(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
N 0000
Bldg. 00
This visit was for an initial home health
agency state licensure survey.
Survey dates: 12-29, 12-30, and
12-31-2014 and 1-2-2015
Facility Number: 013547
Survey Team: Deborah Franco, RN,
PHNS
Census: 8 Active patients
2 Discharged patients
Sample : Record reviews with home
visit: 2
Record reviews without home
visit: 4
Total: 6
Quality Review: Joyce Elder, MSN,
BSN, RN
January 13, 2015
N 0000 N-0000There is no finding here.
410 IAC 17-12-1(a) N 0440
State Form
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: T22X11 Facility ID: 013547
TITLE
If continuation sheet Page 1 of 83
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
Home health agency
administration/management
Rule 12 Sec. 1(a) Organization, services
furnished, administrative control, and lines of
authority for the delegation of responsibility
down to the patient care level shall be:
(1) clearly set forth in writing; and
(2) readily identifiable.
Bldg. 00
Based on agency organizational chart
review and interview, the agency failed to
ensure the organization, administrative
control, and lines of authority down to
the patient level and the patient
populations served were clearly identified
on the organizational chart for 1 of 1
home health agency.
The findings include:
1. Administrative document dated
12-11-2014 titled "Accredo Indiana
Nursing Location", dated 12-11-2014,
bearing an Express Scripts logo in the
upper left hand corner, failed to evidence
the identification of Accredo Health
Group, Inc., seeking licensure in Indiana
as a home health agency, as the subject of
the chart. The document failed to
evidence all personnel participating in
developing the patients' medical plan of
care in that pharmacists employed by
Accredo Health Group, Inc., the national
corporation, but not employed by
Accredo Health Group, home health
N 0440 1. Accredo Health Group, Inc.
(Accredo), which is the entity to
whom the provisional license was
granted, is a national corporation
that operates both pharmacies
and home health agencies. From
a global perspective, Accredo is
owned by Accredo Health, Inc.
(AHI). AHI is a subsidiary of
Medco Health Solutions, Inc.
(Medco). Medco is a subsidiary
of Express Scripts Holding
Company (ESI). Accredo
provided an organizational chart,
as Exhibit A, with the initial
application that summarized this
global corporate structure.
During the survey, a simplified
organization chart was provided
to the surveyor and that simplified
chart was inaccurate in that it did
not fully reflect the scope of
services offered to our patients
and did not fully explain the
corporate structure referenced
above. As a result, we believe
that the chart that was provided to
the surveyor caused confusion.
We have updated the
organizational chart and a copy of
that updated chart is attached as
Exhibit A.With respect to
employees who are involved in
the patient’s medical plan of care,
02/12/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 2 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
agency, participate in developing each
patient's plan of care by entering the
patient medication profile in the
electronic clinical record plan of care.
The document also failed to evidence all
the patient populations served in that the
chart contained a rectangular box labeled
"Infusion Patient."
2. On 12-29-14 at 2:15 PM, the
Alternate Administrator and Nursing
Supervisor, Employee A, indicated the
organizational chart presented was for
Accredo Health Group, Inc, seeking
licensure in Indiana as a home health
agency, which is owned by Accredo
Health Group, Inc., a national
corporation, which is owned by Express
Scripts, a national corporation.
Employee A indicated the agency
provides nursing services for patients
receiving infusions, but also provides
nursing services for patients receiving
inhalation and oral medication under
their medical plans of care. Employee A
indicated pharmacists, not employed by
Accredo Health Group, Inc., home health
agency, and not identified on the
organizational chart, input the patient's
medication profile into each patient's
electronic plan of care. Employee A
indicated she develops each patient's plan
of care but administrative controls
preclude her from adding, deleting, or
the only employees who are
involved in the development of a
patient’s initial plan of care from a
Home Health Agency
perspective, i.e. the drafting of
HFCA Form 485/Form 487,
otherwise referred to as the
nursing Plan of Treatment (POT),
are those employees that are
assigned to a Home Health
Agency (HHA). In this case, the
only employees that participated
in creating/editing the nursing
POT for the patients of the
Indiana HHA were nurses
assigned to the Indiana HHA.
Pharmacists do not participate in
the nursing POT. We believe the
confusion was caused in this
case due to our unique business
model and as a result of a poor
explanation of the interaction of
our systems and employees.
Accredo HHA’s only offers their
services to patients of the
Accredo pharmacies and those
services are solely related to
patient care and training for
medications dispensed by the
Accredo pharmacies. As a result,
we operate under a
company-wide electronic medical
record system which permits an
Accredo HHA nurse to view the
patient’s profile (which includes
medications) in the pharmacy
system, when clinically
necessary. When a patient
enters service with our HHA, our
pharmacy has typically already
received a prescription from the
patient’s physician and that
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 3 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
modifying any information which was
entered by Accredo Health Group, Inc.,
national corporation's pharmacists.
prescription has been added to
the patient’s profile in our
electronic medical record system,
such that our pharmacy can begin
processing the prescription. The
nurse assigned to the HHA can
access that medication
information when creating the
patient’s POT for purposes of the
HHA treatment/services. The
only individuals who are
responsible for entering patient
information directly related to
services performed by our HHA,
such as the POT or records
relating to nurse site visits, are
nurses assigned to our HHA.2.
Unfortunately, as set forth above,
we do not believe our business
model was adequately explained
to the surveyor. Accredo Health
Group, Inc., the national entity, is
the entity that applied for and was
granted a provisional license.
As correctly noted by Employee
A, nursing staff assigned to the
HHA are responsible for creating
a patient’s Plan of Treatment
(POT). However, with respect to
who may add, delete or modify
the POT, Employee A provided
incorrect information to the
surveyor. A nurse may add,
delete or modify any necessary
information pertinent to the HHA
in the patient’s electronic record,
including medication information.
Accredo has provided additional
education to Employee A
regarding this ability and this
training has been documented.
As a proactive measure, this
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 4 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
training was also provided to all
nurses assigned to the Indiana
HHA and specific training
regarding the same will be
provided to all new nurses
assigned to the Indiana HHA in
the future. The Indiana HHA
administrator is and will be
responsible to ensure that this
training take place in the future
and the Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
newly assigned Indiana HHA
nurses two times a year for
compliance with these proactive
training measures for the next
two years.
410 IAC 17-12-1(a)
Home health agency
administration/management
Rule 12 Sec. 1(a) Administrative and
supervisory responsibilities shall not be
delegated to another agency or organization,
and all services not furnished directly,
including services provided through a branch
office, shall be monitored and controlled by
the parent agency.
N 0441
Bldg. 00
Based on clinical record review, review
of the electronic clinical documentation
system "Rx Home", personnel file
review, a corporate memorandum review,
policy review, and interview, the
administrator failed to ensure
administrative responsibilities were not
delegated / completed to another
organization in relation to the
development of patients' medication
N 0441 1. Unfortunately, as set forth in
response to N 440, with respect
to who may add, delete or modify
the patient’s Plan of Treatment
(POT), Employee A provided
incorrect information to the
surveyor. By way of background,
due to our unique business model
and because we receive
prescriptions from prescribers for
medications that are directly
related to our HHA services, an
Accredo employee (such as a
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 5 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
profile in the medical plan of care for 6
of 6 clinical records reviewed (1, 2, 3, 4,
5 and 6), criminal background checks of
its employees for 2 of 2 direct care
providers (Employees A and B), and
budgeting and accounting systems for 1
of 1 agency.
The findings include:
1. Clinical record #1, start of care (SOC)
12-23-14, diagnoses of other chronic
pulmonary heart disease, portal
hypertension, and pulmonary
hypertension included a plan of care for
certification period 12-23-14 to 2-20-15
that failed to include medications taken
by the patient as reported during nursing
visit of 12-23-14 of Synthroid 0.124 mg
by mouth daily and Pramipexole Di-Hcl
0.5 mg by mouth twice a day which were
not new medications for the patient. The
nurse signed the verbal order for start of
care and faxed the plan of care as it
printed from the Rx Home computer
program, without the corrections to the
medications, and also sent a fax to the
physician with an order for the Synthroid
and Pramipexole to update the
medications.
Employee A indicated during interview
on 12-31-14 at 2:30 PM that the Rx
Home program had patient #1's
pharmacist or pharmacy
technician) enters medication(s)
into the company wide computer
system upon the receipt of a
prescription from the prescriber
but that medication is not entered
into the POT by non HHA
personnel. Rather, a nurse
assigned to the Accredo HHA is
able to extract the patient’s
medication profile from the
computer system into the POT
and the HHA nurse then has the
ability to edit the medication
section on the POT, if necessary.
Accredo has provided additional
education to Employee A
regarding this ability and this
training has been documented.
As a proactive measure, this
training was also provided to all
nurses assigned to the Indiana
HHA and specific training
regarding the same will be
provided to all new nurses
assigned to the Indiana HHA in
the future. The Indiana HHA
administrator is and will be
responsible to ensure that this
training take place in the future
and the Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
newly assigned Indiana HHA
nurses two times a year for
compliance with these proactive
training measures for the next
two years.2., 3., 4., 5., 6. Please
see above.7.Please see above.
In addition, while it is accurate
that once the Accredo HHA
submits a Plan of Treatment
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 6 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
medications already entered into the plan
of care by a corporate pharmacist prior to
SOC date and Employee A was
precluded from adding, deleting, or
modifying in any way the medications on
the plan of care to initiate an accurate and
complete plan of care for submission to
the attending physician for authorization.
2. Clinical record #2, SOC 11-18-14,
diagnosis of myasthenia gravis, included
a plan of care for certification period
11-18-14 to 1-16-15 which contained a
medication profile with the patient's
medications.
Employee A indicated during interview
on 12-31-14 at 2:30 PM a corporate
pharmacist entered patient #2's
medications into the agency plan of care.
3. Clinical record #3, SOC 12-19-14,
diagnosis of primary pulmonary
hypertension, included a plan of care for
certification period 12-19-14 to 2-16-15
which contained a medication profile
with the patient's medications.
Employee A indicated during interview
on 12-31-14 at 2:30 PM a corporate
pharmacist entered patient #3's
medications into the agency plan of care.
4. Clinical record #4, SOC 12-12-14,
(POT) to a physician for signature
it may take that physician some
period of time to sign and return
the POT, that timing is outside the
direct control of Accredo. As a
result, Accredo has an internal
monitoring process that it uses to
ensure the timely receipt of a fully
executed POT from a physician’s
office. Also, nurses can print a
patient’s electronic clinical
record. Because Accredo
operates within an electronic
record system, Accredo HHA
nurses do not routinely have a
need to print paper copies of a
patient’s clinical record. Training
was provided to all nurses
assigned to the Indiana HHA
regarding a nurse’s ability to print
a patient’s clinical record and
specific training regarding the
same will be provided to all new
nurses assigned to the Indiana
HHA in the future. The Indiana
HHA administrator is and will be
responsible to ensure that this
training take place in the future
for all newly assigned nurses and
the Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
newly assigned Indiana HHA
nurses two times a year for
compliance with these proactive
training measures for the next
two years. 8. This is a true
statement and we do not believe
that this is a violation of Indiana
HHA regulations. The only
healthcare providers who are
responsible for entering patient
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 7 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
diagnosis of alpha 1 anti-trypsin
deficiency, included a plan of care for
certification period 12-12-14 to 2-9-15
which contained a medication profile
with the patient's medications.
Employee A indicated during interview
on 12-31-14 at 2:30 PM a corporate
pharmacist entered patient #4's
medications into the agency plan of care.
5. Clinical record #5, SOC 10-13-14,
diagnosis of primary pulmonary
hypertension, included a plan of care for
certification period 10-13-14 to 12-12-14
which contained a medication profile
with the patient's medications.
Employee A indicated during interview
on 12-31-14 at 2:30 PM a corporate
pharmacist entered patient #5's
medications into the agency plan of care.
6. Clinical record #6, SOC 11-14-14,
diagnosis of pulmonary hypertension,
included a plan of care for certification
period 11-14-14 to 1-12-15 which
contained a medication profile with the
patient's medications that included
Ferrous sulfate 325 mg tablet, by mouth
as directed.
Employee A indicated during interview
on 12-31-14 at 2:30 PM a corporate
information directly related to
services performed by our HHAs,
such as the Plan of Treatment
(POT) or records relating to nurse
site visits, are nurses assigned to
an HHA. Because Accredo (as a
company) operates both
pharmacies and HHAs, a variety
of healthcare professionals will
input pertinent information, both
clinical and non-clinical, into a
patient’s profile. Various
employees of Accredo have
appropriate levels of access to a
patient’s electronic record and
can make entries into the
patient’s record, in accordance
with their role in the patient’s
care. Accredo’s computer
system is accessed by
employees with unique
usernames and password
protection. In addition, Access to
patient information is logged and
employee access is in
compliance with applicable
HIPAA regulations. 9. Criminal
background checks are
conducted on all employees as
part of the on-boarding process at
the time of hire. This policy is set
by the parent company, ESI, and
is applicable to Accredo. A copy
of the Express Scripts “Hiring and
Recruiting Policy“ is attached as
Exhibit B. A copy of Accredo
policy “10-2 Location Specific
Personnel Record Content” is
also being provided and is
attached as Exhibit C. Criminal
background checks were
completed for Employees A, D,
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 8 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
pharmacist entered patient #6's
medications into the agency plan of care
and there was no frequency included on
the Ferrous sulfate medication order. She
indicated "as directed" is not a complete
medication order because it lacks a
frequency, but Employee A was
precluded from adding, deleting, or
modifying in any way the medications on
the plan of care to initiate an accurate and
complete plan of care prior to submission
to the attending physician for
authorization.
7. On 12-29-14 at 2:00 PM, Employee
A, the alternate administrator indicated
the agency's patients' clinical record is
created and maintained in an electronic
system "Rx Home" which is integrated
into Accredo Health Group, Inc., national
electronic patient record. She indicated
the agency registered nurse develops the
plan of care for each part of the patient's
medical plan of care except field #10,
medications. At start of care, the
registered nurse completes an assessment
and compares the medication profile
obtained with the medications already
entered into the electronic plan of care by
a pharmacist employed by Accredo
Health Group, Inc, the corporation.
When the registered nurse detects
medication discrepancies, the registered
nurse cannot amend the medication
and E and a copy of these
background checks were
submitted to the Indiana
Department of Health with the
initial application for licensure.
However, a copy of those
background checks was not in
the individual employee’s
electronic personnel file at the
time of the survey. Since the
survey was completed, a copy of
these background checks has
been placed in the Accredo
electronic personnel records for
these employees. Accredo will
continue to ensure that criminal
background checks are
conducted on all newly assigned
Indiana HHA nurses. The Indiana
HHA administrator is and will be
responsible to ensure that this
background check is completed
for all newly assigned HHA
nurses and also that a copy has
been added to the nurse’s
electronic personnel file. The
Indiana HHA nursing supervisor
will also audit the electronic
personnel records of all newly
assigned Indiana HHA nurses
three times a year for compliance
for the next two years. Also,
please see response to N 444.10.
This is an accurate statement and
we do not believe it is a violation
of Indiana regulations. Budgeting
and accounting functions were
implemented for the Indiana HHA
and in place at the time of the
survey. These functions are
performed by Accredo, the
licensed entity, and were not
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 9 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
profile in the electronic system prior to
printing and sending the plan of care to
the attending physician for authorization.
The registered nurse then documents the
necessary revisions to the medication
profile and faxes to the attending
physician for an order to modify the plan
of care. Employee A indicated it may
take days or weeks before the signed plan
of care and order to amend the
medication profile are received back from
the attending physician. Employee A
stated the registered nurse is precluded by
Accredo Health Group, Inc, the national
corporation and by administrative
computer program controls from
submitting a complete, correct, and
accurate medication profile to the
attending physician at the start of care.
When queried if the agency could print a
copy of any of its patients' clinical record,
Employee A indicated she could not do
so because the agency clinical record is
integrated into a corporate national
program, Rx Home, which includes this
agency's and all Accredo Health Group,
Inc., the national corporation's, patients
from other states.
8. Review of a policy titled "Clinical
Record Contents", with "Accredo Health
Group, Inc., An Express Scripts
Company" printed on the policy, last
reviewed by Accredo Health Group, Inc.,
delegated to another
organization. In addition, the
HHA’s budget is approved by the
Governing Body. Accounting and
budgeting information related to
the Indiana HHA can be produced
and should have been provided.
In addition, we also believe that
we meet the intent of the
regulation. Because we are a
nationwide company, a dedicated
finance team comprised of
individuals with specific
education, training and
experience in finance/accounting
assist with budgeting and
accounting functions. We believe
that this complies with the intent
of the regulation, given that
individuals employed by the
licensed entity, with more
specialized experience than a
typical HHA administrator would
have, are assisting with the
process and also because the
Governing Body approves the
annual budget.
We understand the importance of
budgeting and accounting
functions and how without such
functions a healthcare provider’s
ability to continue to provide care
may be questionable. Because
we are a national corporation and
have dedicated accounting and
finance teams, we believe that we
are able to better ensure
continuity of care to patient
populations that are unique and
small. For example, in this case,
we were able to open an HHA
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 10 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
the national corporation 7-2014, states
"Clinicians, the physician, and
appropriate business contractor staff will
make entries to the patient record.
Professional staff (RN (registered nurse),
LPN/LVN (licensed practical / vocational
nurse), RD (registered dietician),
pharmacist, and any business contractor
staff will make entries in the patient
clinical record to provide permanent and
continuous records of observations,
interventions, and outcomes."
9. Review of personnel files of
registered nurses identified by the agency
as employees failed to evidence a copy of
a criminal background check as required
by IC 16-27-2 within 3 days of providing
patient care for 2 of 2 registered nurses
who provided direct patient care,
Employees A and B. Any agency
policies regarding hiring procedures,
employment procedures, and required
content of agency personnel files to
include criminal background check for
direct care providers were requested.
Employee A, the alternate administrator /
nursing supervisor, was unable to provide
copies of the agency employees' criminal
background checks. She indicated
criminal background checks were not
stored in the agency electronic personnel
file in "Work Place" program, but were
under the control of the human resources
and provide specialty infusion
services to an Indiana patient
population that was as small as
ten (10) patients.
Finally, to prevent a recurrence of
the surveyor being provided
insufficient information relating to
our budgeting and accounting
implementation, training will be
provided to all supervisory
personnel assigned to the Indiana
HHA. The Indiana HHA
administrator is and will be
responsible to ensure that this
training take place and the
Indiana HHA nursing supervisor
will also audit the electronic
personnel records within the next
three months to ensure
compliance with this proactive
training measure.
11. Please see above.
12. Please see above.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 11 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
department of Accredo Health Group,
Inc, the national corporation. Employee
D indicated on 1-2-14 at 2:00 PM that
Accredo Health Group, Inc, the national
corporation, has an "Onboarding" policy /
procedure which addresses the above, but
this was not produced after request.
10. During entrance conference on
12-29-14, concluding at 2:30 PM, a
written request was made for the
accounting and budgeting systems
implemented by the administrator.
Employee A, the alternate
administrator/nursing supervisor,
indicated the agency did not have
anything to produce as all of these
functions were administered by Accredo
Health Group, the national corporation.
Employee D, the alternate director of
nursing, indicated agency personnel did
not have any role in the accounting and
budgeting or billing.
11. During telephone interview with
Employee E, the administrator, on
12-31-14 at 3:00 PM, she indicated the
agency did not have its own accounting
and budgeting system but Accredo Health
Group, Inc., the corporation, does all
accounting, budgeting, and billing for the
agency.
12. Review of an undated and unsigned
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 12 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
document titled "Nursing Budget:
Indianapolis 2014-2015" states, "Accredo
has a dedicated finance team responsible
for monitoring and recording all
financials associated with the nursing
operations within Accredo and specific to
Indianapolis." On 12-31-14 at 4:30 PM,
Employee A indicated the sentence in
quotations referred to Accredo Health
Group, Inc, the corporation, and she did
not believe anyone at the agency had
access to this data.
410 IAC 17-12-1(b)
Home health agency
administration/management
Rule 12 Sec. 1(b) A governing body, or
designated person(s) so functioning, shall
assume full legal authority and responsibility
for the operation of the home health agency.
The governing body shall do the following:
(1) Appoint a qualified administrator.
(2) Adopt and periodically review written
bylaws or an acceptable equivalent.
(3) Oversee the management and fiscal
affairs of the home health agency.
N 0442
Bldg. 00
Based on power point slides and
memorandum review and interview, the
agency failed to ensure governing body
meeting minutes were provided to
evidence the governing body appointed
an administrator and adopted agency
bylaws for 1 of 1 agency.
N 0442 1. Accredo acknowledges and
admits that there was an
inappropriate delay in providing
the Governing Body meeting
minutes to the surveyor. A copy
of the Accredo annual Governing
Body meeting minutes was not
provided to the surveyor until
January 2, 2014, prior to the
closing call. A copy of the
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 13 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
The findings include:
1. On 12-29-2014, at 2:30 PM, a written
request for all governing body meeting
minutes relative to the Accredo Health
Group home health agency was made.
2. Employee A, the alternate
administrator / nursing supervisor,
indicated on 12-30-14 at 4:00 PM the
home health agency fell under the
authority of the Accredo Health Group,
Inc., the national corporation, had the
same governing body, followed the same
policies and bylaws as the national
corporation and all of its owned home
health agencies, estimated to be
thirty-three (33). Employee E indicated
awareness of only one (1) Accredo
Health Group, Inc, corporate governing
body meeting in 2014 on 12-17- 2014.
All governing body meeting dates and
minutes from any and all governing body
meetings were again requested to
evidence the appointment of an agency
administrator and adoption of agency
bylaws. A print out of power point slides
from 12-17-14 titled "Annual Governing
Body Meeting" was presented. This
document of power point slides failed to
identify which of the people attending
were members of the governing body,
and failed to evidence governing body
Governing Body meeting minutes
is attached as Exhibit D.
Moving forward, to prevent a
recurrence of this delay, Accredo
will ensure that a paper copy of
the Governing Body meeting
minutes are maintained at the
Indiana HHA such that they can
be produced immediately upon
request.
The Indiana HHA administrator is
and will be responsible to ensure
that a paper copy of the
Governing Body meeting minutes
is maintained at the Indiana HHA
and the administrator will also
audit the binder three times a
year for compliance to ensure
that it is up to date for the next
two years.
2. Please see above.
The surveyor was provided a list
of the Governing Body members
who attended the December 17,
2014 annual meeting. Accredo is
also providing a list of the
Governing Body members who
attended the annual meeting on
December 17, 2014, along with
their corporate addresses. This
list is attached as Exhibit E.
3. Please see above.
4. Please see above. For
clarification, the policy number
referenced in the above
paragraph should be listed as
Practice Standard 28-01-06. A
copy of that Practice Standard,
for ease of reference, is attached
as Exhibit F.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 14 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
meeting minutes in which an
administrator was appointed for Accredo
Health Group home health agency
Indiana or adoption of Accredo Health
Group home health agency Indiana
bylaws by a quorum of governing body
members.
3. On 12-31-14 meeting minutes of the
governing body were requested again and
the agency presented a memorandum,
undated, signed by an Accredo Health
Group corporation employee, stating it
was an "acknowledgement and
recognition" of the governing board
naming Employee E administrator for the
agency, Employee A as alternate
administrator and nursing supervisor, and
Employee D as alternate nursing
supervisor effective 7-21-14. No other
documentation demonstrating compliance
was provided.
4. A corporate policy # 21-01-06, created
7-3-13 and revised 12-29-14, of Accredo
Health Group, Inc., states, "This
Governing Body shall cause minutes of
each meeting of this Governing Body and
Committee meetings to be be maintained
... a majority of the members of the
governing body shall constitute a quorum
for for conducting business at any
meeting thereof. The vote of a majority
of members of the governing body shall
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 15 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
be required to approve any action of the
governing body ... the governing body
may fulfill its obligations hereunder by
having one or more members of this
governing body meet with the
management staff of the organization
charged with day to day operations,
provided that minutes are recorded at
such meetings and the governing body
itself subsequently reviews and approves
such minutes."
410 IAC 17-12-1(c)(1)
Home health agency
administration/management
Rule 12 Sec. 1(c) An individual need not be
a home health agency employee or be
present full time at the home health agency
in order to qualify as its administrator. The
administrator, who may also be the
supervising physician or registered nurse
required by subsection (d), shall do the
following:
(1) Organize and direct the home health
agency's ongoing functions.
N 0444
Bldg. 00
Based on observation and interview, the
administrator failed to organize and
direct the home health agency's ongoing
functions to include providing staff
sufficient to cover the hours of operation,
provision for a method of tracking at the
agency level the activity of the agency in
relation to ability to generate lists of
active and discharged patients and reason
for discharge, provision for orientation of
N 0444 Accredo recognizes and
apologizes for the fact that the
surveyor was provided, at times,
inaccurate and insufficient
information such that it could be
accurately demonstrated that
Accredo was operating in
compliance with Indiana
regulations. Since the survey,
we have provided additional
training to all employees assigned
to the Indiana HHA, including the
current administrator. The
contents of that training are set
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 16 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
agency staff (Employee B), provision to
ensure the personnel record of the
nursing supervisor was current and
included a criminal background check
(Employee A), provision for agency
employment / hiring policies to include
the contents of the personnel record and
requirement of a copy of a criminal
background check in accordance with IC
16-27-2 for direct care staff, provision for
the treatment of health records of agency
direct care staff health as confidential,
and provision for the administrator's
presence at the agency for any part of the
initial licensure survey conducted the day
before expiration of the agency's
provisional license for 1 of 1 agency.
The findings included:
1. Indiana State Department of Health
(ISDH) documents completed with data
provided by the agency, state the hours of
operation of Accredo Health Group, Inc.
at 2825 W. Perimeter Rd, Indianapolis
IN, are 8:30 AM to 5:00 PM Monday
through Friday.
A. On 12-29-14 at 10:30 AM, the
surveyor arrived at the address provided
by the agency at 10:30 AM to conduct the
initial state licensure survey. No agency
employees were present.
forth throughout this response. In
addition, we have identified
opportunities of more efficient
means of capturing and storing
documentation such that it may
be produced to the surveyor in a
timely and organized manner.
Finally, if permitted to continue
operations, Accredo will appoint a
full time administrator who is
located on-site at the Indianapolis
HHA. Please see below
responses to address specific
noted deficiencies.
1.A. Accredo HHA nurses are
typically performing patient visits
between the hours of 8:30 a.m.
and 5:00 p.m., in accordance with
the stated hours of operation.
We apologize for the delay in an
employee responding to the HHA
office for the surveyor to
commence the survey. However,
we do not believe that the
regulations require that a nurse
be physically present at the HHA
during the provided hours of
operation. As set forth below, in
response to N 447, the
Indianapolis Accredo HHA has a
toll free phone number that phone
is designed to route to
appropriate personnel if an
employee is not physically in the
office. Unfortunately, as set forth
below in response to N 447, due
to a technical error with the
telephone company, the call
routing was not working
appropriately. We are working
with the telephone company to
ensure that this issue has been
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 17 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
B. On 12-29-14 at 1:15 PM,
Employee A, the alternate administrator /
nursing supervisor, arrived at the agency
and stated the agency has no clerical
staff, that she is the only local employee,
and the agency does not have a provision
to staff during hours of operation if
Employee A is out of the office to see
patients or for any other reason.
2. On 12-31-14 at 2:30 PM, Employee A
indicated the agency's clinical records are
integrated into Accredo Health Group,
Inc., national corporate record system, Rx
Home. Lists of agency patients - active
or discharged, reason for discharge, or
any agency reports could not be extracted
or isolated to provide reports on this
agency's patients or agency business such
as list of employees including date of
hire.
3. The personnel file of Employee B, no
determinable hire date with this agency,
date of first patient contact of 11-21-14
for patient #6, failed to evidence an
expanded criminal background check in
accordance with IC 16-27-2 which was
required because the employee resides in
Kentucky, and failed to evidence any type
of orientation to the position of staff
registered nurse for this Indiana home
health agency.
corrected. Also, if the
Department of Health wishes, we
will provide direct contact
numbers for our Indiana
Administrator and Alternate
Administrator.
Because of the small number of
patients that we were servicing at
the time of the survey, the only
full time on-site nurse assigned to
the Indiana Accredo HHA was the
alternate administrator/nursing
supervisor (Employee A), who
was frequently out seeing
patients, but was available for
calls on her phone.
As indicated above in response to
N 440, Accredo only offers its
HHA services to patients that
receive prescriptions from the
Accredo pharmacy. Due to our
unique service offerings, the
Indiana Accredo HHA is
physically located within a
secured building that also houses
other Accredo functions, including
an Accredo pharmacy. Security
staff manages the traffic in and
out of the building. The security
team was informed that a survey
was expected. The security staff
will be trained on the urgency of
contacting the appropriate
individuals when a representative
from the State of Indiana arrives.
With respect to timing relating to
this survey, Employee E, who
was the administrator, spoke with
the surveyor and alerted her that
she was out-of-state at the time
and that the only other full time
employee assigned to the Indiana
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 18 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
4. The personnel file for the nursing
supervisor/alternate administrator,
Employee A, hire date 5-5-14, failed to
evidence a copy of a proper criminal
background check from the Indiana State
Police Repository as required by IC
16-27-2 within 3 days of services.
5. On 12-31-14 at 2:30 PM, during phone
interview, Employee E indicated her
duties as administrator could be
accomplished by almost daily telephone
calls with the nursing supervisor /
alternate administrator (Employee A) and
receipt of weekly reports. Employee E
indicated she was in Detroit, Michigan
and would not attend any portion of the
initial licensing survey. She was aware
the agency's provisional license was due
to expire 12-30-14, had contacted the
corporation's legal department to inquire
what would happen if the initial licensure
survey did not occur by 12-30-14, and on
1-2-15 at 2:00 PM indicated she had not
been to the agency in October,
November, or December 2014 (the dates
of the provisional license).
HHA was seeing a patient at the
time. Employee E immediately
contacted the Alternate
Administrator (Employee A), who
was seeing a patient, and
indicated that she would complete
the patient visit and return to the
office by 1:30 p.m. This
information was communicated to
the surveyor by Employee E.
Employee A, the alternate
administrator arrived at the office
at approximately 1:15 p.m.
B. This is correct. Please see
above.
2.Although the regulations do not
specifically state that a list of
agency patients or employees
and the details set forth above
must be maintained in a
consolidated report format,
Accredo recognizes that this
information is typically requested
by the Indiana Department of
Health during a survey.
Unfortunately, Employee A did
not appreciate that a patient
census could be provided and, as
a result, we do not believe the
surveyor was provided sufficient
information to determine
compliance. Accredo has
provided additional education to
Employee A regarding the ability
to produce reports containing
pertinent patient information and
this training has been
documented.
As a proactive measure, this
training was also provided to all
nurses assigned to the Indiana
HHA and specific training
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 19 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
regarding the same will be
provided to all new nurses
assigned to the Indiana HHA in
the future. The Indiana HHA
administrator is and will be
responsible to ensure that this
training take place in the future
and the Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
newly assigned Indiana HHA
nurses two times a year for
compliance with these proactive
training measures for the next
two years.
As to the individual employee’s
specific date of hire, this
information will be captured in the
employee’s electronic personnel
file. The Indiana HHA
administrator is and will be
responsible to ensure that this
date is captured for all newly
assigned HHA nurses and also
that a copy has been added to the
nurse’s electronic personnel file.
The Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
newly assigned Indiana HHA
nurses three times a year for
compliance for the next two
years.
3.
As set forth in response to N 441,
criminal background checks are
completed at the time a new
employee is hired. At the time of
the survey, a copy of employee
B’s background check was not in
her electronic personnel file.
Since the survey, the background
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 20 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
check that was completed at the
time of Employee B’s hire has
been placed in her electronic
personnel file.
To be transparent, that
background check was not
completed by the Indiana State
Police (because the nurse was
originally assigned to a different
state). As a result, Accredo has
also requested an expanded
criminal background check from
the Indiana State Police
according to IC 16-27-2.
Further, as a proactive measure,
the Indiana HHA administrator is
and will be responsible to ensure
that a background check that is
performed by the Indiana State
Police is completed for all new
assigned HHA nurses and also
that a copy has been added to the
nurse’s electronic personnel file.
The Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
newly assigned Indiana HHA
nurses three times a year for
compliance for the next two
years.
As indicated above, Accredo will
also ensure that the nurse’s date
of hire is captured in the
employee’s electronic personnel
file, along with the date the nurse
was assigned to see seeing
patients in connection with the
Indiana HHA.
4. Please see above. In addition,
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 21 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
an Indiana State Police limited
criminal background check was
completed for Employee A during
Accredo’s application for
licensure. The report was
submitted with the licensure
application.
At the time of the survey, a copy
of the report from the Indiana
State Police background check
was not in the electronic
personnel file of the nurse. Since
the survey, a copy of that report
has been placed in Employee A’s
electronic personnel file.
5. As set forth above, to provide
additional direct oversight of any
future ongoing activities, if
permitted to continue operations,
Accredo will appoint a full time
administrator who is located
on-site.
410 IAC 17-12-1(c)(2)
Home health agency
administration/management
Rule 12 Sec. 1(c)(2) The administrator, who
may also be the supervising physician or
registered nurse required by subsection (d),
shall do the following:
(2) Maintain ongoing liaison among the
governing body and the staff.
N 0445
Bldg. 00
Based on observation, interview, and
review of agency policy, the
administrator failed to ensure revised
policies were provided to the agency
timely l for 1 of 1 agency.
N 0445 1. A copy of Practice Standard
27.06.03 Patient
Inactivation/Discharge was
provided to the surveyor.
However, the copy initially
provided was an old version,
dated 5/22/2012. When it
became apparent that the old
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 22 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
The findings include:
1. On 12-29-14 at 2:30 PM, a written
request was made to include providing a
copy of agency policy for discharging
patients.
2. On 12-30-14, Employee D provided a
copy of a policy "Patient Inactivation /
Discharge" last revised 5-22-12.
3. During the exit conference on 1-2-15,
beginning at 4:35 PM, Employee E, the
administrator, who participated by
telephone conference, indicated a revised
discharge policy had been emailed to the
alternate administrator 2 days ago.
Employee A indicated she was not aware
the policy had been revised and sent to
her, but months ago she had requested
changes in the policy to bring the agency
into compliance.
4. The policy "Patient Inactivation /
Discharge" indicates the policy was
revised on 10-16-14, but was not
provided to the agency prior to the initial
licensure survey was not received by by
Employee A, the alternate administrator /
nursing supervisor until 1-2-15.
version had been provided, a
current version, dated
10/16/2014, was promptly
provided to the surveyor. For
ease of reference, a copy of
Practice Standard 27.06.03
Patient Inactivation/Discharge is
attached as Exhibit G.
We believe the old version of the
policy was provided in error due
to the employee not accessing
the Accredo policies that are
maintained electronically but
rather providing a paper copy that
the employee had printed for her
own use previously. Because we
are a nationwide company, to
ensure that all employees have
access to updated policies,
Accredo policies are maintained
electronically and our employees
are instructed to access all
policies electronically.
Moving forward, to prevent a
recurrence of this issue, Accredo
has provided additional training to
all employees assigned to the
Indiana HHA regarding accessing
the current version of all Accredo
policies electronically and specific
training regarding the same will
be provided to all new nurses
assigned to the Indiana HHA in
the future. The Indiana HHA
administrator is and will be
responsible to ensure that this
training takes place and the
Indiana HHA nursing supervisor
will also audit the electronic
personnel records of all newly
assigned Indiana HHA nurses two
times a year for compliance with
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 23 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
these proactive training measures
for the next two years.
2., 3., 4. Please see above.
410 IAC 17-12-1(c)(3)
Home health agency
administration/management
Rule 12 410 IAC 17-12-1(c)(3)
Sec. 1(c)(3) The administrator, who may
also be the supervising physician or
registered nurse required by subsection (d),
shall do the following:
(3) Employ qualified personnel and ensure
adequate staff education and evaluations.
N 0446
Bldg. 00
Based on observation, review of
personnel files, and interview, the
administrator failed to employ sufficient
qualified staff to meet the hours of
operations of the agency for 1 of 1
agency and failed to ensure adequate staff
education for 1 of 1 staff nurses
(Employee B) and for 1 of 1 alternate
nursing supervisor (Employee D).
The findings include:
1. Indiana State Department of Health
(ISDH) documents completed with data
provided by the agency state the hours of
N 0446 1., 2., 3. Please see response to
N 444.4.Although the regulations
do not specifically state that
orientation is a required element
of an employee’s hiring process,
Accredo now understands that
this information is requested by
the Indiana Department of Health
during a survey. All employees
complete orientation at the time
of hire. Employee D has been a
nurse with Accredo since 1997.
A copy of Employee D’s resume
was provided as part of the
licensure application. For ease of
reference a copy of Employee D’s
resume is attached as Exhibit H.
Employee B has been a nurse
with Accredo since 2008.
Because these nurses has been
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 24 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
operation of Accredo Health Group, Inc.
at 2825 W. Perimeter Rd, Indianapolis,
IN, are 8:30 AM to 5:00 PM Monday
through Friday.
On December 29, 2014, at 10:30 AM,
the surveyor arrived at the address
provided by the agency at 10:30 AM to
conduct the initial state licensure survey.
No agency employees were present.
2. When Employee E, the administrator,
was reached by phone at 11:35 AM,
Employee E indicated she was in Detroit,
Michigan, on other corporation duties
and would not attend the survey.
Employee E indicated no provision was
made for staff to be at the agency during
hours of operation because the sole
employee of the agency in Indianapolis is
a registered nurse (nursing supervisor)
who provides patient care (Employee A).
She indicated other employees may be
hired in the future but it was not cost
effective to have staff present during
hours of operation at this time.
3. At 1:15 PM, Employee A, the
alternate administrator / nursing
supervisor, arrived at the agency and
stated the agency has no clerical staff,
that she is the only local employee, and
the agency does not have a provision to
staff during hours of operation if
employees of Accredo for years
before being assigned to the
Indiana HHA, there was not a
need to perform another
orientation with respect to their
duties relating to patient care. All
newly hired employees will
continue to complete the existing
orientation process. In addition to
the existing process, in an effort
to address any Indiana specific
concerns, Accredo will add a
specific segment to orientation for
any employee’s that are assigned
to the Indiana HHA that directly
pertains to Indiana’s home health
regulations. New employee’s
completion of orientation will be
documented and that
documentation will be placed in
the nurse’s electronic personnel
file. The Indiana HHA
administrator is and will be
responsible to ensure that this
training take place in the future
and the Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
newly assigned Indiana HHA
nurses two times a year for
compliance with these proactive
training measures for the next
two years.5. Please see response
to N 444.6. Employee D has
acknowledged this error and this
error was not intentional.
Employee D is the alternate
nursing supervisor. Employee D
is not the alternate administrator.
Verbal coaching was provided to
Employee D to reinforce the
importance of accurate
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 25 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
Employee A is out of the office to see
patients or for any other reason. On
1-2-15 at 10:00 AM, Employee A
indicated she is in the office on average
20 hours a week.
4. The personnel records of Employee B
(direct care staff nurse), and Employee D
(alternate nursing supervisor) failed to
evidence documentation of any
orientation to their respective positions
with the agency.
5. On 12-30-14 at 4:00 PM, Employee D
verified the above findings regarding
Employee B and herself, Employee D.
6. On 1-2-15 at 11:30 AM, Employee D,
the alternate nursing supervisor, provided
a hand written list of agency employees
in which she identified herself as
alternate administrator of the agency and
at 4:35 PM Employee D signed the exit
conference attendance record and
identified her position as alternate
administrator.
communication regarding her
title.
Based on review of Indiana State
Department of Health (ISDH)
documents, observation, and
interview, the administrator failed
to ensure the accuracy of the
hours of operation and agency
telephone number for 1 of 1
agency.
410 IAC 17-12-1(c)(4)
Home health agency
administration/management
Rule 12 Sec. 1(c)(4) The administrator,
who may also be the supervising physician
or registered nurse required by subsection
N 0447
Bldg. 00
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 26 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
(d), shall do the following:
(4) Ensure the accuracy of public
information materials and activities.
Based on review of Indiana State
Department of Health (ISDH) documents,
observation, and interview, the
administrator failed to ensure the
accuracy of the hours of operation and
agency telephone number for 1 of 1
agency.
The findings include:
1. ISDH documents completed with data
provided by the agency state the hours of
operation of Accredo Health Group, Inc.
are 8:30 AM to 5:00 PM Monday
through Friday and the phone number of
the agency is (888) 289-2978.
2. On December 29, 2014, at 10:30 AM,
the surveyor arrived at the address
provided by the agency at 10:30 AM to
conduct the initial state licensure survey.
No one was present.
3. The building is a secured facility.
Person AA, a security agent at the front
entrance, was not aware a home health
agency was housed in the building. AA
could not reach agency personnel using
the phone number provided (888)
289-2978 and did not have any further
contact information for the administrator,
N 0447 1. With respect to the hours of
operation, please see response to
N 444. The provided phone
number was accurate and was
functioning at the time of the
survey and during the entire time
that Accredo was operating under
the provisional license. However,
as set for the below, at the time of
the survey, call forwarding was
not functioning properly.2., 3.
Please see response to N 04444.
Please see above.
Due to a technical error within the
phone companies system, if the
call was not answered in the
office, routing of the phone to
offsite contacts was not
functioning properly. Accredo is
working with the telephone
company to ensure that this issue
has been corrected and we will
periodically internally test the
system to ensure proper routing
is completed and that the system
is working as intended.
5., 6., 7. Please see response to
N 0444
8. Employee D is the alternate
nursing supervisor for the Indiana
HHA. Due to the limited number
of patients that were on service
with the Indiana HHA, Employee
D was also assigned to the
Accredo Nursing location in
Louisville, Kentucky. The
frequency of her visits to the
Indianapolis HHA would vary
based on administrative needs
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 27 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
alternate administrator, nursing
supervisor, or alternate nursing
supervisor when the surveyor provided
the names to person AA.
4. The surveyor attempted to reach the
agency at (888) 289-2978 at 10:45,
11:00, and 11:15 AM. The number did
not provide for the opportunity to leave a
voice message or be transferred for
assistance. A recorded message stated,
"You have reached the Accredo Indiana
nursing office, if you know your party's
extension, please enter it now, if not,
please hold for the next available team
member." The phone rang for 2 minutes
without anyone answering.
5. An employee of Accredo Health
Group, Inc., the corporation, rather than
Accredo Health Group, the home health
agency, person BB, approached the
surveyor at 11:18 AM and indicated
no-one from the home health agency was
present nor was anyone from the agency
expected. Person BB provided a phone
number for the named agency
administrator, Employee E.
6. When Employee E, the administrator,
was reached by phone at 11:35 AM,
Employee E indicated she was aware the
provisional license of the agency expired
the next day on December 30, 2014, and
and also the scheduling of
Indiana patient visits.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 28 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
the initial licensure survey was due today
or tomorrow, but was in Detroit,
Michigan, on other corporation duties
and would not attend the survey.
Employee E indicated no provision was
made for staff to be at the agency during
hours of operation in general nor for the
anticipated licensure survey due today or
tomorrow. Employee E indicated she had
contacted the alternate administrator /
nursing supervisor, Employee A, and the
alternate nursing supervisor, Employee
D, who would arrive in approximately 90
minutes.
7. At 1:15 PM, Employee A, the
alternate administrator / nursing
supervisor, arrived at the agency and
stated the agency had no clerical staff,
that she is the only local employee, and
the agency does not have a provision to
staff during hours of operation if
Employee A is out of the office to see
patients or for any other reason.
Employee A could not explain how an
incorrect phone number for the agency
was provided to ISDH.
8. At 2:30 PM, Employee D, the
alternate nursing supervisor, arrived from
Louisville and indicated she was a
nursing supervisor for Accredo Health
Group, Inc., the national corporation, in
Louisville, and comes to the Indiana
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 29 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
Accredo Health Group home health
agency about one day a month.
410 IAC 17-12-1(c)(5)
Home health agency
administration/management
Rule 12 Sec. 1(c)(5) The administrator,
who may also be the supervising physician
or registered nurse required by subsection
(d), shall do the following:
(5) Implement a budgeting and accounting
system.
N 0448
Bldg. 00
Based on document review and
interview, the administrator failed to
implement a budgeting and accounting
system for 1 of 1 agency.
The findings include:
1. During the entrance conference on
12-29-14 ending at 2:30 PM,
documentation of the administrator's
N 0448 2.,,3.Please see response to N
441.02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 30 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
implementation of the agency's
accounting and budgeting system was
requested in writing.
2. On 12-31-14 the agency provided a
document, undated, titled "Nursing
Budget: Indianapolis 2014-2015" which
failed to evidence the name or signature
of the administrator, failed to identify the
source, and failed to include an
accounting and budgeting system. The
document listed some figures for salary,
travel, mileage reimbursement, and
miscellaneous expenses totaling
$233,006 and stated, "Accredo has a
dedicated finance team responsible for
monitoring and recording all financials
associated with the nursing operations
within Accredo and specific to
Indianapolis."
3. Employee E, the administrator,
indicated on 12-31-14 at 3:00 PM, during
a telephone interview, Accredo Health
Group, Inc., the national corporation,
does all the budgeting, accounting, and
finance relative to Accredo Health
Group, Inc, the Indiana home health
agency.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 31 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
410 IAC 17-12-1(c)(6)
Home health agency
administration/management
Rule 12 Sec. 1(c)(6) The administrator, who
may also be the supervising physician or
registered nurse required by subsection (d),
shall do the following:
(6) Ensure that the home health agency
meets all rules and regulations for licensure.
N 0449
Bldg. 00
Based on document review, observation,
and interview, the administrator failed to
ensure the agency met the requirements
for licensure for 1 of 1 agency.
The findings include:
1. Indiana State Department of Health
document provided by the agency, dated
11-21-14, signed by the administrator,
Employee E, titled "Statement of
Readiness" included an attestation the
agency was in compliance with 410 IAC
17 and IC 16-27.
2. The administrator failed to ensure the
organization, administrative control, and
lines of authority down to the patient
level and the patient populations served
were clearly identified on the
organizational chart for 1 of 1 home
N 0449 1. At the time of the survey,
Accredo believed it was compliant
with Indiana home health agency
regulations. Prior to seeking a
provisional license, an analysis of
existing policies was conducted to
ensure compliance with State
regulations. Unfortunately due to
employee deficiencies, the
appropriate information was not
communicated to the surveyor.
We have taken steps to remedy
this situation, including extensive
training, and are committed to
operating in compliance with all
home health agency regulations.
Further, as set forth above, to
provide additional direct oversight
of any future ongoing activities, if
permitted to continue operations,
we will appoint a full time
administrator who is located
on-site.2. Please see response to
N 440., 3.Please see response to
N 441.4. Please see response to
N 442. 5. Please see response to
N 444.6. Please see response to
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 32 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
health agency. (See N 440)
3. The administrator failed to ensure
administrative responsibilities were not
delegated / completed to another
organization in relation to the
development of patients' medication
profile in the medical plan of care for 6
of 6 clinical records reviewed, criminal
background checks of its employees for 2
of 2 direct care providers, and budgeting
and accounting systems for 1 of 1 agency.
(See N 441)
4. The administrator failed to ensure
governing body meeting minutes were
provided to evidence the governing body
appointed an administrator and adopted
agency bylaws for 1 of 1 agency. (See N
442)
5. The administrator failed to organize
and direct the home health agency's
ongoing functions to include providing
staff sufficient to cover the hours of
operation, provision for a method of
tracking at the agency level the activity of
the agency in relation to ability to
generate lists of active and discharged
patients and reason for discharge,
provision for orientation of agency staff,
provision to ensure the personnel record
of the nursing supervisor was current and
included a criminal background check,
N 445. 7. Please see response to
N 4468. Please see response to
N 447 9. Please see response to
N 44810. Please see response to
N 450 11.Please see response to
N 447 and response to N 454. 12.
Please see response to N 456
and 472. 13. Please see
response to N 458. 14. Please
see response to N 460.15. Please
see response to N 462. 16.
Please see response to N 466.
17. Please see response to N
468.18. Please see response to N
468.19.Please see response to N
490. 20. Please see response to
N 518. 21. Please see response
to N 522. 22. Please see
response to N 524. 23.Please
see response to N 542. 24.
Please see response to N 544.
25. Please see response to N
608.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 33 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
provision for agency employment / hiring
policies to include the contents of the
personnel record and requirement of a
copy of a criminal background check in
accordance with IC 16-27-2 for direct
care staff, provision for the treatment of
health records of agency direct care staff
health as confidential, and provision for
the administrator's presence at the agency
for any part of the initial licensure survey
conducted the day before expiration of
the agency's provisional license for 1 of 1
agency. (See N 444)
6. The administrator failed to ensure
revised policies were provided to the
agency timely. (See N 445)
7. The administrator failed to employ
sufficient qualified staff to meet the hours
of operations of the agency for 1 of 1
agency and failed to ensure adequate staff
education for 1 of 1 staff nurses and for 1
of 1 alternate nursing supervisor. (See N
446)
8. The administrator failed to ensure the
accuracy of the hours of operation and
agency telephone number for 1 of 1
agency. (See N 447)
9. The administrator failed to implement
a budgeting and accounting system for 1
of 1 agency. (See N 448)
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 34 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
10. The administrator failed to ensure all
information requested was made
available within the requested timeframe
to determine compliance for 1 of 1
agency. (See N 450)
11. The administrator failed to assure the
the administrator or qualified alternate
was on the premises or capable of being
reached immediately by phone, pager, or
other means for 1 of 1 agency. (See N
454)
12. The administrator failed to provide
documentation of the administrator's
responsibility for an ongoing, quality
assurance program for 1 of 1 agency.
(See N 456 and N 472)
13. The administrator failed to ensure
that personnel practices for employees
are supported by written policies to
determine date of hire and a copy of a
criminal background check in accordance
with IC 16-27-2 was in the file of 1 of 1
direct care staff. (See N 458)
14. The administrator failed to ensure the
personnel record of the supervising nurse
included a copy of a a criminal
background check required by IC
16-27-2. (See N 460)
15. The administrator failed to ensure
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 35 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
that all employees providing direct
patient care had a physical examination
by a physician or nurse practitioner of
sufficient scope to ensure the employee
would not spread infectious or
communicable diseases to the patient
within 180 days prior to the date the
employee had direct patient contact for 2
of 2 registered nurses personnel files
reviewed who provided patient care.
(See N 462)
16. The administrator failed to ensure
employee health records were maintained
and treated as confidential medical
records for 5 of 5 personnel files
reviewed. (See N 466)
17. The administrator failed to make
available, after request, policies related
to personnel practices of the agency for 1
of 1 agency. (See N 468)
18. The administrator failed to make
available, after request, policies related
to personnel practices of the agency for 1
of 1 agency. (See N 488).
19. The administrator failed to develop
and implement a policy requiring the
agency to continue, in good faith, during
the 5 day period after notice of discharge
was provided to the patient or patient's
legal representative for 1 of 1 agency.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 36 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
(See N 490)
20. The administrator failed to ensure its
patients were informed and provided
written information in advance of care
regarding advance directives including a
description of applicable state law for 1
of 2 records reviewed of patients
receiving home visits. (See N 518)
21. The administrator failed to ensure
complete vital signs were obtained to
include temperature for 1 of 1 patients
receiving a home visit whose plan of care
included taking of temperature. (See N
522)
22. The administrator failed to ensure the
medical plan of care was developed in
consultation with the home health agency
staff to include an accurate, complete,
and correct medication orders prior to
sending the medical plan of care to the
attending physician for authorization in 2
of 6 clinical records reviewed. (See N
524)
23. The administrator failed to ensure the
registered nurse made a necessary
revision to the patient's plan of care
regarding a resolution of an incorrectly
reported medication allergy when the
physician notified the nurse the patient
was not allergic to the medication for 1 of
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 37 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
1 clinical record reviewed with an
incorrect allergy reported. (See N 542)
24. The administrator failed to ensure the
registered nurse prepared a clinical note
to resolve a reported medication allergy
in the patients plan of care when the
physician notified the nurse the patient
was not allergic to the medication for 1 of
1 clinical record reviewed with an
incorrect allergy reported. (See N 544)
25. The administrator failed to ensure its
clinical record was maintained in
accordance with accepted professional
standards to include documents
containing the agency's identification and
consent forms stored within the patient's
electronic clinical record that clearly
identify the agency as the provider of
nursing services for 10 of 10 clinical
records reviewed for patient consent
documentation in the clinical record.
(See N 608)
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 38 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
410 IAC 17-12-1(c)(7)
Home health agency
administration/management
Rule 12 Sec. 1(c)(7) The administrator, who
may also be the supervising physician or
registered nurse required by subsection (d)
of this rule, shall do the following:
(7) Upon request, make available to the
Commissioner or his or her designated
agent all:
(A) reports;
(B) records;
(C) minutes;
(D) documentation;
(E) information; and
(F) files;
required to determine compliance within
seventy-two (72) hours of the request or, in
the event the request is made in conjunction
with a survey, by the time the surveyor exits
the home health agency, whichever is
sooner.
N 0450
Bldg. 00
Based on observation and interview, the
administrator failed to ensure all
information requested was made
available within the requested timeframe
N 0450 1.Accredo maintains policies
relating to the above and the
following polices/practice
standards were provided to the
surveyor at the time of the survey:
· Policy 4-7 - Personal Protective
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 39 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
to determine compliance for 1 of 1
agency.
The findings include:
1. On 12-29-14, at 2:30 PM, a written
request was made to include providing a
copy of agency policies for administering
of TB [tuberculin skin test] and related
policies, universal precautions,
communicable disease, governing body
meeting dates and minutes of governing
body meetings, appointment of the
administrator by the governing body, and
quality and performance improvement
program / policies / procedures.
2. On 12-31-14, at 4:00 PM, a verbal
request was made for any policies
regarding hiring, employment, health and
personnel records, criminal background
checks, orientation, competencies, job
descriptions for the administrator,
alternate administrator, nursing
supervisor, alternate nursing supervisor,
agency definition of what comprises the
patients' electronic clinical record, and
the policies in #1 above.
3. On 1-2-15 at 4:00 PM, a request for
any further documentation demonstrating
compliance was made to the nursing
supervisor / alternate administrator,
Employee A, and the alternate nursing
Equipment, attached as Exhibit I;
· Policy 4-5 - Standard
Precautions and Bag Technique,
attached as Exhibit J; · Job Aid -
Fall Program, attached as Exhibit
K; · Practice Standard 27.01.16
- Infection Control Plan, attached
as Exhibit L; · Practice Standard
28.01.06 - Governing Body of
Accredo owned Home Health
Agencies, attached as Exhibit F;
and · Practice Standard
28.01.12 - Immunization
Requirement for Home Health ,
attached as Exhibit M; In
addition, the following
polices/practice standards should
have also been provided: ·
Policy 4-3 - Surveillance,
Analysis, and Prevention of
Infection, attached as Exhibit N; ·
Policy 4-4 - Bloodborne
Pathogens and Control of
Tuberculosis, attached as Exhibit
O; · Policy 4-6 - Hand Hygiene,
attached as Exhibit P; · Policy
4-10 - Communicable Disease,
attached as Exhibit Q; · Policy
4-11 - Tuberculosis Control,
attached as Exhibit R; · Policy
4-13 – Hepatitis B Vaccine
Provision, attached as Exhibit S;
· Policy 4-16 - Health Clearance,
attached as Exhibit T; and ·
Practice Standard 28.01.03 –
Hand Hygiene, attached as
Exhibit U; With respect to
requests for information relating
to the Governing Body, please
see response to N 442. With
respect to information pertaining
to quality improvement, please
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 40 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
supervisor, Employee D. Nothing was
provided. The exit conference was
conducted 1-2-15 at 4:35 PM, at which
time the above policies and requests had
not been made available for
determination of compliance with IC
16-27 and 410 IAC 17. During the exit
conference, Employee E, the
administrator, stated some of the
requested documentation had been
emailed to the Employee A 2 days ago.
The following documentation was then
accessed by Employee A: a list of names
and addresses of members of the
governing body, a revised discharge
policy (which did not meet licensing
requirements), an acknowledgment of
receipt of nursing supervisor job
description for Employee A, the nurse
supervisor / alternate administrator. No
further documentation was provided
demonstrating compliance.
see response to N 456. In
addition, as indicated above,
Accredo will provide additional
training regarding accessing the
current electronic copies of
Accredo policies and practice
standards. 2.In addition to the
above listed policies/practice
standards in response to N 450 #
1, Accredo maintains policies
relating to the above and the
following polices/practice
standards were provided to the
surveyor at the time of the survey:
· Policy - Plan of Treatment,
attached as Exhibit V; · Job Aid -
HR Onboarding, attached as
Exhibit W; and · Practice
Standard 27.06.02 - Medication
Profile, attached as Exhibit X;
The following policies also
existed at the time of the survey
and should have been provided to
the surveyor to evidence
compliance with Indiana
regulations: · Policy 9-1 – Clinical
Records, attached as Exhibit Y; ·
Policy 9-2 – Clinical Record
Contents, attached as Exhibit Z; ·
Policy 9-5 – Transfer of Patient
Records, attached as Exhibit AA;
· Policy 10-3 – Personnel Record
Maintenance, attached as Exhibit
BB; · Practice Standard 27.01.17
– Employee Safety in Home
Environment, attached as Exhibit
CC; · Practice Standard 27.01.19
– Adverse Drug Experience and
Patient Complaint, attached as
Exhibit DD; · Practice Standard
27.01.21 – Medication Delivery by
Company Nurse, attached as
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 41 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
Exhibit EE; · Practice Standard
27.01.26 – Patient Consent for
Services, attached as Exhibit FF;
· Practice Standard 28.01.01 –
Advanced Directives, attached as
Exhibit GG; For additional policies
that also existed at the time of the
survey and that should have been
provided to the surveyor to
evidence compliance with Indiana
regulations, please see those
additional policies identified in this
response. With respect to job
descriptions, since the survey, an
audit of the employee’s personnel
files has been performed and we
have ensured that a document
acknowledging receipt of the
employee’s job description is
contained within each employee’s
electronic personnel file. The
Indiana HHA administrator is and
will be responsible to ensure that
this documentation is maintained
in newly assigned employee’s
personnel files and the Indiana
HHA nursing supervisor will also
audit the electronic personnel
records of all newly assigned
Indiana HHA nurses two times a
year for the next two years for
compliance.3. Accredo
recognizes and apologizes for the
fact that the surveyor was
provided, at times, inaccurate and
insufficient information such that
it could be accurately
demonstrated that Accredo was
operating in compliance with
Indiana regulations.
For additional training and
documentation that Accredo has
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 42 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
completed and/or will be
implementing, please see the
entirety of this response. With
respect to the assignment of a full
time on-site administrator, please
see response to N 444.
Further, in addition to the above
listed policies/practice standards
in response to N 450 # 1 and # 2,
Accredo provided the following to
the surveyor at the time of the
survey:
· Job Aid - Discharge from
Nursing, attached as Exhibit HH;
· Practice Standard 01.03.16
- Quality Meetings, attached as
Exhibit II; and
· Practice Standard 27.06.03
- Patient Inactivation/Discharge,
attached as Exhibit G;
For additional policies that also
existed at the time of the survey
and that should have been
provided to the surveyor to
evidence compliance with Indiana
regulations, please see those
additional policies identified in this
response.
410 IAC 17-12-1(d)
Home health agency
administration/management
Rule 12 Sec. 1(d) The person or similarly
qualified alternate shall be on the premises
or capable of being reached immediately by
phone, pager or other means. In addition,
the person must be able to:
(1) respond to an emergency;
N 0454
Bldg. 00
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 43 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
(2) provide guidance to staff;
(3) answer questions; and
(4) resolve issues;
within a reasonable amount of time, given
the emergency or issue that has been
raised.
Based on observation and interview, the
administrator failed to assure the the
administrator or qualified alternate was
on the premises or capable of being
reached immediately by phone, pager, or
other means for 1 of 1 agency.
Findings include:
1. Indiana State Department of Health
(ISDH) documents state the hours of
operation of Accredo Health Group, Inc.
are 8:30 AM to 5:00 PM Monday
through Friday and the phone number of
the agency is (888) 289-2978.
2. On 12- 29- 2014 at 10:30 AM, the
surveyor arrived at the address provided
by the agency to conduct the agency's
initial state licensure survey.
3. The building is a secured facility.
Person AA, a security agent at the front
entrance, was not aware a home health
agency was housed in the building.
Person AA could not reach agency
personnel using the phone number
provided (888) 289-2978 and did not
N 0454 1,2,3,4,5,7 Please see response
to N 444.02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 44 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
have any further contact information for
the administrator, alternate administrator,
nursing supervisor, or alternate nursing
supervisor when the surveyor provided
the names to person AA.
4. The surveyor attempted to reach the
agency at (888) 289-2978 at 10:45,
11:00, and 11:15 AM. The number did
not provide for the opportunity to leave a
voice message or be transferred for
assistance. A recorded message stated,
"You have reached the Accredo Indiana
nursing office. If you know your party's
extension, please enter it now. If not,
please hold for the next available team
member." The phone rang for 2 minutes
without anyone answering.
5. An employee of Accredo Health
Group, Inc., the corporation, rather than
Accredo Health Group, the home health
agency, person BB, approached the
surveyor at 11:18 AM and indicated no
one from the home health agency was
present nor was anyone from the agency
expected. Person BB provided a phone
number for the named agency
administrator, Employee E.
6. At 11:35 AM, Employee E, the
administrator, was reached by phone at a
number not provided to the Indiana State
Department of Health, over one hour
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 45 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
after arrival at the agency during hours of
operation.
7. At 1:15 PM, Employee A, the
alternate administrator / nursing
supervisor, arrived at the agency 2 3/4
hours after the surveyor arrived during
the agency hours of operation, and stated
the agency has no clerical staff, that she
is the only local employee, and the
agency does not have a provision to staff
during hours of operation if Employee A
is out of the office to see patients or for
any other reason, and the correct phone
number of agency was provided.
410 IAC 17-12-1(e)
Home health agency
administration/management
Rule 12 Sec. 1(e) The administrator shall
be responsible for an ongoing quality
assurance program designed to do the
following:
(1) Objectively and systematically monitor
and evaluate the quality and
appropriateness of patient care.
N 0456
Bldg. 00
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 46 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
(2) Resolve identified problems.
(3) Improve patient care.
Based on interview and review of
Accredo Health Group national
corporation documents, the administrator
failed to provide documentation of the
administrator's responsibility for an
ongoing, quality assurance program for 1
of 1 agency.
Findings include:
1. During the entrance conference on
12-29-14 ending at 2:30 PM,
documentation of the administrator's
implementation of the agency's quality
assurance and performance improvement
plan, policies, and procedures was
requested in writing.
2. On 12-31-14 at 3:00 PM, Employee
E, the administrator, indicated during
phone interview the agency will follow
Accredo Health Group, Inc., the national
corporation's, quality assurance and
performance improvement program,
policies, and procedures. She indicated
no data had yet been collected from
agency clinical record audits or other
sources because the agency has had so
few patients and that she had not not set
any agency specific monitors, standards,
or goals for quality assurance.
N 0456 1. A quality assurance and
performance improvement plan
was implemented at the Indiana
HHA and in place at the time of
the survey. During the survey,
Employee D, the alternate
nursing supervisor, explained the
tools that captured information
related to quality assurance and
performance improvement
program. At the time of the
survey, the surveyor requested
specific results for the Indiana
HHA. However, at that time, the
Indiana location had only seen
patients for approximately 90
days and Accredo’s program
reviews data on a quarterly
basis. As that period of time had
not passed, we informed the
surveyor that results were not
available and that the data would
be evaluated in January (after the
end of the calendar quarter) for
quality assurance and
performance improvement
review. As an example of the
manner in which the data is
presented to the governing body
for all Accredo HHAs, the
surveyor was shown Power Point
presentation slides containing
excerpts of this type of
information. A copy of those
Power Point slides is attached as
Exhibit JJ. In addition, Accredo
has polices relating to quality
assurance and performance
improvement plans. The
following policies are attached: ·
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 47 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
3. On 12-30-14, a print out of power
point slides from 12-17-14 titled "Annual
Governing Body Meeting" was presented
which included slides with data from
Accredo Health Group, Inc., the national
corporation's, fall prevention program,
central venous line infection rates, hand
sanitizer utilization, and influenza
vaccination rate which, according to
Employee A, contained 2013 and 2014
aggregated data from all corporate owned
Accredo Health Group home health
agencies (approximately 33 nationally).
There was no information directly related
to this home health agency.
4. Accredo Health Group corporate
policy # 21-01-06, created 7-3-13 revised
12-29-14, states under the heading of
Governing Body Bylaws, "The
Governing Body will engage in the
following collaborative activities on
behalf of the Corporation for all Accredo
owned licensed home health agencies ...
8. Bears overall responsibility for the
quality of patient care, organizational
systems and processes, to include
granting authority to the local licensed
HHA [home health agency] administrator
for leadership and coordination of the
development, planning, implementation,
and evaluation of the quality management
activities."
Practice Standard 01.03.16,
Quality Meetings, attached as
Exhibit II; and · Practice
Standard 27.01.16, Infection
Control Plan, attached as Exhibit
L 2,3. Please see above4. For
clarification, the policy number
referenced in the above
paragraph should be listed as
Practice Standard 28-01-06. In
addition, please see above.5.
Please see above.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 48 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
5. No further documentation
demonstrating compliance with the
quality assurance requirement was
presented prior to exit.
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 personnel file review and
interview, the agency failed to ensure that
personnel practices for employees are
supported by written policies to
determine date of hire and a copy of a
criminal background check in accordance
with IC 16-27-2 was in the file of 1 of 1
direct care staff (Employee B).
N 0458 1.Employee personnel records
are maintained electronically by
the individual HHA location. All
employee records required to be
maintained by Indiana regulation
will be stored in the electronic file
that is maintained by the Indiana
HHA.
The Indiana HHA administrator is
and will be responsible to ensure
that all employee records
required to be maintained by
Indiana regulation are stored in
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 49 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
The findings include:
1. During entrance conference on
12-29-14, beginning at 1:30 PM,
Employee A indicated the agency's
personnel records were stored
electronically in a program called "Work
Place."
2. The personnel file of Employee B, no
determinable hire date with this agency,
date of first patient contact of 11-21-14
for patient #6, failed to evidence an
expanded criminal background check in
accordance with IC 16-27-2 which was
required because the employee resides in
Kentucky.
4. On 12-30-14 at 4:00 PM, all policies
related to hiring practices, employment
requirements, orientation, provision of
job descriptions, content of personnel
records, requirement for the agency to
obtain and maintain in the personnel file
of direct care staff a copy of the
employees' criminal background check
from the Indiana State Police Repository
in accordance with IC 16-27-2, agency
method of determining date of hire and
health requirements including
tuberculosis screening for direct care staff
who have become, or will become,
employees of this agency while
the electronic file that is
maintained by the Indiana HHA
and the Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
assigned Indiana HHA nurses two
times a year for compliance.
2. Please see response to N 441,
N 444 and N 450.
4., 5. Please see response to N
441 and N 450.
6. Unfortunately, Employee A
provided incorrect information to
the surveyor. The administrator
has access to all HHA
employees’ personnel files and
this information should have been
promptly provided to the surveyor.
In addition, please see response
to N 441 and N 450.
7. Please see response to N 446
and N 447.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 50 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
simultaneously employed by another
state's Accredo Health Group, Inc. home
health agency, were requested but not
provided prior to exit.
5. On 1-2-15 at 2:00 PM, Employee D,
the alternate director of nursing, verified
the findings in the personnel records
reviewed and indicated the agency uses
Accredo Health Group, Inc., the national
corporation, employment policies which
are in an "Onboarding" policy under the
control of human resources from Accredo
Health Group, Inc, the corporation. This
policy was requested but not provided
prior to exit. Employee D brought paper
personnel documents (stored in
Louisville at a different Accredo Health
Group facility) after the initial licensure
survey had begun (Employees B, C, D)
but which she conceded were not part of
the agency's personnel files.
6. On 1-2-15 at 2:00 PM, Employee A,
the alternate administrator / nursing
supervisor, provided a memo from
Express Scripts, dated 12-31-14, that
stated, "All your active employees" had
been screened through 11-2014 and "no
[criminal] charges were located."
Employee A indicated the agency does
not have access to nor may the agency
obtain copies of the criminal history
background checks of agency employees
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 51 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
because this function is the exclusive
domain of human resources of Accredo
Health Group, Inc., the national
corporation, a subsidiary of Express
Scripts.
7. On 12-31-14 at 2:05 PM, Employee E,
the administrator, indicated the date of
hire for Employee B, which was not in
Employee B's personnel file, should be
5-2-14, but was unable to provide a
policy or basis for determining the hire
date stated. She indicated Employee B
was an infusion nurse employed by
Accredo Health Group, Inc., in Kentucky.
Employee E had provided patient care for
the agency patient #6 on 11/21/14.
410 IAC 17-12-1(g)
Home health agency
administration/management
Rule 12 Sec. 1(g) As follows, personnel
records of the supervising nurse, appointed
under subsection (d) of this rule, shall:
(1) Be kept current.
(2) Include a copy of the following:
(A) Limited criminal history pursuant to IC
16-27-2.
(B) Nursing license.
(C) Annual performance evaluations.
(D) Documentation of orientation to the job.
Performance evaluations required by this
subsection must be performed every nine
N 0460
Bldg. 00
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 52 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
(9) to fifteen (15) months of active
employment.
Based on review of the personnel file and
interview, the agency failed to ensure the
personnel record of the supervising nurse
included a copy of a a criminal
background check required by IC 16-27-2
(Employee A).
Findings include:
1. The personnel file for the nursing
supervisor / alternate administrator,
Employee A, hire date 5-5-14, failed to
evidence a copy of a criminal background
check from the Indiana State Police
Repository as required by IC 16-27-2
within 3 days of provision of services.
2. On 12-30-14 at 4:00 PM, the alternate
nursing supervisor, Employee D,
confirmed the above findings and
indicated the alternate administrator /
nursing supervisor's personnel file was
not current. Employee D indicated the
agency stores its personnel records in an
electronic format in a program called
"Work Place." The agency follows the
human resources policies of Accredo
Health Group, Inc., the corporation, titled
"Onboarding." A copy of this policy was
requested but was not provided prior to
exit.
N 0460 1., 2., 3. Please see response to
N 441, N 444 and N 450.02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 53 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
3. On 1-2-15 at 2:00 PM, Employee A,
the alternate administrator / nursing
supervisor, provided a memo from
Express Scripts, dated 12-31-14, that
stated, "All your active employees" had
been screened through 11-2014 and "no
[criminal] charges were located."
Employee A indicated the agency does
not have access to the criminal history
background checks of agency employees
because this function is the exclusive
domain of human resources of Accredo
Health Group, Inc., the national
corporation, a subsidiary of Express
Scripts.
410 IAC 17-12-1(h)
Home health agency
administration/management
Rule 12 Sec. 1(h) Each employee who will
have direct patient contact shall have a
physical examination by a physician or nurse
practitioner no more than one hundred
eighty (180) days before the date that the
employee has direct patient contact. The
physical examination shall be of sufficient
scope to ensure that the employee will not
spread infectious or communicable diseases
to patients.
N 0462
Bldg. 00
Based on personnel file review and
interview, the administrator failed to
N 0462 1. At the time of the survey,
Accredo believed it was compliant
with the applicable regulation.
The electronic personnel files for
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 54 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
ensure that all employees providing direct
patient care had a physical examination
by a physician or nurse practitioner of
sufficient scope to ensure the employee
would not spread infectious or
communicable diseases to the patient
within 180 days prior to the date the
employee had direct patient contact for 2
of 2 registered nurses personnel files
reviewed who provided patient care
(Employees A and B).
The findings include:
1. The personnel file for the nursing
supervisor / alternate administrator,
Employee A, hire date 5-5-14, failed to
evidence documentation of a physical
examination within 180 days prior to
patient care. A copy of a prescription pad
with Employee A's name on it, included
notations dated 4-23-14 that stated,
"Patient is clear and free of any current
communicable diseases. She has no
restrictions at this time." The
prescription pad notation failed to
indicate the date and scope of any
physical examination that was the basis
of this determination, the form was
written and signed by a medical assistant
and co-signed, signature illegible, by a
person Employee A indicated was her
primary care physician.
each nurse contained dated
documentation signed by a
physician that stated the nurse
was free of communicable
diseases.
We now understand that the
State prefers additional detail and
will have all our currently
assigned employees and any
newly assigned employees obtain
documentation that also indicates
a physical examination was
performed by the physician to
arrive at the determination that
the employee is free of
communicable diseases.
The Indiana HHA administrator is
and will be responsible to ensure
that this documentation is placed
in the employee’s electronic
personnel file and the Indiana
HHA nursing supervisor will also
audit the electronic personnel
records of all newly assigned
Indiana HHA nurses two times a
year for the next two years for
compliance.
2. At the time of the survey,
Accredo believed they it was
compliant with the applicable
regulation. The electronic
personnel files for each nurse
contained dated documentation
signed by a physician that stated
the nurse was free of
communicable diseases.
In addition, please see above.
3. Please see above.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 55 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
2. The personnel file for staff nurse,
Employee B, date of hire not determined,
failed to evidence documentation of a
physical examination by a physician or
nurse practitioner of sufficient scope to
ensure the employee would not spread
infectious or communicable diseases
within 180 days prior to services
provided to patient #6 on 11-21-14.
3. On 12-30-14 at 4:00 PM, Employee A
verified the above findings.
410 IAC 17-12-1(j)
Home health agency
administration/management
Rule 12 Sec. 1(j) The information obtained
from the:
(1) physical examinations required by
subsection (h); and
(2) tuberculosis evaluations and clinical
follow-ups required by subsection (i)
must be maintained in separate medical files
and treated as confidential medical records,
N 0466
Bldg. 00
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 56 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
except as provided in subsection (k).
Based on observation, personnel record
review, and interview, the agency failed
to ensure employee health records were
maintained and treated as confidential
medical records for 5 of 5 personnel files
reviewed (Employees A, B, C, D, and E).
The findings include:
1. During review of personnel files on
12-30-14 with Employee D, the
electronic health records of all 5
identified agency employees (Employees
A, B, C, D, and E) were observed to be
scanned into a separate folder but were
not marked as confidential.
2. The electronic file of Employee E
contained a health record for Person CC
dated 8-9-13. Person CC was not listed
on the agency employee roster.
3. On 12-30-14 at 4:00 PM, Employee D
indicated Person CC was not an agency
employee, Person CC's health form
should not have been in Employee E's
electronic personnel file, and the agency's
personnel files were not treated as
confidential in that Accredo Health
Group, Inc, the corporation. Employees
with a log in for "Work Group" could
access personnel files to include
N 0466 1.Accredo employee health
records are maintained
confidentially and in compliance
with applicable HIPAA
regulations. Health files are
maintained electronically and
some information is also
maintained (in duplicate) in hard
copy form.
Access to the health record
portion of the employee’s
electronic folders is limited to the
appropriate administrator,
alternate administrator and
nursing supervisor(s) of the
Accredo HHA.
With respect to the information
that is maintained in hard copy,
that information is kept in a
locked filing cabinet with limited
key access.
2. Person CC is an employee of
Accredo, but not assigned to the
Indianapolis Accredo HHA.
Accredo acknowledged that this
record should not have been in
the electronic personnel files for
the Indianapolis Accredo HHA
employees during the survey.
This document was inadvertently
scanned into the incorrect
electronic personnel record. This
was a human error and the
document has been removed
from the incorrect personnel file
and filed in the correct personnel
file.
3. Please see above.
4. Please see above.
4. Accredo has a policy pertaining
to the confidential nature of
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 57 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
confidential health records. Employee D
stated it was corporate policy to obtain
health information including a physical
exam for all employees.
4. On 1-2-15 at the exit conference at
4:35 PM, Employee E, who participated
by telephone conference, indicated nurse
managers of Accredo Health Group, the
corporation, other than Employee E, the
administrator, could access agency
employees' personnel records to include
confidential health records.
4. After request, policies or evidence of
security measures demonstrating
compliance with the confidential
treatment of the agency personnel's health
records, which were stored in a corporate
computer program, were not provided.
employee’s personnel files and
this policy should have been
made available to the surveyor. A
copy of Policy 10-3 - Personnel
Record Maintenance, is attached
as Exhibit BB. This policy should
have been provided to the
surveyor.
410 IAC 17-12-1(k) and (l)
Home health agency
administration/management
Rule 12 Sec. 1(k) The following records
shall be made available, on request, to the
department for review:
(1) Personnel records and policies that
document the home health agency's
compliance with subsection (f).
(2) Records of physical examinations that
document the agency's compliance with
subsection (h).
(3) Records of the following:
N 0468
Bldg. 00
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 58 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
(A) Tuberculosis evaluations.
(B) Appropriate clinical follow-up for positive
findings.
(C) Any other records that document the
home health agency's compliance with
subsection (i).
(l) The department shall:
(1) treat the information described in
subsection (k) as confidential medical
records; and
(2) use it only for the purposes for which it
was obtained.
Based on observation and interview, the
agency failed to make available, after
request, policies related to personnel
practices of the agency for 1 of 1 agency.
The findings include:
1. On 12-29-14 at 2:30 PM, a written
request was made to provide a copy of
agency policies for administration of TB
[tuberculin skin test] and related policies,
universal precautions, and communicable
disease.
2. On 12-31-14 at 4:00 PM, a verbal
request was made for any policies
regarding hiring procedures, employment
policies, policies concerning health and
personnel records, as well as the policies
in #1 above.
3. On 1-2-15 at 4:00 PM, a request for
N 0468 1., 2., 3. Please see response to
N 450.02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 59 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
any further documentation demonstrating
compliance was made to the nursing
supervisor / alternate administrator,
Employee A, and the alternate nursing
supervisor, Employee D. Employee D
indicated a corporation policy
"Onboarding" addressed the employment
/ hiring practices of Accredo Health
Group, the corporation, but, after request,
this policy was not provided. The exit
conference was conducted 1-2-15 at 4:35
PM, at which time the above policies and
requests had not been made available for
determination of compliance with IC
16-27 and 410 IAC 17. During the exit
conference, Employee E, the
administrator, who participated by
telephone conference, stated some of the
requested documentation had been
emailed 2 days ago to Employee A. The
documents presented included a copy of
Employee A's acknowledgement of
receipt of a job description, but the
agency failed to produce the job
description for review. No further
documentation was provided
demonstrating compliance.
410 IAC 17-12-2(a)
Q A and performance improvement
Rule 12 Sec. 2(a) The home health agency
must develop, implement, maintain, and
evaluate a quality assessment and
performance improvement program. The
N 0472
Bldg. 00
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 60 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
program must reflect the complexity of the
home health organization and services
(including those services provided directly or
under arrangement). The home health
agency must take actions that result in
improvements in the home health agency's
performance across the spectrum of care.
The home health agency's quality
assessment and performance improvement
program must use objective measures.
Based on interview and review of
Accredo Health Group national
corporation documents, the administrator
failed to provide documentation of the
administrator's responsibility for an
ongoing, quality assurance program for 1
of 1 agency.
Findings include:
1. During the entrance conference on
12-29-14 ending at 2:30 PM,
documentation of the administrator's
implementation of the agency's quality
assurance and performance improvement
plan, policies, and procedures was
requested in writing.
2. On 12-31-14 at 3:00 PM, Employee
E, the administrator, indicated during
phone interview the agency will follow
Accredo Health Group, Inc., the national
corporation's, quality assurance and
performance improvement program,
policies, and procedures. She indicated
N 0472 1., 2., 3. Please see response to
N 4564. For clarification, the
policy number referenced in the
above paragraph should be listed
as 28-01-06.
Please see response to N 456.
5. Please see response to N 456.
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 61 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
no data had yet been collected from
agency clinical record audits or other
sources because the agency has had so
few patients and that she had not not set
any agency specific monitors, standards,
or goals for quality assurance.
3. On 12-30-14, a print out of power
point slides from 12-17-14 titled "Annual
Governing Body Meeting" was presented
which included slides with data from
Accredo Health Group, Inc., the national
corporation's, fall prevention program,
central venous line infection rates, hand
sanitizer utilization, and influenza
vaccination rate which, according to
Employee A, contained 2013 and 2014
aggregated data from all corporate owned
Accredo Health Group home health
agencies (approximately 33 nationally).
There was no information directly related
to this home health agency.
4. Accredo Health Group corporate
policy # 21-01-06, created 7-3-13 revised
12-29-14, states under the heading of
Governing Body Bylaws, "The
Governing Body will engage in the
following collaborative activities on
behalf of the Corporation for all Accredo
owned licensed home health agencies ...
8. Bears overall responsibility for the
quality of patient care, organizational
systems and processes, to include
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 62 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
granting authority to the local licensed
HHA [home health agency] administrator
for leadership and coordination of the
development, planning, implementation,
and evaluation of the quality management
activities."
5. No further documentation
demonstrating compliance with the
quality assurance requirement was
presented prior to exit.
410 IAC 17-12-2(i) and (j)
Q A and performance improvement
Rule 12 Sec. 2(i) A home health agency
must develop and implement a policy
requiring a notice of discharge of service to
the patient, the patient's legal representative,
or other individual responsible for the
patient's care at least five (5) calendar days
before the services are stopped.
(j) The five (5) day period described in
subsection (i) of this rule does not apply in
the following circumstances:
(1) The health, safety, and/or welfare of the
N 0488
Bldg. 00
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 63 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
home health agency's employees would be
at immediate and significant risk if the home
health agency continued to provide services
to the patient.
(2) The patient refuses the home health
agency's services.
(3) The patient's services are no longer
reimbursable based on applicable
reimbursement requirements and the home
health agency informs the patient of
community resources to assist the patient
following discharge; or
(4) The patient no longer meets applicable
regulatory criteria, such as lack of
physician's order, and the home health
agency informs the patient of community
resources to assist the patient following
discharge.
Based on policy review and interview,
the agency failed to develop and
implement a policy requiring 5 days
notice of discharge of service to the
patient or patient's legal representative
for 1 of 1 agency.
The findings include:
1. On 12-29-14 at 2:30 PM, a written
request was made for a copy of the
agency discharge policy.
2. On 12-30-14, Employee D provided a
copy of a policy #27-06.03 "Patient
Inactivation / Discharge" last revised
5-22-12 and indicated the policy did not
require 5 days of notice to the patient or
N 0488 1. Please see response to N 445.
In addition, during the survey,
Employee A explained Accredo’s
discharge process and explained
that patients who will be
discharged from nursing services
are provided a minimum of a 5
day notice prior to discharge.
Accredo has identified that
although it is providing the 5 day
minimum notice in compliance
with Indiana regulations, that this
practice is not explicitly set forth
in the Practice Standard
referenced below (Practice
Standard 27.06.03). As a result,
Accredo has developed an
addendum to the above
referenced Practice Standard that
applies to Indiana patients to
address the Indiana regulation. A
copy of that addendum is
attached as Exhibit KK.2., 3., 4.
Please see above and also see
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 64 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
patient's representative prior to discharge.
3. During the exit conference on 1-2-15
beginning at 4:35 PM, Employee E, the
administrator, who participated by
telephone conference, indicated a revised
policy meeting the requirement had been
emailed to the alternate administrator 2
days ago. Employee A indicated she was
not aware the policy had been revised and
sent to her, but she had requested changes
in the policy to bring the agency into
compliance.
4. Review of policy #27-06.03 "Patient
Inactivation / Discharge", revised on
10-16-14, and received by Employee A,
the alternate administrator, on 1-2-15,
failed to provide for 5 days notice of
discharge "Home infusion patients are to
receive a copy of of the patient
medication profile. This information
should be provided to the patient within 5
business days, but no greater than 30
business days, of discharge from all
clinical services ... "
5. During interview with Employee A on
12-29-14 at 2:15 PM, Employee A
indicated the agency has patients with
infusion therapy on their plans of care,
but also serves patients with oral or
inhalation therapy medical plans of care
and that providing a medication profile is
response to N 445.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 65 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
not the same as providing notice of
discharge.
410 IAC 17-12-2(k)
Q A and performance improvement
Rule 12 Sec. 2(k) A home health agency
must continue, in good faith, to attempt to
provide services during the five (5) day
period described in subsection (i) of this
rule. If the home health agency cannot
provide such services during that period, its
continuing attempts to provide the services
must be documented.
N 0490
Bldg. 00
Based on policy review and interview,
the agency failed to develop and
implement a policy requiring the agency
to continue, in good faith, during the 5
day period after notice of discharge was
provided to the patient or patient's legal
representative for 1 of 1 agency.
The findings include:
1. On 12-29-14, at 2:30 PM, a written
N 0490 1.,2.,3.,4. Please see response to
N 445 and N 488.02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 66 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
request was made to provide a copy of
the agency discharge policy.
2. On 12-30-14, Employee D provided a
copy of a policy #27-06.03 "Patient
Inactivation / Discharge" last revised
5-22-12, failed to require the agency to
continue, in good faith, during the 5 day
period after notice of discharge was
provided to the patient or patient's legal
representative, to continue to provide
services, and if the agency cannot provide
services, requiring the agency to
document its attempts to provide
services.
3. During the exit conference on 1-2-15,
beginning at 4:35 PM, Employee E, the
administrator, who participated by
telephone conference, indicated a revised
policy meeting the requirement had been
emailed to the alternate administrator 2
days ago. Employee A indicated she was
not aware the policy had been revised and
sent to her, but she had requested changes
in the policy to bring the agency into
compliance.
4. Review of policy #27-06.03 "Patient
Inactivation / Discharge", revised on
10-16-14, and received by Employee A,
the alternate administrator, on 1-2-15,
failed to require the agency to continue to
provide services, in good faith, during the
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 67 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
5 day period after notice of discharge was
provided to the patient or patient's legal
representative.
410 IAC 17-12-3(e)
Patient Rights
Rule 12 Sec. 3(e)
(e) The home health agency must inform
and distribute written information to the
patient, in advance, concerning its policies
on advance directives, including a
description of applicable state law. The
home health agency may furnish advanced
directives information to a patient at the time
of the first home visit, as long as the
information is furnished before care is
provided.
N 0518
Bldg. 00
Based on observation, interview, and
review of clinical records, the home
health agency failed to ensure its patients
were informed and provided written
information in advance of care regarding
advance directives including a
description of applicable state law for 1
of 2 records reviewed of patients
N 0518 1. Accredo provides each Indiana
patient with a copy of the Indiana
advanced directives information,
unless the patient is under the
age of 18 years old.
Patient # 3 was inadvertently
provided with the prior version of
the Indiana advanced directives
information that was obtained
from the Indiana Department of
Health’s website prior to the new
form being available.
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 68 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
receiving home visits (Patient #3).
The findings include:
1. During home visit to patient #3 on
1-2-15 at 9:00 AM, the patient had an
advance directive brochure provided by
the agency, undated, which failed to
describe applicable state law because it
failed to describe physician order for
scope of treatment.
2. After the home visit of patient #3,
Employee A indicated she had run out of
the form the agency provided "Advance
Directives" published by the Indiana
State Department of Health, revised
7-2013, and had used the above noted
brochure instead.
All Accredo HHA nurses have
been trained on the necessity to
obtain the current version from
the Department of Health’s
website to provide to new patients
and specific training regarding the
same will be provided to all new
nurses assigned to the Indiana
HHA in the future. The Indiana
HHA administrator is and will be
responsible to ensure that this
training take place in the future
and the Indiana HHA nursing
supervisor will also audit the
electronic personnel records of all
newly assigned Indiana HHA
nurses two times a year for
compliance with these proactive
training measures for the next
two years.
2. Please see above
410 IAC 17-13-1(a)
Patient Care
Rule 13 Sec. 1(a) Medical care shall follow
a written medical plan of care established
and periodically reviewed by the physician,
dentist, chiropractor, optometrist or
podiatrist, as follows:
N 0522
Bldg. 00
Based on observation and review of
clinical record, the registered nurse,
N 0522 1. The temperature was not taken
as the patient did not have a
thermometer and the nurse did
not have a thermometer with her
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 69 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
Employee A, failed to obtain complete
vital signs to include temperature for 1 of
1 patients receiving a home visit whose
plan of care included taking of
temperature. (#3).
The findings include:
1. During home visit to patient #3 on
1-2-15 at 9:00 AM, start of care (SOC)
12-19-14, diagnosis of primary
pulmonary hypertension, with plan of
care for certification period of 12-19-14
to 2-16-15, receiving skilled nursing
services for education and monitoring
related to Adempas oral therapy, the
registered nurse took the patient's vital
signs but failed to take the patient's
temperature. Patient 3's plan of care
included an order to monitor vital signs
to include temperature. During the visit,
the patient indicated not being able to
locate a thermometer in his home.
2. On 1-2-15 at 10:00 AM, Employee A
indicated she had not been issued a
thermometer with her nursing bag but
relied on the patients to have a
thermometer in the home to take their
temperature when vital signs were
ordered on the plan of care.
on that visit. However, the nurse
verified that the patient presented
no signs of being febrile. Accredo
will ensure nurses have
thermometers available if the
patient does not have their own
thermometer.2. Please see
above.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 70 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
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
referral.
(xii) Therapy modalities specifying length of
treatment.
(xiii) Any other appropriate items.
N 0524
Bldg. 00
Based on clinical record review, review
of policies, and interview, the agency
failed to ensure the medical plan of care
was developed in consultation with the
home health agency staff to include an
accurate, complete, and correct
medication orders prior to sending the
medical plan of care to the attending
physician for authorization in 2 of 6
clinical records reviewed (1 and 6).
N 0524 1. Unfortunately, as set forth in
prior responses, the surveyor was
provided with incorrect
information. Please see
response to N 440 and N 441.
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 71 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
The findings include:
1. Clinical record #1, start of care (SOC)
12-23-14, diagnosis of other chronic
pulmonary heart disease, portal
hypertension, and pulmonary
hypertension, included a plan of care for
certification period 12-23-14 to 2-20-15
that failed to include medications taken
by the patient as reported during nursing
visit of 12-23-14 of Synthroid 0.124 mg
(milligrams) p.o. (by mouth) daily and
Pramipexole Di-Hcl 0.5 mg p.o. twice a
day which were not new medications for
the patient.
Employee A indicated during interview
on 12-31-14 at 2:30 PM that the Rx
Home program had patient #1's
medications already entered into the plan
of care by an Accredo Health Group, Inc.,
the national corporation, pharmacist prior
to SOC date and agency nurse, Employee
A, was precluded from adding, deleting,
or modifying in any way the medications
on the plan of care to initiate an accurate
and complete plan of care for submission
to the attending physician for
authorization. Employee A had faxed the
plan of care as it printed from the Rx
Home computer program, without the
corrections to the medications, and also
sent a fax to the physician with an order
for the Synthroid and Pramipexole to
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 72 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
update the medications.
2. Clinical record #6, SOC 11-14-14,
diagnosis of pulmonary hypertension,
included a plan of care for certification
period 11-14-14 to 1-12-15 which
contained a medication profile with the
patient's medications including "Ferrous
sulfate 325 mg tablet , p.o. as directed."
Employee A indicated during interview
on 12-31-14 at 2:30 PM an Accredo
Health Group corporate pharmacist
entered patient #6's medications into the
agency plan of care and there was no
frequency included on the Ferrous sulfate
medication order. The order states to
take "as directed" which is not a complete
medication order, but Employee A was
precluded from adding, deleting, or
modifying in any way the medications on
the plan of care to initiate an accurate and
complete plan of care for submission to
the attending physician for authorization.
3. On 12-29-14 at 2:00 PM, Employee
A, the alternate administrator, indicated
the agency's patients' clinical record is
created and maintained in an electronic
system "Rx Home" which is integrated
into Accredo Health Group, Inc., the
national corporation's, electronic patient
record. She indicated the agency
registered nurse develops the plan of care
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 73 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
for each part of the patients' medical plan
of care except field #10, medications. At
start of care, the registered nurse
completes an assessment and compares
the medication profile obtained with the
medications already entered into the
electronic plan of care by a pharmacist
employed by Accredo Health Group, Inc,
the corporation. When the registered
nurse detects medication discrepancies,
the registered nurse cannot amend the
medication profile in the electronic
system if needed to send an accurate and
complete plan of care to the attending
physician for authorization. The agency
nurse must document necessary revisions
to the medication profile and fax to the
attending physician for an order to update
the plan of care until the next
certification period. Employee A
indicated it may take days or weeks
before the signed plan of care and order
to amend the medication profile is
received back from the attending
physician. Employee A stated the
registered nurse is precluded by Accredo
Health Group, Inc, the national
corporation, computer program
administrative controls, from submitting
a complete, correct, and accurate
medication profile to the attending
physician at the start of care.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 74 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
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 clinical record review and
interview, the registered nurse failed to
make a necessary revision to the patient's
plan of care regarding a resolution of an
incorrectly reported medication allergy
when the physician notified the nurse the
patient was not allergic to the medication
for 1 of 1 clinical record reviewed with
an incorrect allergy reported (#2).
The findings include:
1. Clinical record #2, start of care (SOC)
11-18-14, diagnosis of myasthenia gravis,
included a plan of care for certification
period 11-18-14 to 1-16-15 which
identified patient allergy to Benadryl.
N 0542 1. Upon further detailed review of
Clinical Record #2, Benadryl is
not listed as an allergy. The
prescriber’s orders do include
providing Benadryl 25mg in the
event of an anaphylactic
reaction. To ensure patient
confidentially, a redacted copy of
the POT in question is attached
as Exhibit LL. 2. Please see
above.
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 75 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
The plan of care included an order for
Benadryl 25 mg, as needed for
anaphylactic reaction, which had not
been administered to the patient.
2. Employee A indicated on 12-31-14 at
2:30 PM, the allergy had been
investigated when the order for Benadryl
was noted and the physician instructed
Employee A the patient is advised against
taking Benadryl based on patient's
diagnosis but that there was no allergy to
Benadryl. Employee A indicated the
patient had not been administered
Benadryl prior to the incorrectly reported
allergy resolution and she should have
corrected the plan of care and made a
clinical note entry documenting the
resolution provided by patient's physician
but did not do so.
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 clinical record review and
interview, the registered nurse failed to
prepare a clinical note to resolve a
reported medication allergy in the
patients plan of care when the physician
N 0544 1. Please see response to N 542.
Because Benadryl was not listed
as an allergy, a clinical note was
not required.
2. Please see above and also see
response to N 542.
01/30/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 76 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
notified the nurse the patient was not
allergic to the medication for 1 of 1
clinical record reviewed with an incorrect
allergy reported (#2).
The findings include:
1. Clinical record of patient #2, start of
care (SOC) 11-18-14, diagnosis of
myasthenia gravis, included a plan of
care for certification period 11-18-14 to
1-16-15 which identified patient allergy
of Benadryl. The plan of care included
an order for Benadryl 25 milligram as
needed for anaphylactic reaction, which
had not been administered to the patient.
2. Employee A indicated on 12-31-14 at
2:30 PM, the allergy had been
investigated when the order for Benadryl
was noted and the physician instructed
Employee A the patient is advised against
taking Benadryl based on patient's
diagnosis but that there was no allergy to
Benadryl. Employee A indicated the
patient had not been administered
Benadryl prior to the reported allergy
resolution and she should have corrected
the plan of care and made a clinical note
entry documenting the resolution of the
incorrectly reported allergy but did not do
so.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 77 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
410 IAC 17-15-1(a)(1-6)
Clinical Records
Rule 15 Sec. 1(a) Clinical records
containing pertinent past and current
findings in accordance with accepted
professional standards shall be maintained
for every patient as follows:
(1) The medical plan of care and
appropriate identifying information.
(2) Name of the physician, dentist,
chiropractor, podiatrist, or optometrist.
(3) Drug, dietary, treatment, and activity
orders.
(4) Signed and dated clinical notes
contributed to by all assigned personnel.
Clinical notes shall be written the day service
is rendered and incorporated within fourteen
(14) days.
(5) Copies of summary reports sent to the
person responsible for the medical
component of the patient's care.
(6) A discharge summary.
N 0608
Bldg. 00
Based on interview, review of consents,
and review of policy, the agency failed to
ensure its clinical record was maintained
in accordance with accepted professional
standards to include documents
N 0608 1. Accredo disputes the allegation
that its clinical records are not
maintained in accordance with
accepted professional standards.
Patient consent forms are signed
by patients upon admission to
HHA services and the consent
form does in fact show Accredo
02/13/2015 12:00:00AM
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 78 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
containing the agency's identification and
consent forms stored within the patient's
electronic clinical record that clearly
identify the agency as the provider of
nursing services for 10 of 10 clinical
records reviewed for patient consent
documentation in the clinical record.
(#1-10).
The findings include:
1. On 12-29-14 at 1:30 PM during the
entrance conference, Employee A
indicated the consents for the agency's
patients are stored in an electronic
program called "Work Group" but
clinical visit notes were stored in an
electronic program called "Rx Home".
On 1-2-15 at 4:35 PM, Employee E
indicated Accredo Health Group, Inc., the
national corporation, was transitioning
their information technology set up such
that in the near future, consents will be in
the Rx Home clinical record system.
2. Consents for patients #1-10 printed
from the "Work Group" electronic
program were reviewed and each
contained a document / form titled
"Patient Consent and Acknowledgement"
which included the patient's name,
company "Accredo", state Indiana, that
states, "Thank you for choosing Accredo,
we look forward to serving your specialty
as the provider of both pharmacy
and nursing services. As
explained in response to N 440
and N 441, only patients who are
receiving medications from the
Accredo pharmacy are serviced
by the Accredo HHA. As a result,
the consent form encompasses
both pharmacy services and
nursing services. We believe our
consent forms are in compliance
with applicable Federal and State
law. If there are specific
concerns, we would gladly
engage in a collaborative
discussion with Department of
Health to provide an additional
consent form to Indiana HHA
patients that would alleviate any
concerns that the Department of
Health may have. Patient
consent forms are stored
electronically in the clinical
record. For ease of reference, a
copy of the current patient
consent form is attached as
Exhibit MM.2. Please see above.
In addition, because our patients
understand that they are also
receiving medication from the
Accredo specialty pharmacy that
is directly related to the nursing
services provided by Accredo, we
do not believe the addendum
caused any patient confusion
simply because the document
had the name of “Accredo
Specialty Pharmacy” in the upper
right hand corner. However, in an
abundance of caution and in an
effort to alleviate any potential
concern, the words Specialty
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 79 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
pharmacy needs. As a pharmacy, we
have an obligation to ... by signing the
acknowledgement below, you are
indicating ... that you are consenting to
receive pharmacy services as a patient
from Accredo ... By signing this
Agreement & Acknowledgement, you are
agreeing to receive pharmacy services
from Accredo and our pharmacists
and nurses. ... You have the right to
choose the pharmacy you use to receive
your prescriptions and professional
services, which may include
consultation with pharmacists and
nurses ... I authorize the release of any
medical or other information necessary to
provide therapy, services, or products."
On page 2 it states, "Accredo is required
by certain state pharmacy regulations to
provide you with information about
advance directives and your rights ...
Advance Directive Acknowledgement: If
receiving nursing care from Accredo, I
further acknowledge that I have been
given an explanation of the rights under
my state law to accept or refuse treatment
and my right to formulate advance
directives regarding such." Each patient
also signed an addendum providing
notice of additional rights for Indiana
patients which has "Accredo Specialty
Pharmacy" on the form in the upper right
hand corner, but provides the name,
address, and phone number of Accredo
Pharmacy will be removed from
the addendum.3. Please see
above.4. Please see response to
N 444. In addition, please see
Policy 9-2 Clinical Record
Contents, attached as Exhibit
Z. 5.Unfortunately, Employee D
provided an incorrect form to the
surveyor. Upon noticing the
error, Employee D provided the
correct form to the surveyor that
indicated that the Indiana
provisionally licensed HHA was
the provider of record. In
addition, the copy sent to the
physician for signature does
indeed have the Indianapolis HHA
listed as the provider in section
#7 of the Plan of Treatment. A
copy of the correct Plan of
Treatment that was shown to the
surveyor and that was executed
by the prescriber is available for
review upon request.6.This is
correct. Please see above and
for an explanation as to why
patients may receive services
from the Accredo pharmacy and
HHA, please see response to N
440 and N 441.
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 80 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
Health Group, Inc. in the body of the
notice. Patients #1-10 electronically
signed the consents.
3. On 12-29-14 during the entrance
conference which began at 1:30 PM,
Employee A indicated the consent forms
are sent by the pharmacy corporation,
Express Scripts, electronically to the
agency's patients prior to the start of the
patients' medical plan of care which
always includes specialty infusion, oral,
or inhalation medication education and/or
administration for treatment of immune
disorders and/or pulmonary hypertension.
Employee A indicated these medications
are thousands of dollars for each cycle
and are often referred to as "specialty
pharmaceuticals". Employee A, at the
start of care, explains the nursing services
that will be provided and instructs the
patient on the intricacies of Accredo's /
Express Scripts corporate form and its
role in obtaining pre-authorization for the
"specialty" medication in the patient's
plan of care. Employee A acknowledged
the consent form the agency patients sign
for nursing services identifies Accredo
Pharmacy as the entity obtaining consent
rather than Accredo Health Group, Inc.,
the Indiana home health agency. For this
reason, Employee A indicated she
explains at start of care to the patient they
will receive nursing services from this
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 81 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
agency and she answers all the patients'
questions.
4. On 12-31-14 at 2:30 PM, Employee A
indicated the agency's patients' clinical
records were integrated into Accredo
Health Group, Inc., national corporate
record system, Rx Home. Lists of agency
patients - active or discharged, reason for
discharge, or any agency reports could
not be extracted or isolated to provide
reports on this agency's patients. On
1-2-15 at 2:34 PM, Employee A
indicated all the agency clinical records
contained, in addition to agency
generated clinical notes, physician orders,
plan of care, referral, and discharge
summary, other entries from corporate
pharmacists (in addition to the
pharmacists entry of patients' medications
in the plan of care), reimbursement
employees of the corporation, and
corporate nurses at the national call
center. Employee A could not define
what comprises the agency clinical
record.
5. On 12-31-14 at 4:45 PM, Employee
D, provided a printed copy of patient #8's
electronic plan of care, stored in Rx
Home program. The provider was
identified in field #7 of the plan of care
as Accredo Health Group at Louisville,
1700 Eastpoint Parkway, suite 50,
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 82 of 83
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/23/2015PRINTED:
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
INDIANAPOLIS, IN 46241
01/02/2015
ACCREDO HEALTH GROUP INC
2825 WEST PERIMETER RD STE 243
00
Louisville, KY 40223. Employee A
indicated the agency's clinical record is
integrated into an electronic program
which defaults to the Louisville agency
location owned by Accredo Health
Group, Inc., the national corporation,
unless a command is entered to change
the agency location to #197, Indianapolis,
when printing a paper copy of the plan of
care.
6. A policy "Clinical Records", reviewed
7-2014, states on page 2, item 8, "When a
patient is receiving services from more
than one Company entity (e.g., licensed
home care agency and pharmacy), each
entity will maintain a separate clinical
record documenting the services that the
entity provided if required by state
regulations."
State Form Event ID: T22X11 Facility ID: 013547 If continuation sheet Page 83 of 83