Ingalls Home Care Inc.

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on clinical records review and staff interview it was determined that for 4 of 17 (Pts # 6, 12, 11 and 17) clinical records reviewed, the Agency failed to provide patients the services outlined in the PsOC. 3. Pt. #11 was admitted to the Home Care Services on 03/28/24 with the Diagnosis of: Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 03/28/24, that included Aide service “1-3 time per week”. The clinical record lacked documentation of any Aide services provided. 4.Pt. #17 was admitted to the Home Care Services on 02/23/24 with the Diagnosis of: Encounter for Surgical Aftercare. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 02/23/24, that required Aide to provide personal care and assist Bath“each Visit”. The clinical record lacked documentation of any Aide services provided. On 04/04/24, at 9:45 AM, during the interview with the Clinical Manager, it was stated the Aide was on medical leave and the Agency would use the hospice Aide if needed. 5.The findings were confirmed during the interview with the Administrator and Clinical Manager on 04/04/24 between 9:30 AM and 1:30 PM. Findings include: 1. Pt # 6 was admitted to Home Care Services on 03/14/24 with Diagnosis of Aftercare following joint replacement. The Clinical Record was reviewed on 04/03/24. The record contained a POC for certification period 03/14/24 with orders for OT services to evaluate for services between 03/20/24 to 03/23/24. As of 04/04/24 no OT services have been provided to patient. No modification orders were found in the clinical record. 2. Pt # 12 was admitted to Home Care Services on11/09/23 with Diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting left - non-dominant side. The clinical record was reviewed on 04/04/24. The record contained a POC for certification period 01/08/24 to 03/07/24 with orders for Medical Social Worker (MSW) evaluation between 02/01/24 to 02/03/24 and Speech Language Pathology (SLP) evaluation between 02/04/24 to 02/10/24. As of 04/04/24 no MSW or SLP have been provided to patient. No modification orders were found in the clinical record.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on the clinical record review and staff interview, it was determined in 3 of 17 (Pts. #1, 9 and 13) records reviewed, the Agency staff failed to provide services that are ordered in the POC. Findings include: 1. Pt. #1 was admitted to the Home Care Services on 09/30/23 with the Diagnosis of: Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 09/30/23, that required SN service 2 times a week for 4 weeks. The clinical record lacked the SN visits for week two. 2. Pt. #9 was admitted to the Home Care Services on 01/12/24 with the Diagnosis of: Calculus of Kidney with Calculus of Ureter. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 01/12/24, that required PT services 2 times a week for 5 weeks. The clinical record lacked the PT visits for weeks three and four. 3. Pt. #13 was admitted to the Home Care Services on 11/07/23 with the Diagnosis of: Sciatica Right Side. The clinical record was reviewed on 04/04/24. The clinical record contained a POC dated 11/07/23, that required OT services 1 time a week for 1 week, 2 times a week for 3 weeks and 1 time a week for 1 week. The clinical record lacked the OT visits for week three. 4. The findings were confirmed during the interview with the Administrator and Clinical Manager on 04/04/24 between 9:00 AM and 2:00 PM.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on the entrance interview, review of the Agency’s Staff list, review of the organization chart, review of the State Licensing application, review of the Governing body minutes and Staff interview, it was determined the Agency failed to provide documentation that the Governing Body appointed the Administrator. Findings include: 1. On 04/02/24 at 12:30 PM, during the entrance interview, Employee #1 stated she was the new Administrator, hired 03/18/24. 2. The Agency’s staff list and organization chart was reviewed on 04/04/24 at 10:00 AM and included documentation of Employee #1 as the Administrator. 3. The Agency’s State licensing application was reviewed on 04/04/24 at 10:30 AM and lacked documentation of Employee #1 (Administrator). 4. The Agency’s Governing Body minutes for 2023 and 2024 were reviewed on 04/05/24 at 10:40 AM and lacked documentation of the appointment for Employee #1 as the Administrator. During the interview with the Clinical Manager and Administrator, it was stated the appointment will be made at the next Governing Body meeting to be held this April 2024. 5.The findings were confirmed during the interview on 04/05/24 at 11:00 AM with the Clinical Manager and Administrator.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on clinical records reviews and Staff interviews it was determined that in 3 of 17 (Pts # 8, 11 and 17) clinical records reviewed, the Agency failed to provide oversight coordination of patient care. 2. Pt. #11 was admitted to the Home Care Services on 03/28/24 with the Diagnosis of: Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 03/28/24, that included Aide service “1-3 time per week”. The clinical record lacked coordination of care for the Aide services. 3.Pt. #17 was admitted to the Home Care Services on 02/23/24 with the Diagnosis of: Encounter for Surgical Aftercare. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 02/23/24, that required Aide service 1 time a week for 8 weeks. The clinical record lacked the Aide visits for weeks #1 and 2. The clinical record lacked coordination of care for the Aide services. 4. On 04/04/24, at 9:45 AM, during the interview with the Clinical Manager, it was stated the Home Care Aide was on medical leave and the Agency could use the hospice Aide if needed. 5. The findings were confirmed during the interview with the Administrator and Clinical Manager on 04/04/24 between 9:30 AM and 1:30 PM. 1. Pt # 8 was admitted to Home Care Services on 04/13/21 with Diagnosis of Pressure Ulcer of Sacral Region stage 4. The clinical record was reviewed on 04/04/24. The clinical record contained a Plan of Care for Certification period 01/28/24 to 03/27/24 with orders for Aide visits 3 times a week for 8 weeks and 1 time a week for 1 week. The clinical record contained completed Aide visits 3 x a week for weeks 1 to week 5 and 2 visits week 6 of certification period. (Last Aide visit dated 03/07/24). Pt #8 clinical record also contained a SN visit note dated 03/22/24 that included “Aide Supervisory Visit ...Comments: Aide not currently available to visit patient”. During the entrance interview on 04/02/24 with the Administrator and Clinical Manager it was stated that Agency only has 1 Aide on staff and she is currently on Medical Leave.”