PRINTED: 07/18/2017 DEPARTMENT OF HEALTH AND HUMAN … · 2017. 7. 18. · event id: nfsl12...
38
(X1) PROVIDER/SUPPLIER/CLIA DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 07/18/2017 PRINTED: FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE DEFICIENCY) (X5) COMPLETION DATE CROSS-REFERENCED TO THE APPROPRIATE ANGOLA, IN 46703 157117 05/08/2017 CAMERON HOME HEALTH CARE & HOSPICE 416 E MAUMEE ST 00 G 0000 Bldg. 00 This was a revisit for the Federal Home Health Recertification survey completed on February 24, 2017. Survey Dates: May 3, 4, 5, 8, and 9, 2017 Facility #: IN005308 Medicaid Vendor #: 100263930 During this survey, 3 condition level deficiencies were corrected; 14 standard level deficiencies were corrected; and 5 standard level deficiencies were re-cited. Sample: RR w/o HV: 8 RR w/HV: 1 HV w/o RR: 0 Total: 9 G 0000 484.14(e) PERSONNEL POLICIES Personnel practices and patient care are supported by appropriate, written personnel policies. Personnel records include qualifications and licensure that are kept current. G 0141 Bldg. 00 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 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: NFSL12 Facility ID: IN005308 TITLE If continuation sheet Page 1 of 38 (X6) DATE
Transcript of PRINTED: 07/18/2017 DEPARTMENT OF HEALTH AND HUMAN … · 2017. 7. 18. · event id: nfsl12...
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
G 0000
Bldg. 00
This was a revisit for the Federal Home
Health Recertification survey completed
on February 24, 2017.
Survey Dates: May 3, 4, 5, 8, and 9,
2017
Facility #: IN005308
Medicaid Vendor #: 100263930
During this survey, 3 condition level
deficiencies were corrected; 14 standard
level deficiencies were corrected; and 5
standard level deficiencies were re-cited.
Sample:
RR w/o HV: 8
RR w/HV: 1
HV w/o RR: 0
Total: 9
G 0000
484.14(e)
PERSONNEL POLICIES
Personnel practices and patient care are
supported by appropriate, written personnel
policies.
Personnel records include qualifications and
licensure that are kept current.
G 0141
Bldg. 00
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 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: NFSL12 Facility ID: IN005308
TITLE
If continuation sheet Page 1 of 38
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
Based on document review, and
interview, the agency failed to ensure that
personnel records were accurate and kept
current for 2 out of 5 employee records
reviewed. (C, D, and E)
Findings include
1. During review of employee files on
5/8/17, the list of current employees
included employee D, a Registered
Nurse, date of hire 12/5/16, and first
patient contact 12/8/16. The employee
file failed to evidence a complete and
accurate physical examination form.
A. Agency document titled "Post
Offer Physical," dated 12/7/15 contained
4 pages. Page 1 of physical evidenced
employee name, signature, medications,
smoking history, and allergy history.
Page 2 of physical form evidenced
communicable disease history, vaccine
immunization history, and medical
history. Page 3 of physical form was the
employment recommendation statement
in which the name of employee and name
and signature of examining practitioner
or physician was present with statement
that employee was free of communicable
diseases. Page 4 of physical was the
visual exam, physical examination, peak
flow, and hearing exam. Pages 2 and 4
of the form failed to evidence a name or
G 0141 Hospital policy, Post Offer
Physicals for Cameron Hospital
Employees, has been updated.
The nurse will document the
patient's name on each page of
the employee physical. The
registrar will double check that
the form in complete. The
employee health nurse will check
the record for completeness as
well before sealing in an envelop
and placing it in the employee's
medical personnel file.
All current physicals will be
checked for accuracy and names
will be placed on each page of
the physical and resealed in an
envelop.
Director will be responsible for
compliance.
06/30/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 2 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
identifying information to deduce the
information was that of employee D.
2. During review of employee files on
5/8/17, the list of current employees
included employee E, a Social Worker,
date of hire 10/3/16, and first patient
contact 11/30/16. The employee file
failed to evidence a complete and
accurate physical examination form.
A. Agency document titled "Post
Offer Physical" dated 9/2/16 contained 4
pages. Page 1 of physical evidenced
employee name, signature, medications,
smoking history, and allergy history.
Page 2 of physical form evidenced
communicable disease history, vaccine
immunization history, and medical
history. Page 3 of physical form was the
employment recommendation statement
in which the name of employee and name
and signature of examining practitioner
or physician was present with statement
that employee was free of communicable
diseases. Page 4 of physical was the
visual exam, physical examination, peak
flow, and hearing exam. Pages 2 and 4
of the form failed to evidence a name or
identifying information to deduce the
information was that of employee D.
3. During interview on 5/8/17 at 11:19
AM, Employee AA (a member of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 3 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
Employee Health) stated a lot of our
employees print out like that; Urgent
Care completes the physicals, and
employee health prints them out from the
computer; and Urgent Care is a part of
Cameron Hospital but at another
location.
4. During interview on 5/8/17 at 2:13
PM, the Administrator stated she had no
knowledge that the forms do not have
employee identifiers on each page, as
they come in sealed envelopes and are
only to be opened by employee health
and/or surveyors."
484.18(a)
PLAN OF CARE
The plan of care developed in consultation
with the agency staff covers all pertinent
diagnoses, including mental status, types of
services and equipment required, frequency
of visits, prognosis, rehabilitation potential,
functional limitations, activities permitted,
nutritional requirements, medications and
treatments, any safety measures to protect
against injury, instructions for timely
discharge or referral, and any other
appropriate items.
G 0159
Bldg. 00
Based on document review, the agency
failed to ensure the plans of care
contained all accurate and pertinent
information for 1 of 9 clinical records
G 0159 Director reviewed policy on POC
and Physician's Orders was
reviewed with nurses on 6-19-17.
Wound care orders will include
supplies to be used for
06/30/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 4 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
reviewed. (#3)
Findings include
1. Clinical record #3, start of care date
4/15/17, contained a plan of care dated
4/15/17-6/13/17 which indicated "SN
[Skilled Nurse] 1 Week 1; 2 Week 1; 1
Week 8. Skilled Nurse to instruct family
on how to do daily dressing change wet
to dry. Kerlex packing with ABD
[Abdominal gauze pad] and tape." The
record failed to evidence wound care
supplies in the Durable Medical
Equipment (DME) and Supplies section
of the plan of care.
A. Agency document titled "Home
Health Certification and Plan of Care"
signed by the physician on 4/20/17 under
DME and Supplies indicated "Has-Other
(specify) CMS (See Addendum)
Machine-Bio Compression System." The
plan of care failed to evidence wound
care supplies.
2. The agency's policy titled "Home
Health Care Plan of Care and Physician
Orders," PolyStat ID: 35356778, revised
4/2017, stated "Procedure: The Plan of
Care includes: Types of services and
equipment required ... Equipment and
supplies required."
treatment. The order will be
included on the POC.
Case Managers will audit 100%
of case load weekly to verify
current supply list matches
corresponding orders for wound
care.
Office staff responsible for
ordering supplies will verify that
wound care orders exist for each
supply ordered.
Nursing Supervisor will be
responsible for compliance.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 5 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
484.30(a)
DUTIES OF THE REGISTERED NURSE
The registered nurse initiates the plan of
care and necessary revisions.
G 0173
Bldg. 00
Based on document review, and
interview, the agency failed to ensure the
Registered Nurse initiated a correct plan
of care and necessary revisions for 3 of 9
records reviewed. (#7, 8, and 9)
Findings include
1. Clinical record #7, start of care date
4/4/17, contained a plan of care dated
4/4/17-6/2/17 which indicated
medications "clonazepam ... etodolac ...
amitriptyline ... atorvastatin ...
omeprazole ... levothyroxine ...
quetiapine ... citalopram ... Alive
Women's Energy ... Vitamin C ...
acetaminophen ... Probiotic."
A. Agency document titled "SN
[Skilled Nurse] HOME CARE VISIT
ROUTINE" dated 4/13/17 indicated in
the clinical note "PT [PATIENT]
REPORTS CONSTIPATION. HAS
COLACE IN HOME. INSTRUCTED
TO TAKE PRN [AS NEEDED] FOR
CONSTIPATION." The record failed to
evidence Colace on the plan of care and
G 0173 The Administrator reviewed the
policy on Nursing Services on
6/19/17.
Any new medications either
prescription or OTC will be added
to the Med Profile upon discovery.
The physician’s office will be
notified of any change.
A medication evaluation will be
completed by an RN at least
every 2 weeks or with any
medication change.
Compliance will be audited
weekly by office staff and
reported to the Nursing
Supervisor.
Audits will continue weekly until
100% compliance is achieved for
3 continuous months. This
audit has been added to our
clinical record review as well.
Nursing Supervisor will be
responsible for compliance.
06/26/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 6 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
medication profile; and failed to evidence
a physician order for the Colace.
B. Agency document titled " Agency
Medication Profile" reviewed 4/13/17 by
Registered Nurse, indicated medications
"acetaminophen ... Alive Women's
Energy ... amitriptyline ... atorvastatin ...
citalopram ... clonazepam ... etodolac ...
levothyroxine ... omeprazole ... Probiotic
... quetiapine ... Vitamin C." The record
failed to evidence Colace on this
medication profile.
2. Clinical record #8, start of care date
1/20/17, contained a plan of care dated
3/21/17-5/19/17 which indicated
medications "clopidogrel ... loratadine ...
Nitrostat ... alpha lipioc acid ...
cholecalciferol ... Fish oil ... Magnesium
... Multivital ... omeprazole .. Probiotic ...
saw palmetto." The record failed to
evidence the following:
A. Agency document titled "SN
HOME CARE VISIT ROUTINE" dated
5/1/17 indicated in the clinical note
"INSTRUCTED [patient] CAN TAKE
TYLENOL PRN DURING THE DAY
AS [patient] IS PLANNING TO DRIVE
TODAY AND CANNOT TAKE THE
NORCO FOR PAIN WHEN [patient] IS
UP MOVING AROUND." The record
failed to evidence Tylenol on the plan of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 7 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
care and medication profile; failed to
evidence a physician order for the
Tylenol; and failed to evidence the
patient was provided instructions about
not exceeding Tylenol recommended
dose when taking in conjunction with
Norco.
B. A drugs.com search was
completed on 5/8/17 at 2:51 PM with the
following medications: alpha-lipoic acid,
cholecalciferol, loratadine, magnesium
oxide, omeprazole, saw palmetto, fish oil,
nitrostat, norco, probiotic, and tylenol.
The drug interaction report indicated an
Acetainophen (Tylenol) therapeutic
duplication which indicated "The
recommended maximum number of
medicines in the 'acetaminophen'
category to be taken concurrently is
usually one. Your list includes two
medicines belonging to the
'acetaminophen' category: acetaminophen
(active ingredient in Norco
(acetaminophen/hydrocodone)),
acetaminophen (active ingredient in
Tylenol (acetaminohen)). Note: The
benefits of taking this combination of
medicines may outweigh any risks
associated with therapeutic duplication.
This information does not take the place
of talking to your doctor. Always check
with your healthcare provider to
determine if any adjustments to your
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 8 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
medications are needed." The record
failed to evidence that a drug to drug
interaction check was completed by the
agency.
C. Agency document titled " Agency
Medication Profile," reviewed 5/1/17 by
Registered Nurse indicated medications
"alpha lipoic ... cholecalciferol ... fish oil
... loratadine ... magnesium ... nitrostat ...
norco ... omeprazole .. probiotic ... saw
palmetto." The record failed to evidence
Tylenol on the medication profile.
3. Clinical record #9, start of care date
8/2/16, contained a plan of care dated
3/30/17-5/28/17 which indicated
medications "aspirin ... Vimpat ...
polyethylene glycol ... loperamide ...
atenolol ... acetaminophen ... trazodone ...
lorazepam ... guaifenesin ... oxybutynin
... Zoloft ... Lasix ... Neurontin ...
gentamicin ... baclofen ... Keppra ...
levofloxacin ... amoxicillin-potassium
clavulanate ... ranitidine ...
oxycodone-acetaminophen ...
Symbicort." The record failed to
evidence the following:
A. Agency document titled "SN
HOME CARE VISIT ROUTINE" dated
4/12/17 indicated in the clinical note
"LEFT BREAST EXCORIATION 3CM
[centimeters], REDNESS,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 9 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
TENDERNESS, SCANT SWELLING,
NO DRAINAGE NOTED. DENIES
PAIN EXCEPT WITH MOVEMENT
THAT CAUSES RUBBING AND OR
TENDERNESS TO TOUCH. WRITER
CLEANSED ARE WITH MILD SOAP
AND WATER, PATTED DRY.
PATIENT TOLERATED. APPLIED
NYSTATIN POWDER." The record
failed to evidence Nystatin powder on the
plan of care and medication profile; and
failed to evidence a physician order for
the Nystatin.
B. Agency document titled " Agency
Medication Profile" reviewed 5/4/17 by
Registered Nurse indicated medications
"acetaminophen, aspirin, atenolol,
baclofen, Gentamar, guaifenesin, Keppra,
Lasix, loperamide, lorazepam, Neurontin,
oxybutynin, polyethylene glycol,
ranitidine, Symbicort, trazodone, Vimpat,
Zoloft." The record failed to evidence
Nystatin on the medication profile.
4. During interview on 5/8/17 at 2:02
PM, the Administrator stated we were not
able to find anything on those
medications.
5. The agency's policy titled "Home
Health Care and Hospice-Medication
Reconciliation," PolyStat ID: 3531267,
revised 4/2017, stated "Policy: The
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 10 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
Agency will reconcile patient's
medications at time of admission and on
an ongoing basis. Procedure: Any
discrepancies will be reconciled by an
RN [Registered Nurse] with the patient's
physician. Discrepancies include
duplications, omissions, changes,
contraindications and/or unclear
information. ... All current medications
will be entered into documentation
software including dose, route and
frequency. Any medications indicated by
the software as a duplication or
interaction will be noted. Level 1
interactions will be called into the
physician's office and faxed. Level 2
interactions will be faxed to the physician
and Level 3 will be noted in the patient
chart. Medication changes, while the
patient is receiving care, will be
compared to the medication list/profile.
The medication list/profile will be
updated with each new or changed
medication. ... Medication review will be
performed with any medication changes
or as indicated by change in condition."
6. The agency's policy titled "Home
Health Care Plan of Care and Physician
Orders," PolyStat ID: 35356778, revised
4/2017, stated "Policy: Skilled nursing
and other home health services will be in
accordance with a Plan of Care ... Each
Plan of Care must be signed and dated by
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 11 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
the physician. Procedure: ... 5. Care and
services will be provided according to
physician orders. Orders are current and
updated. ... 10. All clinical services are
implemented only in accordance with a
Plan of Care established by a physician's
written order."
7. The agency's policy titled "Home
Health Care Medical Record Content
Policy," PolyStat ID: 3535828, revised
4/2017, stated "Policy: The Agency will
provide an accurate and current medical
record for every patient seen by the
Agency. Procedure: A current
medication profile to include
medication/allergies/sensitivities and
every medication, dose, frequency and
route of administration for prescription
and non-prescription medications, herbal
products and home remedies. Actual or
potential drug/food or drug/drug
interactions. ... Updated orders as
obtained."
484.30(a)
DUTIES OF THE REGISTERED NURSE
The registered nurse prepares clinical and
progress notes, coordinates services,
informs the physician and other personnel of
changes in the patient's condition and
needs.
G 0176
Bldg. 00
Based on document review and policy G 0176 Director reviewed policies on 06/26/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 12 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
review, the agency failed to ensure the
Registered Nurse (RN) notified physician
with changes, and failed to ensure the RN
prepared clinical notes accurately for 1 of
9 records reviewed. (#3)
Findings include
1. Clinical record #3, start of care date
4/15/17, contained a plan of care dated
4/15/17-6/13/17 which indicated "SN
[Skilled Nurse] 1 Week 1; 2 Week 1; 1
Week 8. Skilled Nurse to instruct family
on how to do daily dressing change wet
to dry. Kerlex packing with ABD
[Abdominal gauze pad] and tape.
Continue to monitor healing and any
changes in wound and report to the
doctor as needed." The record failed to
evidence clarification orders for type of
wetting solution to be used on the wound;
and failed to ensure the physician was
notified of wound changes.
A. Agency document titled "SN
HOME CARE SOC [Start of Care]
ASSESSMENT" dated 4/15/17 indicated
on page 4 that patient had a wound on
left lower abdomen measuring 3.2 x. 11 x
5.4 and wound care provided was
"1-Soiled dressing removed, 6-Wound
packed MOISTEN NS [Normal Saline]
KERLIX GAUGE 1/2 ROLL, 7-Wound
Dressing applied ABD AND TAPE."
Nursing Services and the Internal
Guideline for Wounds with
nursing staff on 6-19-17.
Review of the chart performed
with staff. Wet to dry dressing is
considered standard nursing
practice. Treatment to include:
saline soaked gauze unless
otherwise specified. This
definition will be added to
agency's internal guideline for
wounds.
Physician will be notified of any
significant changes to condition or
wounds. Orders will reflect
specific discharge
instructions regarding when to
notify physician for signs and
symptoms of infection e.g. degree
of temperature.
Case Managers will audit 100%
of caseload weekly to determine if
daily wound care documentation
matches wound care orders.
Wound care orders will be
discussed in weekly meetings
with the Nursing Supervisor.
Nursing Supervisor is responsible
for compliance.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 13 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
The wound care order within the plan of
care did not instruct packing to be
moistened. The record failed to evidence
a physician clarification order for type of
wetting solution to be used on the wound.
B. Agency document titled "SN
HOME CARE VISIT ROUTINE" dated
4/20/17 indicated on page 1 that wound
care provided was "1- Soiled dressing
removed, 2-Wound cleansed NS,
66-Wound packed NS MOIST GAUZE
WET TO DRY, 7-Wound dressing
applied ABD x 2." The plan of care
wound orders failed to evidence
instructions to cleanse wound and which
type of wetting solution to use; and failed
to evidence a clarification for the wound
care orders.
C. Agency document titled "SN
HOME CARE VISIT ROUTINE' dated
4/18/17 indicated the patient had a fever
of 100.0 degrees Fahrenheit. The record
failed to evidence the physician was
notified of the temperature.
D. Agency document titled "SN
HOME CARE VISIT ROUTINE' dated
5/1/17 indicated the patient had a fever of
99.0 degrees, purulent drainage from
wound, and fatigue. The clinical note
stated "No s/s [signs and symptoms] of
infection." The record failed to evidence
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 14 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
the physician was notified of the
temperature, purulent drainage from the
wound, and patient report of fatigue.
2. The agency's policy titled "Cameron
Home Health Care and Hospice Internal
Guideline for Wounds," PolyStat ID:
3530918, revised 4/2017, stated "Internal
Guideline: 9. Wound care to be
performed as ordered by physician. 10.
Physician to be notified for the following:
a. Worsening condition/signs and
symptoms of infection."
3. The agency's policy titled "Home
Health Care Nursing Services," PolyStat
ID: 3535634, revised 4/2017, stated
"Policy: Patients receiving nursing
services will have appropriate
assessments, reassessments, care
planning and established outcomes
performed. Purpose: To define the scope
of nursing services offered by the
Agency. Procedure: Nursing care will be
provided in accordance with the patient's
plan of care ... 2. Professional nursing
service will be provided by a Registered
Nurse and include: ... Preparing clinical
and progress notes ... Informing the
physician and other staff of changes in
the patient's needs."
484.55(c) G 0337
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 15 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
DRUG REGIMEN REVIEW
The comprehensive assessment must
include a review of all medications the
patient is currently using in order to identify
any potential adverse effects and drug
reactions, including ineffective drug therapy,
significant side effects, significant drug
interactions, duplicate drug therapy, and
noncompliance with drug therapy.
Bldg. 00
Based on document review, and
interview, the agency failed to ensure the
Registered Nurse (RN) completed a
thorough drug regimen review for 3 of 9
records reviewed. (#7, 8, and 9)
Findings include
1. Clinical record #7, start of care date
4/4/17 contained a plan of care dated
4/4/17-6/2/17 which indicated
medications "clonazepam ... etodolac ...
amitriptyline ... atorvastatin ...
omeprazole ... levothyroxine ...
quetiapine ... citalopram ... Alive
Women's Energy ... Vitamin C ...
acetaminophen ... Probiotic."
A. Agency document titled "SN
[Skilled Nurse] HOME CARE VISIT
ROUTINE" dated 4/13/17 indicated in
the clinical note "PT [PATIENT]
REPORTS CONSTIPATION. HAS
COLACE IN HOME. INSTRUCTED
TO TAKE PRN [AS NEEDED] FOR
CONSTIPATION." The record failed to
evidence Colace on the plan of care and
G 0337 Director reviewed the policies on
Medication Reconciliation,
Medical Record Content and Plan
of Care and Physician Orders
with nursing staff on 6/19/17.
Any new medications either
prescription or OTC will be added
to the Med Profile upon discovery.
The physician’s office will be
notified of any change and orders
received as needed.
A medication evaluation will be
completed by an RN at least
every 2 weeks or with any
medication change.
Compliance will be audited
weekly by office staff and
reported to the Nursing
Supervisor.
Audits will continue weekly until
100% compliance is achieved for
3 continuous months. This
audit has been added to our
clinical record review as well.
Nursing Supervisor will be
responsible for compliance.
06/26/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 16 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
medication profile, and failed to evidence
a physician order was present for the
Colace.
B. Agency document titled " Agency
Medication Profile" reviewed 4/13/17 by
Registered Nurse indicated medications
"acetaminophen ... Alive Women's
Energy ... amitriptyline ... atorvastatin ...
citalopram ... clonazepam ... etodolac ...
levothyroxine ... omeprazole ... Probiotic
... quetiapine ... Vitamin C." The record
failed to evidence Colace on this
medication profile.
2. Clinical record #8, start of care date
1/20/17 contained a plan of care dated
3/21/17-5/19/17 which indicated
medications "clopidogrel ... loratadine ...
Nitrostat ... alpha lipioc acid ...
cholecalciferol ... Fish oil ... Magnesium
... Multivital ... omeprazole .. Probiotic ...
saw palmetto."
A. Agency document titled "SN
HOME CARE VISIT ROUTINE" dated
5/1/17 indicated in the clinical note
"INSTRUCTED [patient] CAN TAKE
TYLENOL PRN DURING THE DAY
AS [patient] IS PLANNING TO DRIVE
TODAY AND CANNOT TAKE THE
NORCO FOR PAIN WHEN [patient] IS
UP MOVING AROUND." The record
failed to evidence Tylenol on the plan of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 17 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
care and medication profile; failed to
evidence a a physician order was present
for the Tylenol; and failed to evidence the
patient received instruction about not
exceeding Tylenol recommended dose in
conjunction with Norco.
B. A drugs.com search was
completed on 5/8/17 at 2:51 PM with the
following medications: alpha-lipoic acid,
cholecalciferol, loratadine, magnesium
oxide, omeprazole, saw palmetto, fish oil,
nitrostat, norco, probiotic, and tylenol.
The drug interaction report indicated an
Acetainophen (Tylenol) therapeutic
duplication which indicated "The
recommended maximum number of
medicines in the 'acetaminophen'
category to be taken concurrently is
usually one. Your list includes two
medicines belonging to the
'acetaminophen' category: acetaminophen
(active ingredient in Norco
(acetaminophen/hydrocodone)),
acetaminophen (active ingredient in
Tylenol (acetaminohen)). Note: The
benefits of taking this combination of
medicines may outweigh any risks
associated with therapeutic duplication.
This information does not take the place
of talking to your doctor. Always check
with your healthcare provider to
determine if any adjustments to your
medications are needed." The record
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 18 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
failed to evidence that a drug to drug
interaction check was completed by the
agency.
C. Agency document titled " Agency
Medication Profile" reviewed 5/1/17 by
Registered Nurse indicated medications
"alpha lipoic ... cholecalciferol ... fish oil
... loratadine ... magnesium ... nitrostat ...
norco ... omeprazole .. probiotic ... saw
palmetto." The record failed to evidence
Tylenol on the medication profile.
3. Clinical record #9, start of care date
8/2/16 contained a plan of care dated
3/30/17-5/28/17 which indicated
medications "aspirin ... Vimpat ...
polyethylene glycol ... loperamide ...
atenolol ... acetaminophen ... trazodone ...
lorazepam ... guaifenesin ... oxybutynin
... Zoloft ... Lasix ... Neurontin ...
gentamicin ... baclofen ... Keppra ...
levofloxacin ... amoxicillin-potassium
clavulanate ... ranitidine ...
oxycodone-acetaminophen ...
Symbicort."
A. Agency document titled "SN
HOME CARE VISIT ROUTINE" dated
4/12/17 indicated in the clinical note
"LEFT BREAST EXCORIATION 3CM,
REDNESS, TENDERNESS, SCANT
SWELLING, NO DRAINAGE NOTED.
DENIES AIN EXCEPT WITH
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 19 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
MOVEMENT THAT CAUSES
RUBBING AND OR TENDERNESS TO
TOUCH. WRITER CLEANSED ARE
WITH MILD SOAP AND WATER,
PATTED DRY. PATIENT
TOLERATED. APPLIED NYSTATIN
POWDER." The record failed to
evidence Nystatin on the plan of care and
medication profile; and failed to evidence
a physician order was present for the
Nystatin.
B. Agency document titled " Agency
Medication Profile" reviewed 5/4/17 by
Registered Nurse indicated medications
"acetaminophen, aspirin, atenolol,
baclofen, Gentamar, guaifenesin, Keppra,
Lasix, loperamide, lorazepam, Neurontin,
oxybutynin, polyethylene glycol,
ranitidine, Symbicort, trazodone, Vimpat,
Zoloft." The record failed to evidence
Nystatin on the medication profile.
4. During interview on 5/8/17 at 2:02
PM, the Administrator stated "we were
not able to find anything on those
medications."
5. The agency's policy titled "Home
Health Care and Hospice-Medication
Reconciliation," PolyStat ID: 3531267,
revised 4/2017, stated "Policy: The
Agency will reconcile patient's
medications at time of admission and on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 20 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
an ongoing basis. Procedure: Any
discrepancies will be reconciled by an
RN [Registered Nurse] with the patient's
physician. Discrepancies include
duplications, omissions, changes,
contraindications and/or unclear
information. ... All current medications
will be entered into documentation
software including dose, route and
frequency. Any medications indicated by
the software as a duplication or
interaction will be noted. Level 1
interactions will be called into the
physician's office and faxed. Level 2
interactions will be faxed to the physician
and Level 3 will be noted in the patient
chart. Medication changes, while the
patient is receiving care, will be
compared to the medication list/profile.
The medication list/profile will be
updated with each new or changed
medication. ... Medication review will be
performed with any medication changes
or as indicated by change in condition."
6. The agency's policy titled "Home
Health Care Plan of Care and Physician
Orders," PolyStat ID: 35356778, revised
4/2017, stated "Policy: Skilled nursing
and other home health services will be in
accordance with a Plan of Care ... Each
Plan of Care must be signed and dated by
the physician. Procedure: The Plan of
Care includes: Types of services and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 21 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
equipment required ... Equipment and
supplies required. ... The Agency
professional staff will promptly alert the
physician to any changes that suggest a
need to alter the Plan of Care. ... 5. Care
and services will be provided according
to physician orders. Orders are current
and updated. ... 10. All clinical services
are implemented only in accordance with
a Plan of Care established by a
physician's written order."
7. The agency's policy titled "Home
Health Care Medical Record Content
Policy," PolyStat ID: 3535828, revised
4/2017, stated "Policy: The Agency will
provide an accurate and current medical
record for every patient seen by the
Agency. Procedure: A current
medication profile to include
medication/allergies/sensitivities and
every medication, dose, frequency and
route of administration for prescription
and non-prescription medications, herbal
products and home remedies. Actual or
potential drug/food or drug/drug
interactions. ... Updated orders as
obtained."
N 0000
Bldg. 00
This was a revisit for the Home Health
State Licensure survey completed on
N 0000
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 22 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
February 24, 2017.
Survey Dates: May 3, 4, 5, 8, and 9,
2017
Facility #: IN005308
Medicaid Vendor #: 100263930
Sample:
RR w/o HV: 8
RR w/HV: 1
HV w/o RR: 0
Total: 9
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.
N 0458
Bldg. 00
Based on document review, and
interview, the agency failed to ensure that
personnel records were accurate and kept
N 0458 Hospital policy, Post Offer
Physicals for Cameron Hospital
Employees, has been updated.
The nurse will document the
06/30/2017 12:00:00AM
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 23 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
current for 2 out of 5 employee records
reviewed. (C, D, and E)
Findings include
1. During review of employee files on
5/8/17, the list of current employees
included employee D, a Registered
Nurse, date of hire 12/5/16, and first
patient contact 12/8/16. The employee
file failed to evidence a complete and
accurate physical examination form.
A. Agency document titled "Post
Offer Physical," dated 12/7/15 contained
4 pages. Page 1 of physical evidenced
employee name, signature, medications,
smoking history, and allergy history.
Page 2 of physical form evidenced
communicable disease history, vaccine
immunization history, and medical
history. Page 3 of physical form was the
employment recommendation statement
in which the name of employee and name
and signature of examining practitioner
or physician was present with statement
that employee was free of communicable
diseases. Page 4 of physical was the
visual exam, physical examination, peak
flow, and hearing exam. Pages 2 and 4
of the form failed to evidence a name or
identifying information to deduce the
information was that of employee D.
patient's name on each page of
the employee physical. The
registrar will double check that
the form in complete. The
employee health nurse will check
the record for completeness as
well before sealing in an envelop
and placing it in the employee's
medical personnel file.
All current physicals will be
checked for accuracy and names
will be placed on each page of
the physical and resealed in an
envelop.
Director will be responsible for
compliance.
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 24 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
2. During review of employee files on
5/8/17, the list of current employees
included employee E, a Social Worker,
date of hire 10/3/16, and first patient
contact 11/30/16. The employee file
failed to evidence a complete and
accurate physical examination form.
A. Agency document titled "Post
Offer Physical" dated 9/2/16 contained 4
pages. Page 1 of physical evidenced
employee name, signature, medications,
smoking history, and allergy history.
Page 2 of physical form evidenced
communicable disease history, vaccine
immunization history, and medical
history. Page 3 of physical form was the
employment recommendation statement
in which the name of employee and name
and signature of examining practitioner
or physician was present with statement
that employee was free of communicable
diseases. Page 4 of physical was the
visual exam, physical examination, peak
flow, and hearing exam. Pages 2 and 4
of the form failed to evidence a name or
identifying information to deduce the
information was that of employee D.
3. During interview on 5/8/17 at 11:19
AM, Employee AA (a member of
Employee Health) stated a lot of our
employees print out like that; Urgent
Care completes the physicals, and
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 25 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
employee health prints them out from the
computer; and Urgent Care is a part of
Cameron Hospital but at another
location.
4. During interview on 5/8/17 at 2:13
PM, the Administrator stated she had no
knowledge that the forms do not have
employee identifiers on each page, as
they come in sealed envelopes and are
only to be opened by employee health
and/or surveyors."
410 IAC 17-13-1(a)(1)
Patient Care
Rule 13 Sec. 1(a)(1) As follows, the medical
plan of care shall:
(A) Be developed in consultation with the
home health agency staff.
(B) Include all services to be provided if a
skilled service is being provided.
(B) Cover all pertinent diagnoses.
(C) Include the following:
(i) Mental status.
(ii) Types of services and equipment
required.
(iii) Frequency and duration of visits.
(iv) Prognosis.
(v) Rehabilitation potential.
(vi) Functional limitations.
(vii) Activities permitted.
(viii) Nutritional requirements.
(ix) Medications and treatments.
(x) Any safety measures to protect
against injury.
(xi) Instructions for timely discharge or
N 0524
Bldg. 00
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 26 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
referral.
(xii) Therapy modalities specifying length of
treatment.
(xiii) Any other appropriate items.
Based on document review, the agency
failed to ensure the plans of care
contained all accurate and pertinent
information for 1 of 9 clinical records
reviewed. (#3)
Findings include
1. Clinical record #3, start of care date
4/15/17, contained a plan of care dated
4/15/17-6/13/17 which indicated "SN
[Skilled Nurse] 1 Week 1; 2 Week 1; 1
Week 8. Skilled Nurse to instruct family
on how to do daily dressing change wet
to dry. Kerlex packing with ABD
[Abdominal gauze pad] and tape." The
record failed to evidence wound care
supplies in the Durable Medical
Equipment (DME) and Supplies section
of the plan of care.
A. Agency document titled "Home
Health Certification and Plan of Care"
signed by the physician on 4/20/17 under
DME and Supplies indicated "Has-Other
(specify) CMS (See Addendum)
Machine-Bio Compression System." The
plan of care failed to evidence wound
care supplies.
2. The agency's policy titled "Home
N 0524 Director reviewed policies on
Nursing Services and the Internal
Guideline for Wounds with
nursing staff on 6-19-17.
Review of the chart performed
with staff. Wet to dry dressing is
considered standard nursing
practice. Treatment to include:
saline soaked gauze unless
otherwise specified. This
definition will be added to
agency's internal guideline for
wounds.
Physician will be notified of any
significant changes to condition or
wounds. Orders will reflect
specific discharge
instructions regarding when to
notify physician for signs and
symptoms of infection e.g. degree
of temperature.
Case Managers will audit 100%
of caseload weekly to determine if
daily wound care documentation
matches wound care orders.
Wound care orders will be
discussed in weekly meetings
with the Nursing Supervisor.
Nursing Supervisor is responsible
for compliance.
06/26/2017 12:00:00AM
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 27 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
Health Care Plan of Care and Physician
Orders," PolyStat ID: 35356778, revised
4/2017, stated "Procedure: The Plan of
Care includes: Types of services and
equipment required ... Equipment and
supplies required."
410 IAC 17-14-1(a)(1)(C)
Scope of Services
Rule 14 Sec. 1(a) (1)(C) Except where
services are limited to therapy only, for
purposes of practice in the home health
setting, the registered nurse shall do the
following:
(C) Initiate the plan of care and necessary
revisions.
N 0542
Bldg. 00
Based on document review, and
interview, the agency failed to ensure the
Registered Nurse initiated a correct plan
of care and necessary revisions for 3 of 9
records reviewed. (#7, 8, and 9)
Findings include
1. Clinical record #7, start of care date
4/4/17, contained a plan of care dated
4/4/17-6/2/17 which indicated
medications "clonazepam ... etodolac ...
amitriptyline ... atorvastatin ...
omeprazole ... levothyroxine ...
quetiapine ... citalopram ... Alive
Women's Energy ... Vitamin C ...
acetaminophen ... Probiotic."
N 0542 Director reviewed the policies on
Medication Reconciliation,
Medical Record Content and Plan
of Care and Physician Orders
with nursing staff on 6/19/17.
Any new medications either
prescription or OTC will be added
to the Med Profile upon discovery.
The physician’s office will be
notified of any change and orders
received as needed.
A medication evaluation will be
completed by an RN at least
every 2 weeks or with any
medication change.
Compliance will be audited
weekly by office staff and
reported to the Nursing
Supervisor.
Audits will continue weekly until
100% compliance is achieved for
06/26/2017 12:00:00AM
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 28 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
A. Agency document titled "SN
[Skilled Nurse] HOME CARE VISIT
ROUTINE" dated 4/13/17 indicated in
the clinical note "PT [PATIENT]
REPORTS CONSTIPATION. HAS
COLACE IN HOME. INSTRUCTED
TO TAKE PRN [AS NEEDED] FOR
CONSTIPATION." The record failed to
evidence Colace on the plan of care and
medication profile; and failed to evidence
a physician order for the Colace.
B. Agency document titled " Agency
Medication Profile" reviewed 4/13/17 by
Registered Nurse, indicated medications
"acetaminophen ... Alive Women's
Energy ... amitriptyline ... atorvastatin ...
citalopram ... clonazepam ... etodolac ...
levothyroxine ... omeprazole ... Probiotic
... quetiapine ... Vitamin C." The record
failed to evidence Colace on this
medication profile.
2. Clinical record #8, start of care date
1/20/17, contained a plan of care dated
3/21/17-5/19/17 which indicated
medications "clopidogrel ... loratadine ...
Nitrostat ... alpha lipioc acid ...
cholecalciferol ... Fish oil ... Magnesium
... Multivital ... omeprazole .. Probiotic ...
saw palmetto." The record failed to
evidence the following:
3 continuous months. This
audit has been added to our
clinical record review as well.
Nursing Supervisor will be
responsible for compliance.
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 29 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
A. Agency document titled "SN
HOME CARE VISIT ROUTINE" dated
5/1/17 indicated in the clinical note
"INSTRUCTED [patient] CAN TAKE
TYLENOL PRN DURING THE DAY
AS [patient] IS PLANNING TO DRIVE
TODAY AND CANNOT TAKE THE
NORCO FOR PAIN WHEN [patient] IS
UP MOVING AROUND." The record
failed to evidence Tylenol on the plan of
care and medication profile; failed to
evidence a physician order for the
Tylenol; and failed to evidence the
patient was provided instructions about
not exceeding Tylenol recommended
dose when taking in conjunction with
Norco.
B. A drugs.com search was
completed on 5/8/17 at 2:51 PM with the
following medications: alpha-lipoic acid,
cholecalciferol, loratadine, magnesium
oxide, omeprazole, saw palmetto, fish oil,
nitrostat, norco, probiotic, and tylenol.
The drug interaction report indicated an
Acetainophen (Tylenol) therapeutic
duplication which indicated "The
recommended maximum number of
medicines in the 'acetaminophen'
category to be taken concurrently is
usually one. Your list includes two
medicines belonging to the
'acetaminophen' category: acetaminophen
(active ingredient in Norco
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 30 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
(acetaminophen/hydrocodone)),
acetaminophen (active ingredient in
Tylenol (acetaminohen)). Note: The
benefits of taking this combination of
medicines may outweigh any risks
associated with therapeutic duplication.
This information does not take the place
of talking to your doctor. Always check
with your healthcare provider to
determine if any adjustments to your
medications are needed." The record
failed to evidence that a drug to drug
interaction check was completed by the
agency.
C. Agency document titled " Agency
Medication Profile," reviewed 5/1/17 by
Registered Nurse indicated medications
"alpha lipoic ... cholecalciferol ... fish oil
... loratadine ... magnesium ... nitrostat ...
norco ... omeprazole .. probiotic ... saw
palmetto." The record failed to evidence
Tylenol on the medication profile.
3. Clinical record #9, start of care date
8/2/16, contained a plan of care dated
3/30/17-5/28/17 which indicated
medications "aspirin ... Vimpat ...
polyethylene glycol ... loperamide ...
atenolol ... acetaminophen ... trazodone ...
lorazepam ... guaifenesin ... oxybutynin
... Zoloft ... Lasix ... Neurontin ...
gentamicin ... baclofen ... Keppra ...
levofloxacin ... amoxicillin-potassium
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 31 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
clavulanate ... ranitidine ...
oxycodone-acetaminophen ...
Symbicort." The record failed to
evidence the following:
A. Agency document titled "SN
HOME CARE VISIT ROUTINE" dated
4/12/17 indicated in the clinical note
"LEFT BREAST EXCORIATION 3CM
[centimeters], REDNESS,
TENDERNESS, SCANT SWELLING,
NO DRAINAGE NOTED. DENIES
PAIN EXCEPT WITH MOVEMENT
THAT CAUSES RUBBING AND OR
TENDERNESS TO TOUCH. WRITER
CLEANSED ARE WITH MILD SOAP
AND WATER, PATTED DRY.
PATIENT TOLERATED. APPLIED
NYSTATIN POWDER." The record
failed to evidence Nystatin powder on the
plan of care and medication profile; and
failed to evidence a physician order for
the Nystatin.
B. Agency document titled " Agency
Medication Profile" reviewed 5/4/17 by
Registered Nurse indicated medications
"acetaminophen, aspirin, atenolol,
baclofen, Gentamar, guaifenesin, Keppra,
Lasix, loperamide, lorazepam, Neurontin,
oxybutynin, polyethylene glycol,
ranitidine, Symbicort, trazodone, Vimpat,
Zoloft." The record failed to evidence
Nystatin on the medication profile.
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 32 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
4. During interview on 5/8/17 at 2:02
PM, the Administrator stated we were not
able to find anything on those
medications.
5. The agency's policy titled "Home
Health Care and Hospice-Medication
Reconciliation," PolyStat ID: 3531267,
revised 4/2017, stated "Policy: The
Agency will reconcile patient's
medications at time of admission and on
an ongoing basis. Procedure: Any
discrepancies will be reconciled by an
RN [Registered Nurse] with the patient's
physician. Discrepancies include
duplications, omissions, changes,
contraindications and/or unclear
information. ... All current medications
will be entered into documentation
software including dose, route and
frequency. Any medications indicated by
the software as a duplication or
interaction will be noted. Level 1
interactions will be called into the
physician's office and faxed. Level 2
interactions will be faxed to the physician
and Level 3 will be noted in the patient
chart. Medication changes, while the
patient is receiving care, will be
compared to the medication list/profile.
The medication list/profile will be
updated with each new or changed
medication. ... Medication review will be
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 33 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
performed with any medication changes
or as indicated by change in condition."
6. The agency's policy titled "Home
Health Care Plan of Care and Physician
Orders," PolyStat ID: 35356778, revised
4/2017, stated "Policy: Skilled nursing
and other home health services will be in
accordance with a Plan of Care ... Each
Plan of Care must be signed and dated by
the physician. Procedure: ... 5. Care and
services will be provided according to
physician orders. Orders are current and
updated. ... 10. All clinical services are
implemented only in accordance with a
Plan of Care established by a physician's
written order."
7. The agency's policy titled "Home
Health Care Medical Record Content
Policy," PolyStat ID: 3535828, revised
4/2017, stated "Policy: The Agency will
provide an accurate and current medical
record for every patient seen by the
Agency. Procedure: A current
medication profile to include
medication/allergies/sensitivities and
every medication, dose, frequency and
route of administration for prescription
and non-prescription medications, herbal
products and home remedies. Actual or
potential drug/food or drug/drug
interactions. ... Updated orders as
obtained."
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 34 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
410 IAC 17-14-1(a)(1)(E)
Scope of Services
Rule 14 Sec. 1(a) (1)(E) Except where
services are limited to therapy only, for
purposes of practice in the home health
setting, the registered nurse shall do the
following:
(E) Prepare clinical notes.
N 0544
Bldg. 00
Based on document review and policy
review, the agency failed to ensure the
Registered Nurse (RN) notified physician
with changes, and failed to ensure the RN
prepared clinical notes accurately for 1 of
9 records reviewed. (#3)
Findings include
1. Clinical record #3, start of care date
4/15/17, contained a plan of care dated
4/15/17-6/13/17 which indicated "SN
[Skilled Nurse] 1 Week 1; 2 Week 1; 1
Week 8. Skilled Nurse to instruct family
on how to do daily dressing change wet
to dry. Kerlex packing with ABD
[Abdominal gauze pad] and tape.
Continue to monitor healing and any
changes in wound and report to the
doctor as needed." The record failed to
evidence clarification orders for type of
wetting solution to be used on the wound;
and failed to ensure the physician was
notified of wound changes.
N 0544 Director reviewed policies on
Nursing Services and the Internal
Guideline for Wounds with
nursing staff on 6-19-17.
Review of the chart performed
with staff. Wet to dry dressing is
considered standard nursing
practice. Treatment to include:
saline soaked gauze unless
otherwise specified. This
definition will be added to
agency's internal guideline for
wounds.
Physician will be notified of any
significant changes to condition or
wounds. Orders will reflect
specific discharge
instructions regarding when to
notify physician for signs and
symptoms of infection e.g. degree
of temperature.
Case Managers will audit 100%
of caseload weekly to determine if
daily wound care documentation
matches wound care orders.
Wound care orders will be
discussed in weekly meetings
with the Nursing Supervisor.
Nursing Supervisor is responsible
for compliance.
06/26/2017 12:00:00AM
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 35 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
A. Agency document titled "SN
HOME CARE SOC [Start of Care]
ASSESSMENT" dated 4/15/17 indicated
on page 4 that patient had a wound on
left lower abdomen measuring 3.2 x. 11 x
5.4 and wound care provided was
"1-Soiled dressing removed, 6-Wound
packed MOISTEN NS [Normal Saline]
KERLIX GAUGE 1/2 ROLL, 7-Wound
Dressing applied ABD AND TAPE."
The wound care order within the plan of
care did not instruct packing to be
moistened. The record failed to evidence
a physician clarification order for type of
wetting solution to be used on the wound.
B. Agency document titled "SN
HOME CARE VISIT ROUTINE" dated
4/20/17 indicated on page 1 that wound
care provided was "1- Soiled dressing
removed, 2-Wound cleansed NS,
66-Wound packed NS MOIST GAUZE
WET TO DRY, 7-Wound dressing
applied ABD x 2." The plan of care
wound orders failed to evidence
instructions to cleanse wound and which
type of wetting solution to use; and failed
to evidence a clarification for the wound
care orders.
C. Agency document titled "SN
HOME CARE VISIT ROUTINE' dated
4/18/17 indicated the patient had a fever
of 100.0 degrees Fahrenheit. The record
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 36 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
failed to evidence the physician was
notified of the temperature.
D. Agency document titled "SN
HOME CARE VISIT ROUTINE' dated
5/1/17 indicated the patient had a fever of
99.0 degrees, purulent drainage from
wound, and fatigue. The clinical note
stated "No s/s [signs and symptoms] of
infection." The record failed to evidence
the physician was notified of the
temperature, purulent drainage from the
wound, and patient report of fatigue.
2. The agency's policy titled "Cameron
Home Health Care and Hospice Internal
Guideline for Wounds," PolyStat ID:
3530918, revised 4/2017, stated "Internal
Guideline: 9. Wound care to be
performed as ordered by physician. 10.
Physician to be notified for the following:
a. Worsening condition/signs and
symptoms of infection."
3. The agency's policy titled "Home
Health Care Nursing Services," PolyStat
ID: 3535634, revised 4/2017, stated
"Policy: Patients receiving nursing
services will have appropriate
assessments, reassessments, care
planning and established outcomes
performed. Purpose: To define the scope
of nursing services offered by the
Agency. Procedure: Nursing care will be
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 37 of 38
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/18/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
ANGOLA, IN 46703
157117 05/08/2017
CAMERON HOME HEALTH CARE & HOSPICE
416 E MAUMEE ST
00
provided in accordance with the patient's
plan of care ... 2. Professional nursing
service will be provided by a Registered
Nurse and include: ... Preparing clinical
and progress notes ... Informing the
physician and other staff of changes in
the patient's needs."
State Form Event ID: NFSL12 Facility ID: IN005308 If continuation sheet Page 38 of 38
