longterm care Assigmt2
BYSTANDER
2567forABOVEBEYONDHOMECAREINCCompliantSurvey20211.pdf
A. BUILDING ______________________ (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________15K024 C
05/25/2021
Printed: 06/22/2021
ANDERSON, IN 46016
1304 MAIN STREETABOVE & BEYOND HOMECARE INC
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
G 000 INITIAL COMMENTS G 000
This was a Federal and state Home Health
complaint survey.
Survey Dates: 5/24/21-5/26/21
Complaint Numbers: IN00354187; Substantiated:
Federal deficiencies were cited.
IN00351609; Substantiated:
Federal deficiencies were cited.
Provider Number: 15K024
Medicaid ID: 200829700
Facility ID: 004808
Census: 106
This deficiency reflects State Findings cited in
accordance with 410 IAC 17.
True G 436 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:
G 436
Based on record review and interview, the agency
failed to provide all services outlined in the plan of
care for 1 of 5 clinical records reviewed (#2).
Findings include:
An undated document titled "Confidential
Admission Packet," stated " ...As a patient ... you
have the right to the following ... participate in, be
informed about, and consent or refuse care, in
advance of. And during treatment where
appropriate, with respect to ... the frequency of
visits ... receive all services outlined in the Plan of
Care ...."
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards 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.
FORM CMS-2567(02-99) Previous Versions Obsolete If continuation sheet Page 1 of 84X0S11
A. BUILDING ______________________ (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________15K024 C
05/25/2021
Printed: 06/22/2021
ANDERSON, IN 46016
1304 MAIN STREETABOVE & BEYOND HOMECARE INC
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
G 436 G 436Continued From page 1
An undated document titled "Service
Agreement/Plan," stated " ...The client shall be
advised of any changes in type or frequency of
services ...."
An undated document titled "Clinical
Documentation," stated " ...Agency will document
each direct communication with the client ...
Telephone or other communication with clients,
physicians, families, or other members of the
health care team will be documented in clinical
progress notes or other interagency
communication form ... Services not provided and
the reason for the missed visits will be
documented and reported to the physician ...."
The clinical record of patient #2 was reviewed on
5/24/2021 at 2:31 PM and indicated a start of
care date of 5/6/2020. The record contained a
plan of care for the certification dates 3/2/2021 to
4/30/2021 and indicated orders for home health
aide visits 5 to 7 days per week, 1 to 2 visits per
day, 3 to 6 hours per visit, during weeks 3 and 4.
The agency failed to provide all services outlined
in the plan of care as evidenced by:
A document titled "Schedules for [Patient #2] -
Visits by All Caregivers May 2021," indicated the
2 seven-hour visits were made on 5/15/2021 and
5/16/2021 (week 3), and 2 seven-hour visits were
made on 5/22/2021 and 5/23/2021 (week 4).
During an interview on 5/26/2021 at 11:00 AM,
when asked if the patient had a right to receive all
care/treatments ordered on the plan of care, the
Clinical Supervisor indicated "yes."
True G 478 Investigate complaints made by patient
CFR(s): 484.50(e)(1)(i)
G 478
FORM CMS-2567(02-99) Previous Versions Obsolete If continuation sheet Page 2 of 84X0S11
A. BUILDING ______________________ (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________15K024 C
05/25/2021
Printed: 06/22/2021
ANDERSON, IN 46016
1304 MAIN STREETABOVE & BEYOND HOMECARE INC
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
G 478 G 478Continued From page 2
(i) Investigate complaints made by a patient, the
patient's representative (if any), and the patient's
caregivers and family, including, but not limited to,
the following topics:
This Element is not met as evidenced by:
Based on record review and interview, the agency
failed to thoroughly investigate and document
complaints for 1 of 1 patient complaints reviewed
(#3).
Findings include:
An undated document titled "Complaint Policy,"
stated " ...The Administrator or designee shall
investigate the complaint ... This investigation
shall include interviewing the complainant, the
employee who is subject of the complaint, and
any other individual who the Administrator or
designee believes may have knowledge of the
complaint ... The Administrator shall document
the investigation and any conclusion reached as a
result of investigation ...."
The clinical record of patient #3 was reviewed on
5/24/2021 at 2:45 PM and indicated a start of
care date of 6/19/2019. The record contained a
plan of care for the certification period 4/9/2021 to
6/7/2021.
An agency complaint reviewed from the complaint
log on 5/24/2021 at 11:20 AM indicated "
...Received phone call from [investigator for
Indiana State Department of Health] [Home
health aide (HHA) D] stated he was charge with
inappropriate relationship with a minor on
5/18/2021 ... Spoke with [Patient #4's Mother] ...
informed of call from investigator ... we were
removing [aide] from home ... she stated she
was aware of charges and didn't want any other
caregiver ... services were to be put on hold ...
FORM CMS-2567(02-99) Previous Versions Obsolete If continuation sheet Page 3 of 84X0S11
A. BUILDING ______________________ (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________15K024 C
05/25/2021
Printed: 06/22/2021
ANDERSON, IN 46016
1304 MAIN STREETABOVE & BEYOND HOMECARE INC
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
G 478 G 478Continued From page 3
spoke with home health aide ... stated we were
removing from home because of charges ...
would suspend until charges were resolved ...
results of investigation: still awaiting outcome of
pending charges ... the agency took the following
immediate action: no allegations of inappropriate
conduct ..." The complaint failed to evidence a
thorough complaint investigation as the patient
was not interviewed and no referrals to outside
agencies were made (i.e., child protective
services).
During an interview on 5/26/2021 at 11:00 AM,
when asked how the agency ensured that
complaints were thoroughly investigated, the
Administrator indicated "do more supervisory
visits and follow up with other clients." When
asked if this process if documented, the Clinical
Supervisor indicated "yes, it would be on the
complaint form."
True G 528 Health, psychosocial, functional, cognition
CFR(s): 484.55(c)(1)
The patient's current health, psychosocial,
functional, and cognitive status;
This Element is not met as evidenced by:
G 528
Based on record review and interview, the
comprehensive assessment failed to contain all
information about the current health status for 1
of 5 records reviewed (#1).
Findings include:
An undated policy titled "Comprehensive Client
Assessment," stated " ...The Comprehensive
Assessment must accurately reflect the client's
status ... Assessment strategies ... MD or facility
information ...."
The clinical record of patient #1 was 5/24/2021 at
FORM CMS-2567(02-99) Previous Versions Obsolete If continuation sheet Page 4 of 84X0S11
A. BUILDING ______________________ (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________15K024 C
05/25/2021
Printed: 06/22/2021
ANDERSON, IN 46016
1304 MAIN STREETABOVE & BEYOND HOMECARE INC
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
G 528 G 528Continued From page 4
1:00 PM and indicated a start of care date of
7/3/19. The record contained a plan of care for
the certification dates 4/32/21 to 6/21/21.
The clinical record contained a recertification
comprehensive assessment completed on
4/24/2021, which indicated on page 10 of 29,
M1306 indicated the patient had no unhealed
pressure injuries/injury at stage 2 or higher. On
page 12 of 29, the Briggs Integumentary Status
Chart, indicated the patient had bilateral stump
(the distal end of a limb left after amputation)
pressure ulcers, and that the wounds were
unable to be assessed, as they were covered.
The comprehensive assessment failed to
evidence an accurate non-conflicting wound
assessment.
During an interview on 5/26/2021 at 11:00 AM,
when asked if all information on the
comprehensive assessment needed to be
accurate for that patient at the time of
assessment, the Clinical Supervisor indicated
"yes."
True G 606 Integrate all services
CFR(s): 484.60(d)(3)
Integrate services, whether services are provided
directly or under arrangement, to assure the
identification of patient needs and factors that
could affect patient safety and treatment
effectiveness and the coordination of care
provided by all disciplines.
This Element is not met as evidenced by:
G 606
Based on record review and interview, the agency
failed to ensure the Registered Nurse coordinated
with other agencies providing care to their
patients for 1 of 5 records reviewed (#2).
Findings include:
FORM CMS-2567(02-99) Previous Versions Obsolete If continuation sheet Page 5 of 84X0S11
A. BUILDING ______________________ (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________15K024 C
05/25/2021
Printed: 06/22/2021
ANDERSON, IN 46016
1304 MAIN STREETABOVE & BEYOND HOMECARE INC
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
G 606 G 606Continued From page 5
An undated document titled "Coordination of
Client Services," stated " ...Coordination of care
will include dealing with multiple programs for the
complex clients [cardiology, wound care,
diabetes, neuro, etc.] ... Documentation must
address the coordination activities ...
Coordination will include providers of care who
are not part of the agency ... When and how
communication happens must be documented ...
The agency Clinical Manager [Supervisor] or their
designee will develop and implement the
coordination plan ...."
During an interview on 5/24/2021 at 2:32 PM,
Patient #2 indicated that she used another
agency for care as well, that her spouse worked
for, so he is able to take care of her, and she
thought they were called "Care Homes."
The clinical record of patient #2 was reviewed on
5/24/2021 at 2:31 PM and indicated a start of
care date of 5/6/2020. The record contained a
plan of care for the certification dates 3/2/21 to
4/30/21. The record failed to evidence
documentation of coordination of care with the
other home health agency involved in the care of
the patient.
During an interview on 5/26/2021 at 11 AM, when
asked if the agency should document
coordination of care with any other agency
involved in a patient's care, the Clinical
Supervisor indicated "yes, if it's a home health
agency."
True G 800 Services provided by HH aide
CFR(s): 484.80(g)(2)
A home health aide provides services that are:
(i) Ordered by the physician or allowed
G 800
FORM CMS-2567(02-99) Previous Versions Obsolete If continuation sheet Page 6 of 84X0S11
A. BUILDING ______________________ (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________15K024 C
05/25/2021
Printed: 06/22/2021
ANDERSON, IN 46016
1304 MAIN STREETABOVE & BEYOND HOMECARE INC
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
G 800 G 800Continued From page 6
practitioner;
(ii) Included in the plan of care;
(iii) Permitted to be performed under state law;
and
(iv) Consistent with the home health aide training.
This Element is not met as evidenced by:
Based on record review and interview, the agency
failed to ensure the home health aide was
providing services in accordance with the plan of
care/aide care plan for 1 of 5 records reviewed
(#1).
Findings include:
An undated document titled "Home Health Aide
Care Plan," stated " ...The Home Health Aide
cannot be responsible for performing any
procedure that is beyond his/her ability ...."
The clinical record of patient #1 was 5/24/2021 at
1:00 PM and indicated a start of care date of
7/3/19. The record contained a plan of care for
the certification dates 4/32/21 to 6/21/21.
The record contained a Home Health Aide Care
Plan, completed on 4/10/2021, indicating "
...Chair Bath (at sink) ... 3/27/2021 until wounds
are healed ... Skin Care: (Moisturize, Inspect) ...
Check stumps [the distal end of a limb left after
amputation] when putting on/taking of prosthetics
...." The record contained a document titled "Visit
Record and Time Sheet," completed by Employee
E (Home Health Aide), indicating the HHA
completed Skin Care (Moisturize, Inspect) on
4/25/2021, 4/26/2021, 4/27/2021, 4/28/2021,
4/29/2021, 4/30/2021, 5/1/2021, 5/2/2021,
5/3/2021, 5/4/2021, 5/5/2021, 5/6/2021, 5/7/2021,
5/8/2021, 5/9/2021, 5/10/2021, 5/11/2021,
5/12/2021, 5/13/2021, 5/14/2021, and 5/15/2021.
The record failed to evidence documentation of a
FORM CMS-2567(02-99) Previous Versions Obsolete If continuation sheet Page 7 of 84X0S11
A. BUILDING ______________________ (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________15K024 C
05/25/2021
Printed: 06/22/2021
ANDERSON, IN 46016
1304 MAIN STREETABOVE & BEYOND HOMECARE INC
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
G 800 G 800Continued From page 7
home health aide care plan that ordered tasks
within the employee's scope of practice,
according to the state law.
During an interview on 5/26/2021 at 11 AM, when
asked if Home Health Aides were permitted by
state law to perform skin assessments, the
Clinical Supervisor indicated "yes."
True
FORM CMS-2567(02-99) Previous Versions Obsolete If continuation sheet Page 8 of 84X0S11
