewed. (C)


Record review of an agency policy revised

11/20/18 titled "Job Descriptions and Job Posting

Policy" stated, "... Job descriptions will contain

the following information: Position title ...

Essential functions ... "

Record review of an agency policy revised

11/13/18 titled "Staff Orientation" stated, "... All

employees and persons providing care on behalf

of HomePointe HealthCare (staff) will participate

in an orientation program specific to his/her

role(s) and responsibilities. ... When the initial

orientation is completed, the staff member will

sign the orientation checklist and a copy will be

retained in the personnel record. ..."

Employee record review for employee C failed to

N 0458 Administrator, Alternate


and Alternate Clinical Supervisor

are all appointed by the Governing

Body on an annual basis. HPHC

did have a policy statement and

sign off for the Alternate

Administrator and Alternate

Director of Nursing job

responsibilities per attached Alt

Admin and DON Policy and Sign

Off, document #15. This was

signed off on prior to this survey

but we failed to provide this

documentation to the surveyor.

The Alternate Director of Nursing

title is now Alternate Clinical

Supervisor; this was revised as

reflected in document #16.

Additionally, a job description and

orientation checklist were created,

completed and signed for the

positions of Alternate


and Alternate Clinical Supervisor,

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evidence a job description and orientation to her

current role.


administrator indicated employee C was appointed

by the board to her current position but there was

no job description for employee C for her current

position.


clinical supervisor indicated the role of the clinical

care manager was different than the role of

alternate clinical supervisor.

see attached documents #17, 18

and 19.


Clinical Supervisor, and Alternate

Administrator were all oriented to

their job duties and signed their

respective job descriptions.


Clinical Supervisor and Alternate

Administrator were all orientated

to their job responsibilities.

CCM staff were re-educated

/in-serviced on ensuring a proper

discharge notice; 30-day for

Waiver clients and 15-day

discharge notice for all other

clients is followed. The Discharge

policy and HPHC’s Discharge

Process were reviewed. A guide

for coordinating the discharge

process was also reviewed with

the CCM’s, refer to document #21.

CCM staff are now aware that just

checking off the discharge box on

the documentation form does not

meet the requirements. The CCM

staff were trained that continued

documentation of the discharge

process with proper timelines

(30-day notice for Waiver and 15-

day notice for all others) must be

documented to prove coordination

of care and meet the discharge

requirements.

Job descriptions and

corresponding orientation

checklists were created and will

be applied and completed as

needed.

The Administrator will be





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responsible for ensure that any

future hires for these positions will

have their job descriptions signed

and have proof of orientation to

their roles.

410 IAC 17-12-1(h)

Home health agency


Rule 12 Sec. 1(h) Each employee who will

have direct patient contact shall have a

physical examination by a physician or nurse

practitioner no more than one hundred eighty

(180) days before the date that the employee

has direct patient contact. The physical

examination shall be of sufficient scope to

ensure that the employee will not spread

infectious or communicable diseases to

patients.

N 0462

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health agency failed to ensure all employees with

direct patient contact had a physical examination

prior to direct patient contact that indicated that

the employee was free from infectious and

communicable disease in 3 of 6 personnel records

reviewed with direct patient contact. (H, I, J)



titled "Health Screening" stated, "... Each

employee ... having direct patient contact with

clients must have documentation of baseline

health screening prior to providing care to clients.

... The physical exam shall be of sufficient scope

to ensure that the person will not spread

infectious or communicable disease to clients. ..."

2. Employee record review for employee H, first

patient contact date 11/4/19, failed to evidence a

N 0462 HPHC utilizes outside

occupational health vendors - to

provide all of our pre-employment

physicals. HPHC has repeatedly

required these facilities to utilize

our internal Physical History

assessment that includes the

statement: Free from infectious

and communicable disease.

On most occasions, HPHC staff

calls the vendors back if our

internal form is not used and/or

the statement “free from infectious

and communicable disease” is not

included on the physical. In the

case of Employee J, we did

contact the occupational health

vendor to request they sign off on

our internal form but we did not

receive it back. Subsequently,

there was no follow through on our

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physical examination that indicated the employee

was free from infectious and communicable

disease .

3. Employee record review for employee I, first




disease.

4. Employee record review for employee J, first




disease.

5. During an interview on 12/3/19 at 3:50 p.m.,

employee E indicated the physician refused to use

the agency's forms which contained the question

regarding if the employee was free from infectious

and communicable disease.

(HPHC) part to keep asking the

vendor for this form. We have now

put in place a tracking form for all

new hires that will trigger the

receipt of our internal form

containing the verbiage and

assessed for –Free from infectious

and communicable disease. See

documents #20 and 20a, both

titled New Employee Checklist

A tracking form for this purpose

was developed and it will be the

responsibility of Human

Resources to ensure that our

internal form is being utilized.

This form contains the verbiage -

Free from infectious and

communicable disease. If the

outside vendor does not utilize our

form, Human Resources will

contact and keep contacting the

outside vendor until we receive a

form containing the statement -

Free from infectious and

communicable disease.

Human Resources will be

responsible to ensuring that all

new hire physical history exams

include the verbiage and assessed

for –Free from infectious and

communicable disease. The

Director will audit 100% of new

employee physical history exams

to ensure compliance.

410 IAC 17-12-2(i) and (j)

Q A and performance improvement

Rule 12 Sec. 2(i) A home health agency

must develop and implement a policy

requiring a notice of discharge of service to

N 0488

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the patient, the patient's legal representative,

or other individual responsible for the patient's

care at least fifteen (15) calendar days before

the services are stopped.

(j) The fifteen (15) day period described in

subsection (i) of this rule does not apply in

the following circumstances:

(1) The health, safety, and/or welfare of the

home health agency's employees would be at

immediate and significant risk if the home

health agency continued to provide services

to the patient.

(2) The patient refuses the home health

agency's services.

(3) The patient's services are no longer

reimbursable based on applicable

reimbursement requirements and the home

health agency informs the patient of

community resources to assist the patient

following discharge; or

(4) The patient no longer meets applicable

regulatory criteria, such as lack of

physician's order, and the home health

agency informs the patient of community

resources to assist the patient following

discharge.


health agency failed to provide patients with a 15

day discharge notice in 1 of 2 closed clinical

records. (#7)



titled "Client Discharge Process" stated, "...

Discharge Criteria ... HomePointe HealthCare will

give a (30) day calendar notice for all waiver

clients, and a fifteen (15) day notice for all other

clients, of discharge before services are

N 0488 CCM staff were re-educated

/in-serviced on ensuring a proper

discharge notice; 30-day for

Waiver clients and 15-day

discharge notice for all other

clients is followed. The Discharge

policy and HPHC’s Discharge

Process were reviewed. A guide

for coordinating the discharge

process was also reviewed with

the CCM’s, refer to document #21.

CCM staff are now aware that just

checking off the discharge box on

12/05/2019 12:00:00AM





01/09/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


HOBART, IN 46342

15K030 12/04/2019


426 CENTER STREET

00

discontinued ..."

Clinical record review for patient #7 evidenced an

agency document titled "Discharge/Transfer

Summary" dated 8/1/19 which indicated the

patient was discharged from the agency on 8/1/19

and that the patient no longer needed services.

The record failed to indicate the patient / caregiver

was provided a 15 day discharge notice prior to

the discharge date.


employee D indicated there was no

documentation of a 15 day notice.

the documentation form does not

meet the requirements. The CCM

staff were trained that continued

documentation of the discharge

process with proper timelines

(30-day notice for Waiver and 15-

day notice for all others) must be

documented to prove coordination

of care and meet the discharge

requirements.

The CCM’s will follow the policy

and process for all discharge

clients. As part of our ongoing

Process Improvement Plan for

QAPI, the Director will oversee

compliance with 100% of audits

for discharge clients.

The CCM’s and Director will

ensure 100% compliance for all

future discharges.


Documents

G 0000 - in