PRINTED: 03/30/2012 DEPARTMENT OF HEALTH AND ... - Indiana

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

03/30/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

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

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PERCEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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KOKOMO, IN 46902

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03/12/2012

COMFORT HOME HEALTH LLC

1815 S PLATE STREET

N0000

N0000This was a home health state complaint

investigation.

Complaint # IN 00103250 -

Substantiated: State deficiencies related to

the allegation are cited. Unrelated

defiencies are also cited.

Survey Date: March 8 and 12, 2012

Facility #: 012349

Medicaid Vendor #: 201004280

Surveyor: Bridget Boston, RN, PHNS

Quality Review: Joyce Elder, MSN, BSN,

RN

March 15, 2012

State Form

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

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

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 disclosable 14

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: IEQT11 Facility ID: 012349

TITLE

If continuation sheet Page 1 of 42

(X6) DATE




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N0408

410 IAC 17-10-1(d)

Licensure

Rule 10 Sec. 1(d) Disclosure of ownership

and management information must be made

to the department at the time of the home

health agency's initial request for licensure,

for each survey, and at the time of any

change in ownership or management. The

disclosure must include the names and

addresses of the following:

(1) All persons having at least five percent

(5%) ownership or controlling interest in the

home health agency.

(2) Each person who is:

(A) an officer;

(B) a director;

(C) a managing agent; or

(D) a managing employee;

of the home health agency and evidence

supporting the qualifications required by this

article.

(3) The corporation, association, or other

company that is responsible for the

management of the home health agency.

(4) The chief executive officer and the

chairman or equivalent position of the

governing body of that corporation,

association, or other legal entity responsible

for the management of the home health

agency.

N408 We take seriously our

responsibility to notify the State in

a timely manner of any changes

under Rule 10 Sec. 1(d).

Disclosure of management

change was refaxed to the

correct fax number on 3.15.12.

The agency received notification

that additional information was

required to include a new criminal

history and another letter. This

information was refaxed on

03/28/2012 12:00:00AMN0408Based on document review and interview,

the agency failed to ensure the state

agency was notified of a change in the

agency management positions of alternate

director of nursing and alternate

administrator for 1 of 1 agency.

Findings:

1. On 3/8/12 at 12:15 PM, employee G,

State Form Event ID: IEQT11 Facility ID: 012349 If continuation sheet Page 2 of 42




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3.28.2012. Prevention: The

agency will prevent the deficiency

from reccuring by utilizing the

correct fax number

(317-233-7157). Additionally, we

will keep a binder of changes sent

to the State and if we do not

receive a written notification back

of receipt and acceptance, we will

follow-up until we have resolution.

The administrator will be

responsible for correcting the

deficiency. The deficiency was

corrected on 3.28.2012

the director of nursing, indicated a new

individual was in the position as the

alternate administrator and alternate

director of nursing since January 2012.

The agency was unable to provide

documentation the state had been notified

of this management change.

2. Personnel file B evidenced an untitled

document, signed by employee F and

dated 10/31/11, that indicated the position

held by employee F at the time was the

assistant director of nursing.

3. On 3/12/12 at 4 PM, employee F

indicated she held the position as the

alternate administrator and alternate

director of nursing unofficially before

January 2012.





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N0458

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

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.

N0458 The deficiency will be

corrected by: A Criminal History

from the Indiana State Repository

will be run on all current and

future staff when both a married

and maiden name are disclosed

to us on a social security card,

drivers license, name on

application or professional

license. All files will be audited for

compliance. Prevention: On an

ongoing basis 10% of Employee

files will be audited quarterly.

HR manager has been

inserviced on requirement to run

background check on all names

as listed on above instances.

The administrator and human

resource manager will be

responsible for monitoring this

corrective action.

04/15/2012 12:00:00AMN0458Based on personnel file and interview, the

agency failed to ensure a criminal history

was obtained from the Indiana central

repository for criminal history

information as required by IC 16-27-2

under all the employee's names for 1 (File

A) of 1 files reviewed of staff noted to

have a name change prior to their date of

hire.

The findings include:

1. Personnel file A, a home health aide,

date of hire 6/8/11 evidenced a document

titled "Certificate of Marriage" which

indicated the date of marriage was June

13, 2011. The employee completed an

application for employment with her new





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married name on June 1, 2011. The

agency completed a limited criminal

history from the Indiana central repository

under her married name on June 13, 2011.

The agency failed to complete a limited

criminal history search under the

employee's maiden name and the name as

listed on the home health registry.

2. On March 12, 2012, at 4:45 PM, the

administrator / director of nursing

indicated she was not aware of a need to

check the criminal history of an

individual under all names in which they

have represented themselves and maiden

names.





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N0508

410 IAC 17-12-3(b)(2)(E)

Patient Rights

Rule 12 Sec. 3(b)(2)(E)

(b) The patient has the right to exercise his

or her rights as a patient of the home health

agency as follows:

(2) The patient has the right to the

following:

(E) Confidentiality of the clinical records

maintained by the home health agency. The

home health agency shall advise the patient

of the agency's policies and procedures

regarding disclosure of clinical records.

N0508 The process to correct

the deficiency will include, a

locked receptacle at 211 S.

Anderson St., Elwood, IN 46036

for employees to place their

notes. Only a Comfort Home

Health employee will have a key

to the locked receptacle to

transport notes to the Kokomo

office. Ancillary staff will be

instructed to give all paperwork to

only a Comfort Home Health

employee for transport to the

office. Comfort Home Health

does not have any branch offices,

however, our nursing

supervisor for this patient is also

employed by Heaven Sent (a

home health care located in

Elwood, IN) and she instructed

employee J to drop off

documentation at that location.

Going forward, Comfort Home

Health will have a locked

receptacle at the Elwood location

for employees to drop

documentation off to our nursing

supervisor. Prevention: All staff

will be inserviced as to the

04/15/2012 12:00:00AMN0508

Based on clinical record, administrative

document, and Indiana State Department

of Health (ISDH) data base review and

interview, the agency failed to ensure all

clinical records information was kept

confidential and not able to be accessed

by employees from another agency for 1

of 1 agency reviewed with the potential to

affect all patient records.

Findings include:

1. During a telephone call on 3/12/12 at

1:50 PM, employee K indicated her

immediate supervisor was employee E

and she was instructed to drop off her

patient record documents every Sunday

evening by placing the documents

through the mail slot in the door of

another agency, Heaven Sent in Elwood,

Indiana. She indicated the documents

were not placed in a sealed envelope or a





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appropriate place to deposit

clinical records after hours for

confidential patient paperwork

and to only give paperwork to a

Comfort Home Health employee

to transport to the office.

Responsibility: All employees will

be responsible for ensuring all

clinical record information is kept

confidential.

locked container, but dropped into the

mail slot on the door of the agency office.

Employee E was to retrieve them on

Monday mornings.

2. On 3/12/12 at 3:55 PM, employee G

indicated the agency did not have a policy

or procedure in place to to identify and

protect documents once the documents

left the possession of the field staff and

were not received by the agency or in the

event they became lost. She indicated

the case managers are to meet with the

field staff weekly to pick up all the

documents or the field staff can drive to

the office and turn them in themselves.

She indicated the transfer of the patient's

documents were to be from one staff 's

hands to another's, then to the office.

3. During a telephone call interview On

March 14, 2012, at 10:49 AM, employee

J indicated she only worked for Comfort

Health Care out of the Elwood office and

that employee E was her immediate

supervisor and owner of the agency for

which she worked. She indicated she

obtained assignments and turned in visit

notes to employee E at the Comfort Home

Health office in Elwood, Indiana.

4. The administrative documentation

failed to evidence the home health agency

had a branch office.





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5. The ISDH data base failed to evidence

the agency had a branch office.





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N0514

410 IAC 17-12-3(c)

Patient Rights

Rule 12 Sec. 3(c)

(c) The home health agency shall do the

following:

(1) Investigate complaints made by a

patient or the patient's family or legal

representative regarding either of the

following:

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

furnished.

(B) The lack of respect for the patient's

property by anyone furnishing services on

behalf of the home health agency.

(2) Document both the existence of the

complaint and the resolution of the complaint.

N0514 The Agency has a

Grievance Policy and complaint

log in place that was not utilized

in this instance. The deficiency

will be corrected by inservicing

employee E on Administrative

Policy 1.35 Patient/Client

Grievance Procedures.

Prevention: The agency will

inservice all staff regarding the

above policy reinforcing the

seriousness of which our agency

views complaints and the need to

report them immediately.

The complaint log is reviewed

quarterly in Agency QI meetings.

The administrator will be

responsible for ensuring

compliance and day-to-day

monitoring of Agency complaints.

04/15/2012 12:00:00AMN0514Based on clinical record and policy

review and interview, the agency failed to

ensure all complaints regarding a lack of

respect for patient's property were

investigated in 1 (#3) of 5 clinical records

reviewed with the potential to affect all of

the patients served by the agency.

Findings include:

1. While investigating this same

complaint on 1/27/12 at 1:25 PM at

another agency, employee E identified

herself as also working as a registered

nurse with Comfort Home Health and

caring for patient #3 for both home health

agencies. She indicated the power of

attorney (POA) for patient # 3 called her,

on approximately December 19, 2011,

and requested two specific individuals

that were rendering care to the patient, on





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behalf of Comfort Home Health, no

longer be assigned to the patient. The

individuals were identified as employees

A and D, home health aides for Comfort

Home Health. She indicated she did not

know why the request was made until a

staff member informed her that the

patient's POA "had accused the aides of

stealing" money and possessions from the

patient. She indicated that, since the

agency was not staffing the patient 24

hours a day, they could not be

responsible. Employee E indicated she

did not have any documentation to

evidence the accusation or complaint was

acknowledged or investigated.

2. On March 8, 2012, at 1:25 PM, the

administrator / director of nursing

indicated the agency had only received

one complaint since they began providing

services in 2010 and that complaint was

received in March of 2012. She indicated

that when a staff member received a

complaint regarding theft, the nurse was

to react immediately and to notify the

agency administration.

3. During a telephone interview on

March 12, 2012, at 3:05 PM, employee E

indicated she received the request from

the patient's POA to no longer schedule

employees A and D with the patient. She

indicated she did not know why the POA





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had made the request and did not

investigate the reasons.

4. Clinical record #3, start of care

8/10/11, included a plan of care (POC) for

the certification period 12/6/11 through

2/5/12 with orders for a skilled nurse once

a day for insulin injections and daily

glucose monitoring. The POC also

included orders for a home health aide 6

hours a day, seven days a week, for 9

weeks. The clinical record evidenced

employees A, D, I, and J, home health

aides, and employee K, a licensed

practical nurse, provided services for this

agency through 12/26/11. The clinical

record failed to evidence any complaint or

investigation was conducted when

employee E, a registered nurse, was

informed of the allegation.

5. The undated policy titled "1.35 Patient

/ Client Grievance Procedure" states, "All

grievances and concerns are to be dealt

with by the administrator or his / her

designee. When a grievance is received,

whether written or verbal, it is to be

documented in the patient / client's

clinical record by the administrator or his

/ her designee."





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N0596

410 IAC 17-14-1(l)(A)

Scope of Services

Rule 14 Sec. 1(l) The home health agency

shall be responsible for ensuring that, prior to

patient contact, the individuals who furnish

home health aide services on its behalf meet

the requirements of this section as follows:

(1) The home health aide shall:

(A) have successfully completed a

competency evaluation program that

addresses each of the subjects listed in

subsection (h) of this rule; and

N0596 How Corrected: The

agency will have the contracted

RN recompetency check all home

health aides in the required

manner addressing

deficient subject areas found in

state regulation 410 1AC

17-4-1(h). Prior to competency

checking the home health aides,

the contracted RN will review all

subject areas that must be

checked to include Policy 410

IAC 17-14-1, the Agency policies

4.49 Home Health Aide Testing

and Competency and 2.48

Definition of a Home Health Aide.

The Agency will amend the

competency check off form to

remove colostomy and g-tube

care. Prevention: All

competency checks will be

performed by the contracted RN

per above regulation and ADON

will observe the contracted RN

performing the initial home health

aide competency check off to

ensure compliance with the

Regs. In most instances we will

utilize a local facility for the

bathing component of the skills

04/15/2012 12:00:00AMN0596Based on personnel file and agency policy

review and staff interview, the agency

failed to ensure the home health aide

competency evaluation was completed in

the required manner and addressed all of

the subject areas found at 410 IAC

17-14-1(h) for 5 (Files A, B, D, I and J) of

5 home health aide files reviewed.


1. On March 8, 2012 at 1:15 PM, the

director of nursing indicated the

contracted nurse evaluated all of the aides'

competency of skills in the basement of

the agency office and gave a tour of the

area utilized for the testing. She indicated

the testing was performed on an office

table and the contracted nurse brought in

all the equipment used for the testing; she

indicated the contracted nurse brought in

a wheelchair, cane, walker, and all the

linens for bathing. While reviewing the

documentation, she indicated the aides





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check off to occur with a client

or pseudo-client. Documentation

of completion of any training or

re-training will be placed in the

employee's file. The ADON will

be responsible to ensure that all

home health aides are

competency checked in the

required manner. The deficiency

will be corrected on all new hires

initial skills competency check-off

and all existing home health aides

will be recompetency checked in

the deficient areas.

were talked through the tasks of using a

Hoyer lift, gastronomy feedings, and

colostomy care during their skills check

off and that all the tasks were not actually

demonstrated and evaluated on a client or

pseudo - client. She indicated the nurses

try to schedule supervisory visits of the

aides while they are rendering care so that

they can evaluate some of the skills not

actually demonstrated during the original

evaluation of the aide's skills. She

indicated there was no agency policy that

stated how the staff were actually tested

or observed and the written agreement

between the agency and the contracted

registered nurse did not specify how the

agency expected the nurse to evaluate the

skills of the aides.


March 13, 2012, at 5:28 PM, employee H

indicated that she did not complete any

actual bathing during the aide's

competency testing; she indicated the task

of bathing was talked through and not

observed on an actual patient or

pseudo-patient. She indicated she uses a

cane and walker that are stored in a closet

onsite and she brings linens to the testing.

She also indicated she does not test the

aides on the use of a Hoyer lift transfer,

gastronomy feedings, and colostomy care.






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H indicated she felt uncomfortable having

the aides perform skills and be evaluated

for the purpose of the skills check off.

She indicated she does not observe the

aides in any setting actually performing

the skills on patients or pseudo - patients.

She indicated she has not observed any

staff completing a bed bath in any setting,

the skills documented as observed are not

performed, and the tasks are only

discussed. he indicated the discussions

last one and a half to two hours for the

evaluation of an aide's skills.

4. The agency's undated policy # 4.49

titled "Home Health Aide Testing and

Competency" states, "Each home health

and personal care worker ... shall

demonstrate competence for their position

as demonstrated by one or more of the

following: a. completion of an approved

75 hours training program. b. On-site

observation of competency. The agency

shall be responsible for implementing

training and testing procedures for aides

and must provide the preparation

necessary for aides to successfully pass a

competency evaluation or use only aides

that meet the personnel qualifications for

Home health aides as specified in section

484.4 of the federal regulations. The

agency shall establish the competency of

its aides through a testing program."





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5. The undated policy # 2.48 titled

"Home Health Aide Service" stated,

"Duties of a Home Health Aide ... The

following patient / client care procedures

are usually demonstrated / observed

before being performed in each patient /

client situation: 1) assist patient in and out

of bed. 2) Assist with transfer from bed to

chair, chair to commode and return. 3)

assist with turning patient in bed. 4) assist

with use of prosthesis. 5) assist with use

of special equipment, such as walker,

wheelchair, and crutches. 6) encourage

active exercises. c. The following patient

/ client care procedures are generally not

to be performed until they have been

demonstrated / observed in each patient /

client situation. 1) Assist with tub bath or

shower. 2) care of catheter drainage bag.

3) apply simple, non-sterile dressings. 4)

Give simple skin care and apply lotion, or

skin barrier. 5) perform simple soaks. 6)

Assist with the application of elastic

stocking. 7) Assist patient / client to

perform exercise / activities as taught and

supervised by therapist. 8) Use of Hoyer

lift. 9) Assist with use of oxygen

equipment."

6. Personnel file A, date of hire 6/8/11,

evidenced the document titled "Certified

Home Health / Hospice Aide Check List"

that states, "Check skills being





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demonstrated. Initial and date when each

skill is evaluated. ... * Mandated - Must

be performed on a client or a pseudo -

client. Pseudo - client means a live body

not a manikin. Bathing must be done

with the pseudo client not wearing any

clothing or bathing must be utilizing a

patient." The document contained a list

of skills to be tested. Preceding each skill

grouping there is an asterisk preceding the

group indicating the skill was to be

completed and evaluated on a client or

pseudo - client. The list included the

skills: 1) Mobility - ambulation: Assist

cane, walker, crutches. 2) ROM [range of

motion]: Upper and Lower active,

passive. 3) Transfer: Assist wheelchair

bed to chair. 4) Positioning: In a bed. In

a chair. 5) Personal Care: Oral: Dentures,

natural teeth, gum care. 6) Bed bath. 7)

Bath shower, Tub, sponge. 8) Nail Care

Finger / Toes - soak, file, and trim. 9)

Hair: Shampoo, bed sink, bathtub. 10)

Prevention of Skin Breakdown:

Recognition of pressure areas appropriate

massage techniques. 11) Bodily functions

- toileting, bathroom, bedpan, urinal,

bedside commode, dwelling catheter. 12)

Vital Signs: Temperature, respiration, and

pulse. 13) Fluid Balance: Measurement

In-take Out- put. 14) Environmental

Services: Linen Change: Bed Occupied

with patient, bed unoccupied. 15)

Universal Precautions, as written by the





03/30/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET

agency, are used and followed. 16)

Medication Assistance competent client,

mentally incompetent. Under the area

titled "Other Individual Agency

Requirements" was additional skills to be

tested and included "1) Use of Special

Equipment. 2) Hoyer Lift. 3) G

[gastronomy] - Tube Feedings. and 4)

Colostomy Care." The document

indicated all of the skills listed were

demonstrated and evaluated on 6/10/11 by

employee H. The task gastronomy

feedings and colostomy care are not in the

scope of practice of the home health aide.

7. Personnel file B, date of hire 10/17/11,














group indicating that the skill was to be









03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET




a chair. 50 Personal Care: Oral: Dentures,


























demonstrated and evaluated on 10/20/11

by employee H. The task gastronomy







03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET

8. Personnel file D, date of hire 6/3/11,






































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B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET



















9. Personnel file I, a home health aide,

date of hire 9/8/11, evidenced the

document titled "Certified Home Health /

Hospice Aide Check List" that states,

"Check skills being demonstrated. Initial

and date when each skill is evaluated. ...

* Mandated - Must be performed on a

client or a pseudo - client. Pseudo - client

means a live body not a manikin. Bathing

must be done with the pseudo client not

wearing any clothing or bathing must be

utilizing a patient." The document

contained a list of skills to be tested.

Preceding each skill grouping there is an

asterisk preceding the group indicating





03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET

that the skill was to be completed and

evaluated on a client or pseudo - client.

The list included the skills: 1) Mobility -

ambulation: Assist cane, walker, crutches.

2) ROM [range of motion]: Upper and

Lower active, passive. 3) Transfer: Assist

wheelchair bed to chair. 4) Positioning:

In a bed. In a chair. 50 Personal Care:

Oral: Dentures, natural teeth, gum care.

6) Bed bath. 7) Bath shower, Tub,

sponge. 8) Nail Care Finger / Toes -

soak, file, and trim. 9) Hair: Shampoo,

bed sink, bathtub. 10) Prevention of Skin

Breakdown: Recognition of pressure areas

appropriate massage techniques. 11)

Bodily functions - toileting, bathroom,

bedpan, urinal, bedside commode,

dwelling catheter. 12) Vital Signs:

Temperature, respiration, and pulse. 13)

Fluid Balance: Measurement In-take Out-

put. 14) Environmental Services: Linen

Change: Bed Occupied with patient, bed

unoccupied. 15) Universal Precautions,

as written by the agency, are used and

followed. 16) Medication Assistance

competent client, mentally incompetent.

Under the area titled "Other Individual

Agency Requirements" was additional

skills to be tested and included "1) Use of

Special Equipment. 2) Hoyer Lift. 3) G









03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET




10. Personnel file J, date of hire 8/10/11


































03/30/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET























During a telephone call interview On


J indicated she had never been to the

Kokomo office, that she only worked for

Comfort Health Care out of the Elwood

office, and that employee E was her

immediate supervisor and owner of the

agency for which she worked. She

indicated she picked up assignments and

turned in visit notes to employee E at the

Comfort Home Health office in Elwood,





03/30/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET

Indiana.





03/30/2012PRINTED:

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A. BUILDING

B. WING

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(X4) ID

PREFIX

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TAG



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(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET

N0598

410 IAC 17-14-1(l)(2)

Scope of Services

Rule 14 Sec. 1(l)(2) The home health agency

shall maintain documentation which

demonstrates that the requirements of this

subsection and subsection (h) of this rule

were met.

N0598 How Corrected: The

agency will have the contracted

RN recompetency check all home

health aides in the required

manner addressing deficient

subject areas found in state

regulation 410 1AC 17-4-1(h).

Prior to competency checking the

home health aides, the contracted

RN will review all subject areas

that must be checked to include

Policy 410 IAC 17-14-1, the

Agency policies 4.49 Home

Health Aide Testing and

Competency and 2.48 Definition

of a Home Health Aide. The

Agency will amend the

competency check off form to

remove colostomy and g-tube

care. Prevention: All

competency checks will be

performed by the contracted RN

per above regulation and ADON

will observe the contracted RN

performing the initial home health

aide competency check off to

ensure compliance with the Regs.

In most instances we will utilize a

local facility for the bathing

component of the skills check off

to occur with a client or

pseudo-client. Documentation of

completion of any training or

re-training will be placed in the

employee's file. The ADON will

04/15/2012 12:00:00AMN0598Based on personnel file and policy review

and interview, the agency failed to ensure

documentation of the home health aide

competency evaluation was accurate and

met the requirements for 5 (Files A, B, D,

I and J) of 5 home health aide files

reviewed.


1. On March 8, 2012 at 1:15 PM, the

director of nursing indicated the

contracted nurse evaluated all of the aides'

competency of skills in the basement of

the agency office and gave a tour of the

area utilized for the testing. She indicated

the testing was performed on an office

table and the contracted nurse brought in

all the equipment used for the testing; she

indicated the contracted nurse brought in

a wheelchair, cane, walker, and all the

linens for bathing. While reviewing the

documentation, she indicated the aides

were talked through the tasks of using a

Hoyer lift, gastronomy feedings, and

colostomy care during their skills check

off and that all the tasks were not actually

demonstrated and evaluated on a client or





03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET

be responsible to ensure that all

home health aides are

competency checked in the

required manner. The deficiency

will be corrected on all new hires

initial skills competency check-off

and all existing home health aides

will be recompetency checked in

the deficient areas.

pseudo - client. She indicated the nurses

try to schedule supervisory visits of the

aides while they are rendering care so that

they can evaluate some of the skills not

actually demonstrated during the original

evaluation of the aide's skills. She

indicated there was no agency policy that

stated how the staff were actually tested

or observed and the written agreement

between the agency and the contracted

registered nurse did not specify how the

agency expected the nurse to evaluate the

skills of the aides.


March 13, 2012, at 5:28 PM, employee H

indicated that she did not complete any

actual bathing during the aide's

competency testing; she indicated the task

of bathing was talked through and not

observed on an actual patient or

pseudo-patient. She indicated she uses a

cane and walker that are stored in a closet

onsite and she brings linens to the testing.

She also indicated she does not test the

aides on the use of a Hoyer lift transfer,

gastronomy feedings, and colostomy care.



H indicated she felt uncomfortable having

the aides perform skills and be evaluated

for the purpose of the skills check off.

She indicated she does not observe the





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OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

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(X4) ID

PREFIX

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TAG



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KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET

aides in any setting actually performing

the skills on patients or pseudo - patients.

She indicated she has not observed any

staff completing a bed bath in any setting,

the skills documented as observed are not

performed, and the tasks are only

discussed. he indicated the discussions

last one and a half to two hours for the

evaluation of an aide's skills.

4. The agency's undated policy # 4.49

titled "Home Health Aide Testing and

Competency" states, "Each home health

and personal care worker ... shall

demonstrate competence for their position

as demonstrated by one or more of the

following: a. completion of an approved

75 hours training program. b. On-site

observation of competency. The agency

shall be responsible for implementing

training and testing procedures for aides

and must provide the preparation

necessary for aides to successfully pass a

competency evaluation or use only aides

that meet the personnel qualifications for

Home health aides as specified in section

484.4 of the federal regulations. The

agency shall establish the competency of

its aides through a testing program."

5. The undated policy # 2.48 titled

"Home Health Aide Service" stated,

"Duties of a Home Health Aide ... The

following patient / client care procedures





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(X3) DATE SURVEY

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(X4) ID

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TAG



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(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET

are usually demonstrated / observed

before being performed in each patient /

client situation: 1) assist patient in and out

of bed. 2) Assist with transfer from bed to

chair, chair to commode and return. 3)

assist with turning patient in bed. 4) assist

with use of prosthesis. 5) assist with use

of special equipment, such as walker,

wheelchair, and crutches. 6) encourage

active exercises. c. The following patient

/ client care procedures are generally not

to be performed until they have been

demonstrated / observed in each patient /

client situation. 1) Assist with tub bath or

shower. 2) care of catheter drainage bag.

3) apply simple, non-sterile dressings. 4)

Give simple skin care and apply lotion, or

skin barrier. 5) perform simple soaks. 6)

Assist with the application of elastic

stocking. 7) Assist patient / client to

perform exercise / activities as taught and

supervised by therapist. 8) Use of Hoyer

lift. 9) Assist with use of oxygen

equipment."

6. Personnel file A, date of hire 6/8/11,













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B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET






group indicating the skill was to be








a chair. 5) Personal Care: Oral: Dentures,

























03/30/2012PRINTED:

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(X3) DATE SURVEY

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(X4) ID

PREFIX

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET










7. Personnel file B, date of hire 10/17/11,




























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(X3) DATE SURVEY

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(X4) ID

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TAG



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(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET

























demonstrated and evaluated on 10/20/11

by employee H. The task gastronomy



8. Personnel file D, date of hire 6/3/11,









03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET







































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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET














9. Personnel file I, a home health aide,

date of hire 9/8/11, evidenced the

document titled "Certified Home Health /

Hospice Aide Check List" that states,

"Check skills being demonstrated. Initial

and date when each skill is evaluated. ...

* Mandated - Must be performed on a

client or a pseudo - client. Pseudo - client

means a live body not a manikin. Bathing

must be done with the pseudo client not

wearing any clothing or bathing must be

utilizing a patient." The document

contained a list of skills to be tested.

Preceding each skill grouping there is an

asterisk preceding the group indicating

that the skill was to be completed and

evaluated on a client or pseudo - client.

The list included the skills: 1) Mobility -

ambulation: Assist cane, walker, crutches.

2) ROM [range of motion]: Upper and





03/30/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET

Lower active, passive. 3) Transfer: Assist

wheelchair bed to chair. 4) Positioning:

In a bed. In a chair. 50 Personal Care:

Oral: Dentures, natural teeth, gum care.

6) Bed bath. 7) Bath shower, Tub,

sponge. 8) Nail Care Finger / Toes -

soak, file, and trim. 9) Hair: Shampoo,

bed sink, bathtub. 10) Prevention of Skin

Breakdown: Recognition of pressure areas

appropriate massage techniques. 11)

Bodily functions - toileting, bathroom,

bedpan, urinal, bedside commode,

dwelling catheter. 12) Vital Signs:

Temperature, respiration, and pulse. 13)

Fluid Balance: Measurement In-take Out-

put. 14) Environmental Services: Linen

Change: Bed Occupied with patient, bed

unoccupied. 15) Universal Precautions,

as written by the agency, are used and

followed. 16) Medication Assistance

competent client, mentally incompetent.

Under the area titled "Other Individual

Agency Requirements" was additional

skills to be tested and included "1) Use of

Special Equipment. 2) Hoyer Lift. 3) G








10. Personnel file J, date of hire 8/10/11





03/30/2012PRINTED:

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A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET







































03/30/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET


















During a telephone call interview On


J indicated she had never been to the

Kokomo office, that she only worked for

Comfort Health Care out of the Elwood

office, and that employee E was her

immediate supervisor and owner of the

agency for which she worked. She

indicated she picked up assignments and

turned in visit notes to employee E at the

Comfort Home Health office in Elwood,

Indiana.





03/30/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET

N0608

410 IAC 17-15-1(a)(1-6)

Clinical Records

Rule 15 Sec. 1(a) Clinical records containing

pertinent past and current findings in

accordance with accepted professional

standards shall be maintained for every

patient as follows:

(1) The medical plan of care and

appropriate identifying information.

(2) Name of the physician, dentist,

chiropractor, podiatrist, or optometrist.

(3) Drug, dietary, treatment, and activity

orders.

(4) Signed and dated clinical notes

contributed to by all assigned personnel.

Clinical notes shall be written the day service

is rendered and incorporated within fourteen

(14) days.

(5) Copies of summary reports sent to the

person responsible for the medical

component of the patient's care.

(6) A discharge summary.

N0608 The process to correct

the deficiency will include, a

locked receptacle at 211 S.

Anderson St., Elwood, IN 46036

for employees to place their

notes. Only a Comfort Home

Health employee will have a key

to the locked receptacle to

transport notes to the Kokomo

office. Ancillary staff will be

instructed to give all paperwork to

only a Comfort Home Health

employee for transport to the

office. Comfort Home Health

does not have any branch offices,

however, our nursing supervisor

for this patient is also employed

by Heaven Sent (a home health

care located in Elwood, IN) and

she instructed employee J to drop

04/15/2012 12:00:00AMN0608Based on clinical record, administrative




clinical records could be maintained once

records left the possession of field staff or

were lost for 1 of 1 agency reviewed with

the potential to affect all patient records.

Findings include:










03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET

off documentation at that location.

















confidential.









Monday mornings.




























03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET











03/30/2012PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET

N0614

410 IAC 17-15-1(c)

Clinical Records

Rule 15 Sec. 1(c) Clinical record information

shall be safeguarded against loss or

unauthorized use. Written procedures shall

govern use and removal of records and

conditions for release of information. Patient's

written consent shall be required for release

of information not authorized by law. Current

service files shall be maintained at the parent

or branch office from which the services are

provided until the patient is discharged from

service. Closed files may be stored away

from the parent or branch office provided they

can be returned to the office within

seventy-two (72) hours. Closed files do not

become current service files if the patient is

readmitted to service.

N0614 The process to correct the

deficiency will include, a locked

receptacle at 211 S. Anderson

St., Elwood, IN 46036 for

employees to place their notes.

Only a Comfort Home Health

employee will have a key to the

locked receptacle to transport

notes to the Kokomo office.

Ancillary staff will be instructed to

give all paperwork to only a


for transport to the office.

Comfort Home Health does not

have any branch offices,

however, our nursing supervisor

for this patient is also employed

by Heaven Sent (a home health

care located in Elwood, IN) and

she instructed employee J to drop

off documentation at that location.




04/15/2012 12:00:00AMN0614

Based on clinical record, administrative




clinical records information was kept

confidential and not able to be accessed

by employees from another agency and

there were written procedures regarding

how clinical record information was

protected for 1 of 1 agency reviewed with

the potential to affect all patient records.

Findings include:









03/30/2012PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

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03/12/2012


1815 S PLATE STREET














confidential.










Monday mornings.



























03/30/2012PRINTED:

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OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


KOKOMO, IN 46902

157631

00

03/12/2012


1815 S PLATE STREET









Documents

PRINTED: 03/30/2012 DEPARTMENT OF HEALTH AND ... - Indiana