g 0000 - in
TRANSCRIPT
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
G 0000
Bldg. 00
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
G 0000
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
G 0480
Bldg. 00
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
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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
G 0484
Bldg. 00
Based on record review and interview, the home
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
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
and resolution of a complaint 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
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. ..."
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, 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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 3 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
484.55(c)(1)
Health, psychosocial, functional, cognition
The patient's current health, psychosocial,
functional, and cognitive status;
G 0528
Bldg. 00
Based on record review and interview, the home
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.
The findings include:
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 4 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
nutritional status to include the amount and
frequency of the tube feeding and water flushes.
4. Clinical record review for patient #4, start of
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
"Recert/Follow-Up Assessment OASIS D" dated
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 5 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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.
G 0572
Bldg. 00
Based on record review and interview, the home
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)
The findings include:
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 6 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
3. Clinical record review for patient #2, start of
care 4/10/17, evidenced an agency document titled
"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.
4. Clinical record review for patient #4, start of
care 12/15/09, evidenced an agency document
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 ..."
Review of an agency document titled
"HomePointe HealthCare Nursing Flow Sheet
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 7 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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.
During an interview on 12/3/19 at 9:45 a.m., the
clinical supervisor indicated the nurse was to
complete a full head-to-toe assessment at every
visit to include an assessment of any wounds.
5. Clinical record review for patient #6, start of
care 7/13/10, evidenced an agency document titled
"Home Health Certification and Plan of Care" for
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.
6. Clinical record review for patient #7, start of
care 7/6/19, evidenced 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 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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 8 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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.
During an interview on 12/4/19 at 10:53 a.m.,
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
05/05/08, evidenced an agency document titled
"Home Health Certification and Plan of Care" for
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
"HomePointe HealthCare Nursing Flow Sheet
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 9 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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
"HomePointe HealthCare Nursing Flow Sheet
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.
During an interview on 12/4/19 at 10:44 a.m.,
Employee D indicated the wound should be
completely assessed at every visit to include
color, odor, drainage and size.
During an interview on 12/04/19 at 10:46 a.m., the
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;
G 0574
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 10 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
(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.
Based on record review and interview, the home
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)
The findings include:
1. Review of an agency policy revised 1/11/18
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
12/31/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 11 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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."
2. Clinical record review for patient #1, start of
care 5/23/18, evidenced an agency document titled
"Home Health Certification and Plan of Care" for
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
titled "Recert/Follow-Up Assessment OASIS D"
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.
During an interview on 12/2/19 at 2:20 p.m.,
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.
3. Clinical record review for patient #2, start of
care 4/10/17, evidenced an agency document titled
"Comprehensive Assessment" dated 11/25/19
which indicated the patient was NPO.
Record review of an agency document titled
"Home Health Certification and Plan of Care" for
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 12 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
During an interview on 12/4/19 at 9:58 a.m.,
employee D indicated the patient's NPO status
should be included on the plan of care.
4. Clinical record review for patient #3, start of
care 5/22/18, evidenced an agency document titled
"Home Health Certification and Plan of Care" for
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.
During an interview on 12/4/19 at 10:15 a.m.,
employee D indicated the plan of care did not
include the specific hours for the home health aide
and respite nursing services.
During an interview on 12/4/10 at 10:13 a.m.,
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.
5. Clinical record review for patient #4, start of
care 12/15/09, evidenced an agency document
titled "Home Health Certification and Plan of
Care" for certification period 10/27/19 - 12/25/19
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 13 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
which stated, "... Oxygen PRN to keep sats
[greater] than 90% ..."
Record review of an agency document titled
"Recert/Follow-Up Assessment OASIS D" dated
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.
During an interview on 12/4/19 at 10:23 a.m.,
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.
6. Clinical record review for patient #6, start of
care 7/13/10, evidenced an agency document titled
"Home Health Certification and Plan of Care" for
certification period 9/23/19 - 11/21/19 and signed
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 ...
During an interview on 12/3/19 at 2:30 p.m.,
employee D indicated the plan of care was not
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 14 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
individualized to include where the topical
medications were to be applied as needed.
During an interview on 12/3/10 at 2:35 p.m., the
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.]
7. Clinical record review for patient #7, start of
care 7/6/19, evidenced an agency document titled
"Home Health Certification and Plan of Care" for
certification period 7/6/19 - 9/4/19 which failed to
evidence patient/caregiver education
individualized for the patient.
During an interview on 12/4/19 at 10:48 a.m.,
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.
9. Clinical record review for patient #5, start of
care 05/05/18, evidenced an agency document
titled "Home Health Certification and Plan of
Care" for certification period 10/26/19 - 12/24/19
stated " ...Nutritional Requirements ... 1 carton
Boost High Protein [nutritional formula] bolus
[method of liquid feeding] GB [Gastrostomy
button, surgically placed tube to access stomach
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 15 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
for feeding, hydration, and medication] 3x [three
times] daily. ..."
Record review of an agency document titled
"HomePointe HealthCare Nursing Flow Sheet
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
Bldg. 00
Based on record review and interview, the home
health agency failed to ensure all orders were
recorded in the plan of care in 2 of 7 clinical
records reviewed. (#4, #7)
The findings include:
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. ...
2. Clinical record review for patient #7, start of
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
12/31/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 16 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
"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.
During an interview on 12/4/19 at 10:48 a.m.,
employee D indicated the plan of care did not
incorporate the order to assess mom's feeding
technique and parent education.
3. Clinical record review for patient #4, start of
care 12/15/19, evidenced an agency document
titled "Recert/Follow-Up Assessment OASIS D"
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
certification period 10/27/19 - 12/25/19 and signed
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 17 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
wound care order for mepilex foam dressing to the
left ear was incorporated in the plan of care.
During an interview on 12/3/19 at 11:42 a.m., the
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
Bldg. 00
Based on record review and interview, the home
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)
The findings include:
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 ..."
Clinical record review for patient #4, start of care
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.
12/31/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 18 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
applied as ordered to the left ear.
During an interview on 12/3/19 at 11:42 a.m., the
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
Based on record review and interview, the home
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
12/31/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 19 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
The findings include:
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. ..."
2. Clinical record review for patient #4, start of
care 12/15/09, evidenced agency documents titled
"HomePointe HealthCare Nursing Flow Sheet
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.
During an interview on 12/4/19 at 10:36 a.m.,
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 20 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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
Bldg. 00
Based on record review and interview, the home
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)
The findings include:
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
12/31/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 21 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
reporting, and coordinated evaluation between all
disciplines involved in the client's care. ..."
2. Clinical record review for patient #2, start of
care 4/10/17, evidenced an agency document titled
"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.
During an interview on 12/4/19 at 9:58 a.m.,
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.
During an interview on 12/4/19 at 10:20 a.m.,
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
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 22 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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)
The findings include:
1. Review of an agency policy revised 1/11/18
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.
12/31/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 23 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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
removed the glove from her right hand, applied a
new glove to her right hand and suctioned the
patient's tracheostomy. At 1:35 p.m., the nurse
removed the glove from her right hand, applied a
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,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 24 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 25 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
disease prevention.
Based on record review and interview, the home
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)
The findings include:
Review of an agency policy revised 9/23/19 titled
"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. ... "
Clinical record review for patient #4, start of care
12/15/19, evidenced an agency document titled
"HomePointe HealthCare Nursing Flow Sheet
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
"HomePointe HealthCare Nursing Flow Sheet
Shift Assessment" dated 9/9/19 indicated the
patient was receiving antibiotic eye drops for an
eye infection.
During an interview on 12/4/19 at 10:25 a.m., the
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
12/11/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 26 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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
Bldg. 00
Based on record review and interview, the home
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)
The findings include:
Review of an agency policy revised 11/13/18 titled
"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
12/06/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 27 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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.
During an interview on 12/2/19 at 10:38 a.m.,
employee C indicated the address listed on the
plan of care was not the address where the patient
received services from the agency staff.
During an interview on 12/2/19 at 10:55 a.m., the
patient's caregiver indicated the address listed on
the plan of care was incorrect.
During an interview on 12/4/19 at 10:16 a.m., the
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.
G 1024
Bldg. 00
Based on record review and interview, the home G 1024 All staff were in-serviced on 12/31/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 28 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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)
The findings include:
1. Review of an agency policy revised 11/13/18
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. ... "
2. Clinical record review for patient #3, start of
care 5/22/18, evidenced an agency document titled
"HomePointe HealthCare Nursing Flow Sheet
Shift Assessment" dated and signed by the
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..
During an interview on 12/2/19 at 3:10 p.m., the
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 29 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
During an interview on 12/2/19 at 4:15 p.m., the
clinical supervisor indicated the home health aide
visit notes should include the staff's title.
17-15-1(a)(7)
N 0000
Bldg. 00
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
Bldg. 00
Based on record review and interview, the home
health agency failed to ensure clear lines of
authority were readily identifiable and delineated
down to the patient level in 1 of 1 agency.
The findings include:
Review of an agency document titled
"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
12/06/2019 12:00:00AM
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 30 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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.
During an interview on 11/27/19 at 2:30 p.m., the
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
administration/management
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
Bldg. 00
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 findings include:
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
12/06/2019 12:00:00AM
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 31 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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
Administrator, Clinical Supervisor
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
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 32 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
respective job descriptions.
Clinical Supervisor, Alternate
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
administration/management
Rule 12 Sec. 1(f) Personnel practices for
employees shall be supported by written
N 0458
Bldg. 00
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 33 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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.
Based on record review and interview, the home
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)
The findings include:
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
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
Administrator, Clinical Supervisor
and Alternate Clinical Supervisor,
12/05/2019 12:00:00AM
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 34 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
evidence a job description and orientation to her
current role.
During an interview on 12/3/19 at 9:25 a.m., the
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.
During an interview on 12/3/19 at 9:27 a.m., the
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, Alternate
Clinical Supervisor, and Alternate
Administrator were all oriented to
their job duties and signed their
respective job descriptions.
Clinical Supervisor, Alternate
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
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 35 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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
administration/management
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
Bldg. 00
Based on record review and interview, the home
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)
The findings include:
1. Review of an agency policy revised 11/13/18
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
12/31/2019 12:00:00AM
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 36 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
physical examination that indicated the employee
was free from infectious and communicable
disease .
3. Employee record review for employee I, first
patient contact date 4/14/19, failed to evidence a
physical examination that indicated the employee
was free from infectious and communicable
disease.
4. Employee record review for employee J, first
patient contact date 6/15/15, failed to evidence a
physical examination that indicated the employee
was free from infectious and communicable
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
Bldg. 00
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 37 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
426 CENTER STREET
00
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.
Based on record review and interview, the home
health agency failed to provide patients with a 15
day discharge notice in 1 of 2 closed clinical
records. (#7)
The findings include:
1. Review of an agency policy revised 11/28/19
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
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 38 of 39
(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
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
HOBART, IN 46342
15K030 12/04/2019
HOMEPOINTE HEALTHCARE
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.
During an interview on 12/4/19 at 10:52 a.m.,
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.
State Form Event ID: H5IC11 Facility ID: 006663 If continuation sheet Page 39 of 39