Every finding on record at A Plus Home Health Care Incorporated

An Emergency Preparedness Survey was conducted in accordance with 42 CFR 484.102 by the Indiana Department of Health. Survey Dates: 3/13/2025, 3/14/2025, and 3/17/2025 Census: 27 At this Emergency Preparedness survey, A Plus Home Health Care Inc was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health provider. Survey Dates: 3/13/2025, 3/14/2025, and 3/17/2025 Unduplicated skilled admissions: 51 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. A partially Extended Survey was announced to the Administrator on 3/17/2025 at 11:15 AM. Abbreviations used in report: Home Health Aide [HHA], Registered Nurse [RN], Plan of Care [POC], Skilled Nurse [SN], and Physical Therapist (PT). QR: 3/26/2025 A 1

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each patient received the home health services as ordered and written in the individualized plan of care that identifies patient-specific measurable outcomes and goals in 2 of 5 active clinical records reviewed (Patient #1, 4) and 2 of 2 closed clinical records reviewed (Patients #6, 7). Findings include: 1. The clinical record for Patient #1 included an initial POC dated 2/24/2025 to 4/24/2025 for SN visits once a week for two weeks then every other week for 4 weeks and PT services. The clinical record failed to evidence an SN visit was conducted the week of 3/12/2025 nor an attempt to reschedule the missed visit on 3/12/2025. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator relayed there were no attempts to reschedule the missed visit around Patient’s appointment. 2. The clinical record for Patient #4 included a POC dated 12/27/2024 to 2/24/2025 for SN visits once a week for 8 weeks and HHA visits twice a week for eight weeks and a subsequent POC dated 2/25/2025 to 4/25/2025 for SN visits once a week for nine weeks and HHA visits twice a week for 9 weeks. The clinical record included HHA missed visit documentation for 1/30/2025, 2/20/2025, and 2/25/2205 due to Patient not answering the door. The clinical record failed to evidence attempts to reschedule HHA visits. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator relayed the visits were missed because Patient did not answer the door and there were no attempts to do a wellness check nor reschedule the visits. 3. The closed clinical record for Patient #6 included a POC dated 1/2/2025 to 3/2/2025 for SN visits once a week for eight weeks. The clinical record included missed visit documentation on Monday, 1/13/2025 and Monday, 2/3/2025 due to ‘cancellation of care’. The clinical record failed to evidence attempts to reschedule care during the week of 1/13/2025 and 2/3/2025. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator relayed there were no attempts to reschedule Patient’s missed visits on 1/13/2025 and 2/3/2025. 4. The closed clinical record for Patient #7 included a POC dated 12/27/2024 to 2/24/2025 for SN services once a week for one week then every other week for four weeks. A SN visit was documented and dated 01/3/2025. The clinical record included a physician order dated 1/16/2025 to change the SN visit frequency to once a week for two weeks. The record evidenced SN visit were conducted weekly for 3 weeks, the SN visits were dated weekly and included the date of 01/30/2025. The clinical record failed to evidence an order nor physician communication for SN services the week of 1/30/2025. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator relayed there was not an order for a SN visit the week of 1/30/2025. 410 IAC 17-13-1(a)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure all patient care orders were recorded in the POC in 3 of 3 active clinical records reviewed with PT services (Patients #1, 3, 5) and 1 of 1 closed clinical record with PT services (Patient #7). Findings include: 1. The clinical record for Patient #1 included an initial POC dated 2/24/2025 to 4/24/2025 for SN visits and one PT evaluation. A PT evaluation was documented on 2/26/2025 that included PT frequency ordered as twice a week for 3 weeks, interventions, goals, and was signed by the physician on 3/7/2025. The clinical record failed to evidence a POC that included PT orders, frequencies, interventions and goals on the POC nor an addendum to the initial POC. 2. The clinical record for Patient #3 included an initial POC dated 2/26/2025 to 4/26/2025 for SN, HHA, and one PT evaluation visit. The clinical record included a PT evaluation documented on 2/27/2025 that indicated PT frequency ordered as once a week for one week then twice a week for three weeks. The PT evaluation included interventions, goals, and was signed by the physician on 3/12/2025. The clinical record failed to evidence the POC included the PT orders, frequencies, interventions and goals on nor an addendum to the initial POC. 3. The clinical record for Patient #5 included a POC dated 1/19/2025 to 3/19/2025 for SN services and one PT evaluation visit. The clinical record included a PT evaluation documented on 1/20/2025 that indicated PT frequency ordered as twice a week for three weeks, included interventions and goals, and was signed by the physician on 2/3/2025. The clinical record failed evidence the POC included PT orders, frequencies, interventions, and goals nor on an addendum to the initial POC. 4. The closed clinical record for Patient #7 included a POC dated 12/27/2024 to 2/24/2025 for SN, HHA, and a PT evaluation visit. The record included a PT evaluation that was documented on 01/03/2025 that indicated PT frequency order once a week for one week then twice a week for three weeks, included interventions and goals, and was signed by the physician on 01/21/2025. The clinical record failed to evidence the POC included the PT orders, frequencies, interventions and goals nor an addendum to the initial POC. During an interview on 2/14/2025 beginning at 10:00 AM, a clinical record review interview was conducted with the Administrator for Patients #1, 3, 5, and 7. The administrator relayed the PT evaluation documentation was the PT POC and orders. She revealed PT orders were not included in the POC nor was there an addendum to the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure services and treatments were administered only as ordered by a physician in 3 of 3 active clinical records reviewed with PT services (Patient #1, 3, 5) and 1 of 1 closed clinical records reviewed with PT services (Patient #7). Findings include: 1.The clinical record for Patient #1 included an initial POC dated 2/24/2025 to 4/24/2025 for SN visits and one PT evaluation. A PT evaluation was documented on 2/26/2025 that included PT frequency ordered as twice a week for 3 weeks, interventions, goals, and was signed by the physician on 3/7/2025. PT visits were documented on 2/28/2025 and 3/5/2025. The clinical record failed to evidence a verbal nor written order was received for the PT therapy provided on 2/28/2025 and 3/5/2025, prior to the PT evaluation being signed by the attending on 3/7/2025. 2. The clinical record for Patient #3 included an initial POC dated 2/26/2025 to 4/26/2025 for SN, HHA, and one PT evaluation visit. The clinical record included a PT evaluation documented on 2/27/2025 that indicated PT frequency ordered as once a week for one week then twice a week for three weeks. The PT evaluation included intervention and goals and was signed by the physician on 3/12/2025. PT visits were documented on 2/28/2025, 3/4/2025, and 3/6/2025. The clinical record failed to evidence a verbal nor written order was received for the PT therapy provided on 2/28/2025, 3/4/2025, and 3/6/2025, prior to the PT evaluation was signed on 3/10/2025. 3. The clinical record for Patient #5 included a POC dated 1/19/2025 to 3/19/2025 for SN services and one PT evaluation visit. The clinical record included a PT evaluation documented on 1/20/2025 that indicated PT frequency ordered as twice a week for three weeks, included intervention and goals, and was signed by the physician on 2/3/2025. PT visits were documented on 1/22/2025, 1/27/2025, and 1/29/2025. The clinical record failed to evidence a verbal nor written order was received for the PT therapy provided on 1/22/2025, 1/27/2025, and 1/29/2025, prior to the PT evaluation was signed on 2/3/2025. 4. The closed clinical record for Patient #7 included a POC dated 12/27/2024 to 2/24/2025 for SN, HHA, and a PT evaluation visit. The record included a PT evaluation that was documented on 1/3/2025 that indicated PT frequency order once a week for one week then twice a week for three weeks, included interventions and goals, and was signed by the physician on 1/21/2025. PT visits were documented on 01/6/2026, 01/8/2025, 01/13/2025, 01/17/2025, and 01/20/2025. The clinical record failed to evidence a verbal nor written order was received for the PT therapy provided on 01/6/2026, 01/8/2025, 01/13/2025, 01/17/2025, and 01/20/2025, visits prior to the PT evaluation was signed on 01/21/2025. During an interview on 3/17/2025 beginning at 10:00 AM, interviews were conducted with the Administrator regarding the chart review of Patients #1, 3, 5, and 7. The Administrator relayed the PT evaluations included the PT POC orders and there were no verbal orders, nor written ordered received, for the PT therapy provided, prior to the physician signing patients PT evaluation. 410 IAC 17-13-1(a)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations and interviews, the agency failed to ensure accepted standards of practice to prevent the transmission of infections and diseases were followed in 1 of 3 active clinical records reviewed with home visits (Patient 1). Findings include: During a home visit observation for Patient #1 on 3/14/2025 beginning at 12:44 PM, PT 2 used a blood pressure cuff and a thermometer from a supply bag to assess Patient. After use, PT 2 used Radiance disinfectant wipes to disinfect the blood pressure cuff and thermometer and then returned the items to the supply bag within 5 seconds after wiping. The direction for use [DFU] on the disinfectant wipes indicated the product required 4 minutes of dry time to disinfect surfaces. PT 2 failed to follow the DFU of 4 to sanitize the supplies before returning to their home visit bag. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator did not know the required dry time of sanitation wipes, staff were not trained on the dry time of wipes, and indicated education would be provided to their staff. 410 IAC 17-12-1(m)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the contents of the clinical record included a completed transfer summary that was sent to the primary care provider within 2 business days if the patient was admitted into a health care facility in 1 of 1 active clinical record reviewed with a hospitalization in the current care period (Patient #4) and 2 out of 2 closed clinical records reviewed (Patient #6, 7). Findings include: 1.The clinical record for Patient #4 included a POC dated 2/25/2025 to 4/25/2025 for SN visits once a week for nine weeks and HHA visits twice a week for 9 weeks. The clinical record included a physician order dated 3/4/2025 that indicated Patient was admitted into a hospital on 3/3/2025 due to a fall. The clinical record failed to evidence a transfer summary sent to the physician within 2 business days of the notification of the Patient’s hospitalization. 2. The closed clinical record for Patient #6 included a POC dated 1/2/2025 to 3/2/2025 for SN visits once a week for eight weeks. The clinical record included documentation that Patient was admitted into a hospital for respiratory problems dated 2/27/2025. The clinical record failed to evidence a transfer summary sent to the physician within 2 business days of the notification of the Patient’s hospitalization. 3. The closed clinical record for Patient #7 included a POC dated 12/27/2024 to 2/24/2025 for SN, HHA, and PT services. The clinical record included documentation that Patient was admitted to a hospital on 2/22/2025 due to fainting and weakness. The clinical record failed to evidence a transfer summary sent to the physician within 2 business days of the notification of the Patient’s hospitalization. During an interview on 3/17/2025 beginning at 10:00 AM, the records for Patient 4, Patient 6, and Patient 7 were reviewed with the Administrator. The Administrator revealed the agency did not send transfer summaries for these patients that were transferred for emergent care and hospitalized. 410 IAC 17-15-1(a)(7)

This visit was a recertification, re-licensure, and emergency preparedness survey. The survey visit took place from 3/14/2022 to 3/17/2022. Facility ID: 003986 At this Emergency Preparedness survey, A Plus Home Health Care Incorporated was found to be in compliance with 42 CFR 484.102 Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies.

This visit was a recertification, re-licensure, and emergency preparedness survey. The survey visit took place from 3/14/2022 to 3/17/2022. Facility ID: 003986 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Quality Review Completed 04/05/2022

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the patient's current health status in 1 of 1 patient records reviewed with a feeding tube (#1). The findings include: Record review on 3/17/2022, evidenced an agency policy titled, "CHART - GENERAL INFORMATION", dated 2004, which stated, " ... General Instructions ... Be pertinent and concise ... Reflect the patient's status (assessment) ... Address the patient's needs, problems, capabilities...." Record review evidenced an agency document titled, "JOB DESCRIPTION - TITLE: PHYSICAL THERAPIST", dated 2004, which stated, " ... Writes clear, concise and accurate clinical notes, evaluations and other required documentations on a timely basis...." Clinical record review on 3/14/2022, for patient #1, start of care 11/1/2021, certification period 3/1/2022 to 4/29/2022, primary diagnosis of Epilepsy (seizure disorder), evidenced an agency document titled, "PT [physical therapy] Evaluation", dated 3/2/2022 and signed by PT (physical therapist) G. The evaluation had a subsection titled, "Physical Assessment", which stated, " ... Skin: Impairment present. Pressure ulcer (sacral [area at the base of the spine] region)...." Clinical record review evidenced an agency document titled, "OASIS [the patient-specific, standardized assessment used in Medicare home health care] D1 Recertification", dated 2/24/2022, signed by RN (registered nurse) H. This assessment had a section titled, "Integumentary [related to the skin] Status". In the subsection titled, "Skin", "Ulcer [a sore or wound that develops on the skin]" was indicated with a check-mark. The subsection titled, "Current Number of Unhealed Pressure Ulcers / Injuries at Each Stage", indicated the patient had no pressure ulcers / injuries. Clinical record review evidenced an agency document titled, "LPN [licensed practical nurse] / LVN [licensed vocational nurse] Skilled Nursing Visit", dated 3/1/2022, and signed by LPN I. Review of this assessment failed to evidence a patient wound. During an interview on 3/17/2022 at 10:18 a.m., the administrator indicated each discipline performed their own comprehensive assessment. The administrator indicated the patient did not have a wound from 2/24/2022 to present. The administrator indicated the physical therapist's evaluation failed to include a current assessment. The administrator indicated the patient did not have a wound at the time of the OASIS Recertification, and the nurse may have marked "Ulcer" in error. 17-14-1(a)(1)(A)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure services were provided as ordered in the plan of care in 2 of 4 records reviewed not receiving therapy services (#3, #7). The findings include: 1. Record review on 3/17/2021, evidenced an agency policy titled, "PLAN OF CARE", dated 2004, which stated, " ... A plan of care is developed for each patient admitted to the home health program in consultation with the referring physician. ... The plan is based on the patient's diagnosis and and assessment of the patient's immediate and long-range needs and resources...." 2. Record review evidenced an agency policy titled, "CONFORMANCE WITH PHYSICIAN'S ORDERS", dated 2004, which stated, " ... A Plus Home Health Care Inc. staff administers drugs and treatments ONLY AS ORDERED by the physician...." 3. Record review evidenced an agency document titled, "JOB DESCRIPTION - TITLE: HOME HEALTH NURSE (REGISTERED NURSE)", dated 2004, which stated, " ... PRINCIPAL FUNCTION: Provides nursing care to assigned patients utilizing the Nursing Process to assess, plan, implement and evaluate patient service based upon a physician's plan of care ... Implementation 1. Provides direct patient care with clinical competence according to the plan of treatment, nursing care plan and established standards. 2. Initiates preventative and rehabilitation nursing procedures as planned for patient's care and safety...." 4. Clinical record review for patient #3, start of care 6/28/2021, certification period 2/23/2022 to 4/23/2022, primary diagnosis of Type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar as a fuel), evidenced an agency document titled, "Home Health Certification and Plan of Care". The plan of care had a subsection titled, "Orders and Treatments", which stated, " ... SN [skilled nurse] to assess skin for breakdown Q [each] visit...." Observation of a home visit for patient #3 was conducted on 3/15/2022, at 12:53 p.m. At 1:02 p.m., LPN [license practical nurse] I was observed checking the patient's vital signs. The patient was observed sitting in a recliner, wearing a long sleeved shirt, sweatpants, and socks. At 1:03 p.m., LPN I placed a blood pressure cuff on the patient's right arm and checked the patient's blood pressure manually. At 1:05 p.m., LPN I was observed placing their stethoscope to the patient's back and the patient's chest, outside of the patient's shirt. At 1:06 p.m., LPN I was observed feeling the patient's feet, outside of the patient's socks. LPN failed to move or remove any of the patient's clothing while performing the physical assessment. Observation of the home visit failed to evidence LPN I assessed the patient's skin for breakdown. During an interview on 3/17/2022, at 11:02 a.m., the administrator indicated a nurse should assess skin for breakdown by visualizing the skin, and looking for any new signs of a wound. When informed of the findings, the administrator indicated the nurse could not have assessed the patient's skin if all clothing remained intact. Clinical record review for patient #3 evidenced an agency document titled, "Home Health Certification and Plan of Care". The plan of care had a subsection titled, "Orders and Treatments", which stated, " ... Notify physician of: ... Fasting blood sugar greater than (>) 150 or less than () 250 or less than (

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the individualized plan of care included all services, medications and treatments in 2 of 7 records reviewed (#1, #7). The findings include: 1. Record review on 3/17/2022, evidenced an agency policy titled, "PLAN OF CARE", dated 2004, which stated, " ... The Plan of care ... includes the following information: ... Functional limitations and activities permitted as well as safety measures ... Orders for treatments and medications ordered ... Medical supplies and DME [durable medical equipment] ordered, and those already available to patient ... Significant clinical findings...." 2. During observation of a home visit for patient #1 on 3/16/2022, at 7:30 a.m., HHA [home health aide] F was observed giving the patient a bed bath. At 8:07 a.m., HHA F exposed the patient's abdomen. A feeding tube with a gauze dressing around it was observed on the patient's abdomen. Clinical record review on 3/14/2022, for patient #1, start of care 11/1/2021, certification period 3/1/2022 to 4/29/2022, primary diagnosis of Epilepsy (seizure disorder), evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the administrator on 3/14/2022. Review of the plan of care failed to evidence feeding tube assessment and site care. During an interview on 3/17/2022 at 10:23 a.m., the administrator indicated the assessment and care of a feeding tube should be included in the plan of care for all patients with a feeding tube. 3. Clinical record review on 3/16/2022, for patient #7, start of care 6/2/2021, certification period 11/29/2021 to 1/27/2022, primary diagnosis of Chronic venous hypertension with ulcer (increased pressure in the veins, resulting in damage to the skin) and inflammation of left lower extremity (left leg), evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 12/20/2021. The plan of care had a subsection titled, "Medications", which stated, " ... Oxygen Permeable Lens Products 1 ml [milliliter] 3 L/min [liters per minute] continues [sic] at home, 2L/min portable...." During an interview on 3/17/2022 at 11:40 a.m., the administrator indicated she did not know what "Oxygen Permeable Lens Products" was, and that it should not be on the plan of care. The administrator indicated the plan of care failed to evidence the patient was on oxygen per nasal cannula (a short tube that sits inside the nostril). 17-13-1(a)(1)(B)

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conform with all physician orders in 2 of 3 records reviewed receiving physical therapy (#2, #5). The findings include: 1. Record review on 3/17/2022, evidenced an agency policy titled, "CONFORMANCE WITH PHYSICIAN'S ORDERS", dated 2004, which stated, "1. Original orders of a physician and all subsequent intermittent orders must be signed by the patient's physician and incorporated as part of the patient's record maintained by the agency ... 5. All discontinued orders are to be cancelled in writing and signed by the physician, if the original order does not include an expiration date...." 2. Clinical record review for patient #2 on 3/15/2022, start of care 2/1/2022, certification period 2/1/2022 to 4/1/2022, primary diagnosis of Type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar as a fuel), evidenced an agency document titled, "FACE TO FACE ENCOUNTER FORM", signed by the physician. This form stated, " ... I feel that the following home health services are medically necessary (check all that apply): ...." The following services were indicated: Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health Aide. Clinical record review evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 2/4/2022. The plan of care had a subsection titled, "Orders and Treatments", which stated, " ... SN [skilled nurse]: 1 X 5 wks every other week ... PT [physical therapy]: 1 X 1 wk to eval [evaluate] and treat ... HHA [home health aide]: refused...." Review of the plan of care failed to evidence occupational therapy. Clinical record review of all visit notes, physician orders, and communication notes failed to evidence the patient received any occupational therapy or the discontinuation of the order for occupational therapy. During an interview on 3/17/2022, at 10:50 a.m., the administrator indicated the orders to initiate care were received from the physician on the Face to Face form, which was signed by the physician. The administrator indicated the patient was receiving only skilled nursing and physical therapy services, and had refused home health aide and occupational therapy services. When queried, the administrator indicated the clinical record failed to evidence patient's refusal of occupational therapy or discontinuation of the order for occupational therapy. 3. Clinical record review on 3/16/2022, for patient #5, start of care 2/9/2022, certification period 2/9/2022 to 4/9/2022, primary diagnosis of Encounter for change or removal of surgical wound dressing evidenced an agency document titled, "FACE TO FACE ENCOUNTER FORM", signed by the physician. This form stated, " ... No driving for 6 weeks, no heavy lifting more than 10 lbs [pounds] for 6 - 8 weeks, avoid continuous arm movements above head...." Clinical record review evidenced an agency document titled, "Home Health Certification and Plan of Care". Review of the plan of care failed to evidence any driving, lifting, or arm movement restrictions. Clinical record review evidenced a group of agency documents titled, "LPN [licensed practical nurse] / LVN [licensed vocational nurse] - Skilled Nursing Visit", dated 2/11/2022, 2/15/2022, 2/18/2022, 2/22/2022, 3/1/2022, and 3/8/2022. Review of each of the nurse's notes failed to evidence any driving, lifting, or arm movement restrictions. Clinical record review evidenced a group of agency documents titled, "PT [physical therapy] Visit", dated 2/13/2022, 2/23/2022 and 2/25/2022. Review of each of the physical therapy notes failed to evidence any driving, lifting, or arm movement restrictions. Clinical record review evidenced an agency document titled, "PT Evaluation", dated 2/11/2022, signed by the physician and PT [physical therapist] E. Review of the evaluation failed evidence any driving, lifting, or arm movement restrictions. During an interview on 3/17/2022, at 10:50 a.m., the administrator indicated the orders to initiate care were received from the physician on the Face to Face form, which was signed by the physician. When informed of the findings, the administrator indicated she talked to the physical therapist about the restrictions and the therapist failed to include them in the plan of care. The administrator stated about the restrictions, "They should be in there".

This visit was a federal focused infection control and complaint survey with 1 complaint. The survey visit took place 5/3/2021 to 5/6/2021. Facility ID: 003986 Complaint: IN00331046 - substantiated with related and unrelated findings. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the home health agency failed to meet the patient's needs , in 1 of 1 active records reviewed receiving wound care. (#3). The findings include: Record review on 5/6/2021, evidenced an agency policy titled, "JOB DESCRIPTION - TITLE: HOME HEALTH NURSE (REGISTERED NURSE)", with copyright date 2004, which stated, "PRINCIPAL FUNCTION: Provides nursing care to assigned patients utilizing the Nursing Process to assess, plan, implement and evaluate patient service based upon a physician's plan of care. Coordinates care delivered by other health disciplines for assigned patients ... C. Implementation 1. Provides direct patient care with clinical competence according to the plan of treatment, nursing care plan and established standards. 2. Initiates preventative and rehabilitation nursing procedures as planned for patient's care and safety. 3. Observes and monitors patient's status and progress toward planned outcomes ... 5. Coordinates and supervises care delivery and patient status related to other health disciplines...." Record review on 5/6/2021, evidenced an agency policy titled, "PATIENT CARE PLAN", with copyright date 2004, which stated, "1. The Patient care plan shall be written by appropriate member of the home health services team based upon plan of care and an assessment of the patient's needs, resources, family, environment, and goals ... The patient care plan shall be updated as often as the patient's condition necessitates, or at least every 60 days...." Record review on 5/6/2021, evidenced and agency policy titled, "PERIODIC REVIEW OF PLAN OF CARE", with copyright date 2004, which stated, " ... The professional personnel ... are expected to alert the physician to any changes in the patient's condition, which would indicate the need for altering the plan of care...." Record review on 5/6/2021, evidenced an agency policy titled, "COORDINATION OF PATIENT SERVICES", with copyright date 2004, which stated, "All personnel providing services are to maintain liaison to ensure that their efforts effectively complement one another and support the objectives of the company and those outlined in the Plan of care. a. Individual responsibilities to further coordination of patient care are delineated in the job description and standard of performance. b. Documentation of effective interchange, reporting, and coordinated patient evaluation is to be maintained in the clinical records...." Clinical record review on 5/5/2021 for patient #3, start of care 6/20/2017, certification period 4/5/2020 to 6/3/2020, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/13/2020. This plan of care had a subcategory titled, "Medications", which stated, "Santyl [a topical medication that removes dead tissue from wounds] External 250 UNIT / GM [units per gram] 1 apply to the left buttock daily until healed. Cleanse left buttock with normal saline, apply Santyl ointment and cover with gauze daily till healed..." This plan of care had a subcategory titled, "Goals and Outcomes", which stated, "SN [skilled nurse] goals ... Patient skin integrity will remain intact during this episode...." Clinical record review evidenced an agency document titled, "OASIS [Outcome and Assessment Information Set] [a standardized assessment used in home health] -D1 Recertification", dated 3/31/2020, signed by employee D, RN [registered nurse]. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.3 cm, Width: 0.2 cm, Depth: 0.1cm...." Skilled nurse visit notes dated 4/9/2020, 4/14/2020, 4/21/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.3 cm, Width: 0.2cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." A skilled nursing visit note dated 4/29/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.2cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." Skilled nursing visit notes dated 5/5/2020, 5/12/2020, 5/18/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." A skilled nursing visit note dated 5/26/2020 failed to evidence any wound documentation. Clinical record review evidenced an agency document titled, "OASIS-D1 Recertification", dated 6/2/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Review of all skilled nurse's notes and communication notes during the certification period failed to evidence physician notification of the wound not healing with current treatment. Clinical record review for patient #3 of certification period 6/4/2020 to 8/2/2020, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 6/9/2020. This plan of care had a subcategory titled, "Medications", which stated, "Santyl [a topical medication that removes dead tissue from wounds] External 250 UNIT / GM [units per gram] 1 apply to the left buttock daily until healed. Cleanse left buttock with normal saline, apply Santyl ointment and cover with gauze daily till healed..." This plan of care had a subcategory titled, "Goals and Outcomes", which stated, "SN [skilled nurse] goals ... Patient / caregiver skin integrity will remain intact during this episode...." Clinical record review evidenced an agency document titled, "OASIS-D1 Recertification", dated 6/2/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Clinical record review evidenced a group of agency documents titled, "Skilled Nursing Visit". A skilled nursing visit note dated 6/8/2020 failed to evidence any wound documentation. Clinical record review evidenced an agency document titled, "OASIS-D1 Transfer", dated 6/15/2020, signed by employee D, RN. This document stated, " ... Comments: Admitted at ... [hospital A] ... due to dyspnea [shortness of breath]". Review of patient's #3's medical record from hospital A evidenced a document titled, "Ancillary Progress Notes", dated 6/17/2020, signed by person B, RN, employee of hospital A. This note evidenced a wound photo and assessment which stated, "Wound #1 ... Pressure Injury Left Ischium [the lower, back part of the hip] ... Pressure Injury Stage 4 [a wound that is very deep, reaching into muscle and bone and causing extensive damage] Wound length 4.5 cm, Wound Width 2.5 cm, Wound Depth 1 cm...." Clinical record review evidenced an agency document titled, "OASIS-D1 Resumption of Care", dated 6/19/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Clinical record review evidenced skilled nursing visits dated 6/22/2020, 6/29/2020, and 7/6/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." Review of all skilled nurse's notes and communication notes during the certification period failed to evidence physician notification of the wound not healing with current treatment. Review of the patient's electronic medical record [Kinnser] evidenced the wound care orders had not changed since initiated on 9/17/2019. During an interview on 5/6/2021 at 11:11 a.m., the administrator indicated the agency should ensure a patient with wounds' needs were being met by assessing the wound at each visit, informing the physician if the wound was not healing, and changing wound care as needed. The administrator stated, "The nurse should update the doctor if treatment isn't working. We tell them it doesn't work. Wounds should heal in less than 60 days". When informed of the findings on 5/6/2021 at 11:45 a.m., the administrator stated about the discrepancy between the hospital wound assessment on 6/17/2020 and the agency's SN assessment on 6/19/2021, "It's impossible. I'm going to investigate." When queried if the agency met the patient's needs, the administrator stated, "No. I'm going to see what's going on. It's really concerning". 17-14-1(a)(1)(B)

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to update and revise the comprehensive assessment of the OASIS (Outcome and Assessment Information Set) as frequently as the patient's condition warrants due to a major decline in the patient's health status in 1 of 2 discharged records reviewed receiving wound care (#4). The findings include: Review of the agency policy copyrighted in 2004, titled "Plan of Care," stated "... A plan of care is developed for each patient admitted to the home health program in consultation with the referring physician ... The Plan of care ... includes the following information ... Orders for treatments and medications ordered ... Periodic review of the Plan of care will occur at least once every sixty (60) days, or after hospitalization (resumption of care) or significant changes in status, as delineated in Medicare regulations ... The patient care plan shall be updated as often as the patient's condition necessitates, or at least every 60 days ...." Clinical record review on 5/5/2021 for patient #4, primary diagnosis: Cellulitis (bacterial skin infection where the infected skin appears swollen and red and is typically painful and warm to the touch) of buttock, start of care 9/25/2020, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 9/25/20 - 11/23/20, and signed by the administrator. This document stated "... Patient's fasting blood sugar (measuring blood sugar after an overnight fast of not eating) will remain between 100 mg/dL [milligrams per deciliter] and 120 mg/dL ... Notify physician of: ... Fasting blood sugar greater than (>) 120 or less than (<) 60 ... SN (Skilled Nurse) to report to physician if patient experiences pain level not acceptable to patient, pain level greater than 6/10 [pain scale with 0 being no pain and 10 being the most severe] ...." A record review evidenced an untitled agency comprehensive assessment, dated 9/25/2020, signed by the administrator. This document had a subsection titled "Integumentary [skin] Status," which indicated the patient had two wounds. This subsection indicated wound 1 measurements were 0cm (centimeters) in length x 0cm in width x 0cm in depth. This document had a subsection titled "Pain Scale," which indicated the intensity of pain was a 5 (on a scale of 0-10, with 0 being no pain and 10 being the most severe). This document had a subsection titled "Endocrine (System of glands that secrete hormones directly into the blood)," which indicated the blood sugar was 91 mg/dL. A record review evidenced an agency document titled "RN [Registered Nurse] - Skilled Nursing Visit," dated 10/6/2020, and signed by the administrator. This document indicated there were 5 wounds, 3 of which were not present on admission. This document indicated wound 1 measurements were 3.0 cm in length, 1.5cm in width, and 0 cm in depth. This document indicated the patient's pain intensity was a 10. This document also indicated the fasting blood sugar was 138 mg/dL. A record review evidenced an untitled agency discharge comprehensive assessment, dated 10/12/2020, and signed by the administrator. Record review failed to evidence the agency performed a new comprehensive assessment after the patient experienced a major decline in their health status on 10/6/2020. Clinical record review failed to evidence an updated comprehensive assessment to include the patient's 3 new wounds, the uncontrolled fasting blood sugar, and the patient's increase in pain. During an interview on 5/5/21 at 10:39 a.m., the administrator indicated wound 1 got worse since admission. She indicated the patient was noncompliant with her pain medication, resulting in her pain being a 10 out of 10. The administrator indicated the comprehensive assessment should have been updated due to the major decline in the patient's health status.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care was followed and individualized in 3 of 3 records reviewed receiving home health aide services (#1, #2, #3). 1. Record review on 5/6/2021, evidenced an agency policy titled, "PLAN OF CARE", with copyright date 2004, which stated, "1. A plan of care is developed for each patient admitted to the home health program in consultation with the referring physician. The Plan of care must be signed and dated by a physician responsible for the care of the patient and filed into the patient's record. The plan is based on the patient's diagnosis and an assessment of the patient's immediate and long-range needs and resources. The patient and / or caregiver(s) are to be active participants in creating the plan of care ... 2. The Plan of care is recorded on HCFA form 485 and includes the following information: ... g. Functional limitations and activities permitted as well as safety measures. h. Orders for treatments and medications ordered ... 3. Orders for therapy services include the specific procedures and modalities to be used, amount, frequency, and duration." 2. Record review on 5/6/2021, evidenced an agency policy titled, "CONFORMANCE WITH PHYSICIAN'S ORDERS", with copyright date 2004, which stated, "1. Original orders of a physician and all subsequent intermittent orders must be signed by the patient's physician and incorporated as part of the patient's record maintained by the agency ... staff administers drugs and treatments ONLY AS ORDERED by the physician...." 3. Record review on 5/6/2021, evidenced an agency policy titled, "JOB DESCRIPTION - TITLE: HOME HEALTH NURSE (REGISTERED NURSE)", with copyright date 2004, which stated, "PRINCIPAL FUNCTION: Provides nursing care to assigned patients utilizing the Nursing Process to assess, plan, implement and evaluate patient service based upon a physician's plan of care. Coordinates care delivered by other health disciplines for assigned patients ... C. Implementation 1. Provides direct patient care with clinical competence according to the plan of treatment, nursing care plan and established standards. 2. Initiates preventative and rehabilitation nursing procedures as planned for patient's care and safety. 3. Observes and monitors patient's status and progress toward planned outcomes ... 5. Coordinates and supervises care delivery and patient status related to other health disciplines...." 4. Clinical record review on 5/3/2021 for patient #1, start of care 3/25/2021, certification period 3/25/2021 to 5/23/2021, and primary diagnosis of Pressure ulcer of right buttock, stage 2, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/20/2021. The plan of care had a subcategory titled, "Safety Measures", which stated, "Keep pathway clear ... Anticoagulant Precautions. Safety in ADLs [activities of daily living] ... Fall Precautions...." The plan of care had a subcategory titled, "Orders and Treatments", which stated, " ... SN [skilled nurse] 1 x 5 wks - Educate on disease process, meds, changing dressing, safety ... HHA [home health aide] 1x1 wk, 2 x 8 wks - To assist with ADL, personal hygiene and bathing ... SN will educate patient / caregiver on fall and injury risk reduction techniques ... SN will educate patient / caregiver on home safety...." Review of patient #1's electronic medical record (Kinnser) on 5/3/2021, evidenced skilled nursing visit notes on 4/9/2021 and 4/22/2021. The note dated 4/9/2021, failed to evidence fall precautions, anticoagulant precautions, or any other safety measures were taught, enforced, or assessed. The note dated 4/22/2021, failed to evidence anticoagulant precautions were taught, enforced, or assessed. Review of the patient's electronic medical record (Kinnser) on 5/3/2021, evidenced home health aide visit notes dated 3/25/2021, 3/26/2021, 3/29/2021, 4/1/2021, 4/5/2021, 4/8/2021, 4/12/2021, 4/15/2021, 4/22/2021, 4/26/2021 and 4/29/2021. Each of these notes failed to evidence fall precautions and anticoagulant precautions. During an interview on 5/6/2021 at 11:23 a.m., the administrator indicated the patient, family, and all disciplines of staff should be aware of and enforce fall and anticoagulant precautions. The administrator indicated safety precautions should be addressed by all disciplines of staff at each visit, and should be documented in the visit notes. When informed of the findings, the administrator indicated the skilled nurse and home health aide documentation failed to evidence following the safety precautions (anticoagulant precautions and fall precautions) established in the plan of care. Clinical record review evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/20/2021. The plan of care had a subcategory titled, "Orders and Treatments", which stated, " ... SN [skilled nurse] 1x5 wks - Educate on disease process, meds, changing dressing, safety ... Assessment of patient with Pressure ulcer...." Clinical record review evidenced an agency document titled, "OASIS [Outcome and Assessment Information Set] [a standardized assessment used in home health] -D1 Start of Care", dated 3/25/2021, signed by the administrator. This assessment had a section titled, "(M1311) Current Number of Unhealed Pressure Ulcers / Injuries at Each Stage", which indicated the patient had one stage 2 pressure ulcer [a partial thickness loss of skin presenting as a shallow open ulcer]. This wound assessment stated, "Wound 1 - Location: inner buttock - right, Status: Open, Present on Admission, Type: Pressure Ulcer, Stage: II, Size: Length: 2.0 cm, Width: 0.5 cm...." Review of the patient's electronic medical record (Kinnser), evidenced the next SN visit was 4/9/2021. The skilled nursing note from 4/9/2021, failed to evidence assessment of the pressure ulcer. During an interview on 5/6/2021 at 11:04 a.m., the administrator indicated the skilled nurse should assess the wound and perform wound care at each visit for this patient. When informed of the findings, the administrator indicated the documentation failed to evidence a wound assessment or wound care was performed on 4/9/2021. 5. Clinical record review on 5/5/2021 for patient #3, start of care 6/20/2017, certification period 6/4/2020 to 8/2/2020, and primary diagnosis of Cutaneous abscess of buttock, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 6/9/2020. The plan of care had a subcategory titled, "Safety Measures", which stated, "Keep pathway clear ... Fall Precautions ... Anticoagulant Precautions...." Review of patient #3's electronic medical record (Kinnser) on 5/5/2021, evidenced skilled nursing visits on the following dates which failed to evidence anticoagulant precautions: 6/8/2020, 6/22/2020, 6/29/2020, and 7/6/2020. Clinical record review for patient #3, certification period 4/5/2020 to 6/3/2020, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/13/2020. The plan of care had a subcategory titled, "Safety Measures", which stated, "Keep pathway clear ... Fall Precautions ... Anticoagulant Precautions...." Review of patient #3's electronic medical record (Kinnser) on 5/5/2021, evidenced skilled nursing visits on the following dates which failed to evidence anticoagulant precautions: 4/9/2020, 4/14/2020, 4/29/2020, 5/5/2020, 5/12/2020, 5/18/2020 and 5/26/2020. During an interview on 5/6/2021 at 11:42 a.m., the administrator indicated the skilled nurse visit notes failed to evidence the anticoagulant precautions established in the plan of care. Clinical record review of certification period 4/5/2020 to 6/3/2020, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/13/2020. This plan of care had a subcategory titled, "Orders and Treatments", which stated, " ... SN [skilled nurse] 1 x 9 [once a week for 9 weeks] ... Assessment of patient with Cutaneous abscess of buttock, Encounter for change or removal of surgical wound dressing....". This plan of care had a subcategory titled, "Treatments" which stated, "Medications Santyl [a topical medication that removes dead tissue from wounds] External 250 UNIT / GM [units per gram] 1 apply to the left buttock daily until healed. Cleanse left buttock with normal saline, apply Santyl ointment and cover with gauze daily till healed..." Clinical record review evidenced an agency document titled, "OASIS [Outcome and Assessment Information Set] [a standardized assessment used in home health] -D1 Recertification", dated 3/31/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Size: Length: 0.3 cm, Width: 0.2 cm, Depth: 0.1cm...." Skilled nurse visit notes dated 4/9/2020, 4/14/2020, 4/21/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.3 cm, Width: 0.2cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." A skilled nursing visit note dated 4/29/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound... Size: Length: 0.2 cm, Width: 0.2cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." Skilled nursing visit notes dated 5/5/2020, 5/12/2020, 5/18/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." A skilled nursing visit note dated 5/26/2020 failed to evidence any wound documentation. Clinical record review evidenced an agency document titled, "OASIS-D1 Recertification", dated 6/2/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Clinical record review for patient #3 of certification period 6/4/2020 to 8/2/2020, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 6/9/2020. This plan of care had a subcategory titled, "Orders and Treatments", which stated, " ... SN [skilled nurse] 1 x 8 [once a week for 8 weeks] ... Assessment of patient with Cutaneous abscess of buttock, Encounter for change or removal of surgical wound dressing....". This plan of care had a subcategory titled, "Treatments", which stated, "Medications Santyl [a topical medication that removes dead tissue from wounds] External 250 UNIT / GM [units per gram] 1 apply to the left buttock daily until healed. Cleanse left buttock with normal saline, apply Santyl ointment and cover with gauze daily till healed..." This plan of care had a subcategory titled, "Goals and Outcomes", which stated, "SN [skilled nurse] goals ... Patient / caregiver skin integrity will remain intact during this episode...." Clinical record review evidenced an agency document titled, "OASIS-D1 Recertification", dated 6/2/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Clinical record review evidenced a group of agency documents titled, "Skilled Nursing Visit". A skilled nursing visit note dated 6/8/2020 failed to evidence any wound documentation. Clinical record review evidenced an agency document titled, "OASIS-D1 Resumption of Care", dated 6/19/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Clinical record review evidenced skilled nursing visits dated 6/22/2020, 6/29/2020, and 7/6/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." During an interview on 5/6/2021 at 11:04 a.m., the administrator indicated the skilled nurse should assess the wound and perform wound care at each visit for this patient. When informed of the findings, the administrator indicated the skilled nurse's documentation failed to evidence a wound assessment or wound care was performed on 5/26/2020 and 6/8/2020. 6. Clinical record review on 5/4/2021 for patient #2, primary diagnosis: Hemiplegia following cerebral infarction affecting left non dominate side (paralysis of one side of the body following a stroke), start of care 10/24/2019, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 4/16/2021 - 6/14/2021, and signed by RN (registered nurse) D. This document had a subsection titled "Safety Measures," which stated "... Keep side Rails up ...." During a home visit on 5/4/21 at 11:25 a.m. for patient #2, the home health aide was observed performing a bed bath. The home health aide was observed taking the two basins being used for the bed bath into the bathroom located in a different room to be cleaned out and refilled with fresh water. When the clinician left the patient's side to clean the basins, she was observed to have left the side rail down while leaving the patient unattended. The home health aide failed to follow the plan of care. During an interview on 5/6/21 at 10:04 a.m., the administrator indicated the side rails should be down while performing a bed bath, but the clinician should have put the side rails up when she left the patient's side. 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized plan of care included all services, safety measures, medications and treatments in 3 of 3 records receiving home health aide services (#1, #2, #3). The findings include: 1. Record review on 5/6/2021, evidenced an agency policy titled, "PLAN OF CARE", with copyright date 2004, which stated, "1. A plan of care is developed for each patient admitted to the home health program in consultation with the referring physician. The Plan of care must be signed and dated by a physician responsible for the care of the patient and filed into the patient's record. The plan is based on the patient's diagnosis and an assessment of the patient's immediate and long-range needs and resources. The patient and / or caregiver(s) are to be active participants in creating the plan of care ... 2. The Plan of care is recorded on HCFA form 485 and includes the following information: ... g. Functional limitations and activities permitted as well as safety measures. h. Orders for treatments and medications ordered ... 3. Orders for therapy services include the specific procedures and modalities to be used, amount, frequency, and duration." 2. Clinical record review on 5/3/2021 for patient #1, start of care 3/25/2021, certification period 3/25/2021 to 5/23/2021, and primary diagnosis of Pressure ulcer of right buttock, stage 2, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/20/2021. The plan of care had a subcategory titled, "Orders and Treatments", which stated, " ... SN [skilled nurse]: 1 x 5 wks - Educate on disease process, meds, changing dressing, safety...." Review of the patient's electronic medical record (Kinnser) on 5/3/2021, evidenced skilled nursing visits were made on 3/25/2021, 4/9/2021, and 4/22/2021. During an interview on 5/6/2021 at 11:16 a.m., the administrator indicated "1 x 5 wks" meant 5 visits within the certification period, and the skilled nurse visits should be every other week. When queried, the administrator indicated the plan of care failed to clearly evidence the frequency of skilled nursing visits. The administrator stated, "We should write every other week. I should specify." Clinical record review evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/20/2021. The plan of care had a subcategory titled, "Medications", which stated, " ... Tolnaftate External [an anti-fungal medication] 1% 1 Apply to under breast bilateral [both sides] - topical...." During an interview on 5/6/2021 at 11:27 a.m., the administrator indicated all medication orders should contain the frequency the medication was taken. When informed of the findings, the administrator indicated the plan of care failed to evidence a complete order for the medication. 3. Clinical record review on 5/5/2021 for patient #3, start of care 6/20/2017, certification period 6/4/2020 to 8/2/2020, and primary diagnosis of Cutaneous abscess of buttock, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 6/9/2020. The plan of care had a subcategory titled, "Medications", which stated, " ... Cranberry Concentrate Oral 500 MG [milligram] 30 Cap(s) daily...." When informed of the findings on 5/6/2021 at 11:36 a.m., the administrator stated, "No, it should be one cap daily. That's not right". 4. Clinical record review on 5/4/2021 for patient #2, primary diagnosis: Hemiplegia following cerebral infarction affecting left non dominate side (paralysis of one side of the body following a stroke), start of care 10/24/2019, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 4/16/2021 - 6/14/2021, and signed by RN (registered nurse) D. This document had a subsection titled "Medications," which stated "... Calmoseptine [moisture barrier to prevent irritation] External 0.44-20.6% 1 application to the affected are [sic] topically twice a day as needed ...." Clinical record review failed to evidence the agency included where the affected area was located to apply the Calmoseptine and indications for when the Calmoseptine should be applied. During an interview on 5/6/21 at 10:10 a.m., the administrator indicated the plan of care did not specify where the Calmoseptine was to be applied and that it should say where the affected area was located. 17-13-1(a)(1)(B)(D)(iii, ii, x)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to record the verbal orders in the plan of care in 1 of 2 discharged records reviewed receiving wound care (#4). The findings include: Review of the agency policy copyrighted in 2004, titled "Plan of Care," stated "... A plan of care is developed for each patient admitted to the home health program in consultation with the referring physician ... The Plan of care ... includes the following information ... Orders for treatments and medications ordered ... Periodic review of the Plan of care will occur at least once every sixty (60) days, or after hospitalization (resumption of care) or significant changes in status, as delineated in Medicare regulations ... The patient care plan shall be updated as often as the patient's condition necessitates, or at least every 60 days...." Clinical record review on 5/5/2021 for patient #4, primary diagnosis: Cellulitis (bacterial skin infection where the infected skin appears swollen and red and is typically painful and warm to the touch) of buttock, start of care 9/25/2020, evidenced an agency document titled "Physician Order," dated 10/1/20, and signed by the administrator. This document stated "... Current Medication ... New ... Bepreve Ophthalmic Solution [used to treat itching of the eye due to allergies] ... New ... Olopatadine HCL [hydrochloride] Ophthalmic Solution [used to treat itching of the eye caused by pink eye] ... New ... Phytoplex Silicone Cream [creates a water-resistant film over the skin to help reduce moisture loss] ... New ... Bydureon BCise [improve glycemic control in adults with type 2 diabetes mellitus]...." A record review evidenced an agency document titled "Home Health Certification and Plan of Care," dated 9/25/2020, and signed by the administrator. This document had a subsection titled "Medications." This subsection failed to include the medications Bepreve Ophthalmic Solution, Olopatadine HCL Ophthalmic Solution, Phytoplex Silicone Cream, and Bydureon BCise. Clinical record review failed to evidence the agency updated the plan of care to include the new medications ordered per the verbal order from 10/1/20. During an interview on 5/5/21 at 10:19 a.m., the administrator indicated they would not add these medications to the plan of care because the verbal order was received after the plan of care was established. She indicated the only time medications are updated in the plan of care is when care is initiated or recertified.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the physician was alerted to patient's conditions indicating outcomes were not being achieved and the plan of care should be altered in 1 of 2 discharged records receiving wound care (#3). The findings include: Record review on 5/6/2021, evidenced an agency policy titled, "JOB DESCRIPTION - TITLE: HOME HEALTH NURSE (REGISTERED NURSE)", with copyright date 2004, which stated, "PRINCIPAL FUNCTION: Provides nursing care to assigned patients utilizing the Nursing Process to assess, plan, implement and evaluate patient service based upon a physician's plan of care. Coordinates care delivered by other health disciplines for assigned patients ... C. Implementation 1. Provides direct patient care with clinical competence according to the plan of treatment, nursing care plan and established standards. 2. Initiates preventative and rehabilitation nursing procedures as planned for patient's care and safety. 3. Observes and monitors patient's status and progress toward planned outcomes ... 5. Coordinates and supervises care delivery and patient status related to other health disciplines...." Record review on 5/6/2021, evidenced an agency policy titled, "PATIENT CARE PLAN", with copyright date 2004, which stated, "1. The Patient care plan shall be written by appropriate member of the home health services team based upon plan of care and an assessment of the patient's needs, resources, family, environment, and goals ... The patient care plan shall be updated as often as the patient's condition necessitates, or at least every 60 days...." Record review on 5/6/2021, evidenced and agency policy titled, "PERIODIC REVIEW OF PLAN OF CARE", with copyright date 2004, which stated, " ... The professional personnel ... are expected to alert the physician to any changes in the patient's condition, which would indicate the need for altering the plan of care...." Record review on 5/6/2021, evidenced an agency policy titled, "COORDINATION OF PATIENT SERVICES", with copyright date 2004, which stated, "All personnel providing services are to maintain liaison to ensure that their efforts effectively complement one another and support the objectives of the company and those outlined in the Plan of care. a. Individual responsibilities to further coordination of patient care are delineated in the job description and standard of performance. b. Documentation of effective interchange, reporting, and coordinated patient evaluation is to be maintained in the clinical records...." Clinical record review on 5/5/2021 for patient #3, start of care 6/20/2017, certification period 4/5/2020 to 6/3/2020, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/13/2020. This plan of care had a subcategory titled, "Medications", which stated, "Santyl [a topical medication that removes dead tissue from wounds] External 250 UNIT / GM [units per gram] 1 apply to the left buttock daily until healed. Cleanse left buttock with normal saline, apply Santyl ointment and cover with gauze daily till healed..." This plan of care had a subcategory titled, "Goals and Outcomes", which stated, "SN [skilled nurse] goals ... Patient skin integrity will remain intact during this episode...." Clinical record review evidenced an agency document titled, "OASIS [Outcome and Assessment Information Set] [a standardized assessment used in home health] -D1 Recertification", dated 3/31/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Size: Length: 0.3 cm, Width: 0.2 cm, Depth: 0.1cm...." Skilled nurse visit notes dated 4/9/2020, 4/14/2020, 4/21/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.3 cm, Width: 0.2cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." A skilled nursing visit note dated 4/29/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound... Size: Length: 0.2 cm, Width: 0.2cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." Skilled nursing visit notes dated 5/5/2020, 5/12/2020, 5/18/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." A skilled nursing visit note dated 5/26/2020 failed to evidence any wound documentation. Clinical record review evidenced an agency document titled, "OASIS-D1 Recertification", dated 6/2/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Review of all skilled nurse's notes and communication notes during the certification period failed to evidence physician notification of the wound not healing with current treatment. Clinical record review for patient #3 of certification period 6/4/2020 to 8/2/2020, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 6/9/2020. This plan of care had a subcategory titled, "Medications", which stated, "Santyl [a topical medication that removes dead tissue from wounds] External 250 UNIT / GM [units per gram] 1 apply to the left buttock daily until healed. Cleanse left buttock with normal saline, apply Santyl ointment and cover with gauze daily till healed..." This plan of care had a subcategory titled, "Goals and Outcomes", which stated, "SN [skilled nurse] goals ... Patient / caregiver skin integrity will remain intact during this episode...." Clinical record review evidenced an agency document titled, "OASIS-D1 Recertification", dated 6/2/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Clinical record review evidenced a group of agency documents titled, "Skilled Nursing Visit". A skilled nursing visit note dated 6/8/2020 failed to evidence any wound documentation. Clinical record review evidenced an agency document titled, "OASIS-D1 Resumption of Care", dated 6/19/2020, signed by employee D, RN. This assessment had a subcategory titled, "Wound Care Worksheet", which stated, "Wound 1 - Location: left buttock ... Size: Length: 0.2 cm, Width: 0.1 cm, Depth: 0.1cm...." Clinical record review evidenced skilled nursing visits dated 6/22/2020, 6/29/2020, and 7/6/2020, signed by employee D, RN, stated, "Wound 1 - Location: left buttock ... Type: Surgical wound ... Size: Length: 0.2 cm, Width: 0.1cm, Depth, 0.1 cm ... Treatment: cleansed with 0.9% NS [normal saline] Santyl and gauze applied...." Review of all skilled nurse's notes and communication notes during the certification period failed to evidence physician notification of the wound not healing with current treatment. During an interview on 5/6/2021 at 11:12 a.m., the administrator indicated the skilled nurse should assess wounds at every visit, and if the wound was not improving, the nurse should inform the physician. The administrator stated, "The nurse should update the doctor if treatment wasn't working. We tell them it doesn't work. Wounds should heal in less than 60 days". When informed of the findings, the administrator indicated the home health agency failed to ensure the physician was notified of the wound not healing with current treatment. 17-13-1(a)(2)

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to provide the patient and caregiver with a copy of written instructions outlining the visit schedule, including frequency of visits by the agency personnel and personnel acting on behalf of the agency in 1 of 1 home visits (#2) The findings include: Review of the agency policy, copyrighted in 2004 titled "Patient Bill of Rights - Home Health Agency," stated "... A Plus Home Health Care Inc. exists primarily for the purpose of providing high quality care that meets or exceeds accepted standard for care ... In accordance with this philosophy, A Plus Home Health Care Inc. wishes to advise you of the following rights and responsibilities and to assist you in understanding and exercising these rights ... Patient's Rights: As part of A Plus Home Health Care, Inc. you and your representative(s) have the right to ... Be fully informed in advance about the care and treatment to be furnished, including the skilled staff that will furnish the care and the proposed number of visits they will make to your home...." Clinical record review on 5/4/2021 for patient #2, primary diagnosis: Hemiplegia following cerebral infarction affecting left non dominate side (paralysis of one side of the body following a stroke), start of care 10/24/2019, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 4/16/2021 - 6/14/2021, and signed by RN (registered nurse) D. This document stated "... SN [Skilled Nursing]: 1x4 [once a week for 4 weeks] ... PT [Physical Therapy]: 2x3 [twice a week for three weeks] ... HHA [Home Health Aide]: 1x1 [once a week for one week] ...." During a home visit on 5/4/2021 at 10:55 a.m. for patient #2, the patient's admission packet folder was observed and failed to evidence the patient and caregivers were provided with a visit schedule of when the SN, PT, and home health aide were to visit as ordered in the plan of care. During an interview on 5/6/2021 at 10:00 a.m., the administrator indicated they call and tell the patient when they will be there. She indicated they also call the day before they arrive and when they are on their way and indicated even though she always calls three times, the patient should still have a visit schedule.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to provide the patient and caregiver with the medication schedule/instructions, including: medication name, dosage, frequency and which medications will be administered by the home health agency in 1 of 1 home visits. (#2) The findings include: Review of the agency policy, copyrighted in 2004, titled "Patient Bill of Rights - Home Health Agency," stated "... A Plus Home Health Care Inc. exists primarily for the purpose of providing high quality care that meets or exceeds accepted standard for care ... In accordance with this philosophy, A Plus Home Health Care Inc. wishes to advise you of the following rights and responsibilities and to assist you in understanding and exercising these rights ... Patient's Rights: As part of A Plus Home Health Care, Inc. you and your representative(s) have the right to ... Be fully informed in advance about the care and treatment to be furnished...." Clinical record review on 5/4/2021 for patient #2, primary diagnosis: Hemiplegia following cerebral infarction affecting left non dominate side (paralysis of one side of the body following a stroke), start of care 10/24/2019, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 4/16/2021 - 6/14/2021, and signed by RN (registered nurse) D. This document indicated the patient was taking the medications Calmoseptine (used to treat and prevent minor skin irritations), Meloxicam (reduces pain, swelling, and stiffness of the joints), and Cetirizine hydrochloride (used to treat allergies). During a home visit on 5/4/2021 at 10:55 a.m. for patient #2, the patient's admission packet folder was observed and evidenced an unsigned agency document titled "Home Medication Schedule," dated 10/26/2019. Clinical record review of the medication profile failed to evidence the patient was taking the medications Calmoseptine, Meloxicam, and Cetirizine hydrochloride as indicated in the plan of care. During an interview on 5/6/2021 at 10:00 a.m., the administrator indicated the medication profile should match the medications in the plan of care, but it depends on whether or not the patient or family member informs us of all the medications the patient is taking. She indicated the medications from the plan of care should be included in the medication profile in the home.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure the home health aide followed accepted standards of practice to prevent the transmission of infections and communicable diseases in 1 of 1 home visits (#2) The findings include: Review of the agency policy, copyrighted in 2004, titled "Job Description-Title: Home Health Aide," stated "... Provides personal care, physical assistance, therapeutic exercises, and nursing supervised procedures to patients with medical and nursing needs. Maintains a clean and safe environment for the patient. Care is provided under the supervision of a Registered Professional Nurse and in accordance with the physician's plan of care ... Responsibilities ... Provides personal care; bathing, positioning, oral hygiene, hair care, shaving and linen changes ... Provides supportive service as needed to maintain a sanitary, safe environment for the patient, i.e. cleans bathroom, changes linens, etc ... Performs other duties appropriate to education or experience, as assigned ... Adheres to the agency's policies and procedures, and follows all applicable Indiana and Medicare regulations...." Clinical record review on 5/4/2021 for patient #2, primary diagnosis: Hemiplegia following cerebral infarction affecting left non dominate side (paralysis of one side of the body following a stroke), start of care 10/24/2019, evidenced an agency document titled "Aide Care Plan," dated 4/12/21, and signed by RN (Registered Nurse) D. This document had a subsection titled "Personal Care," which stated "... Complete Bath ... Q visit [every visit]...." A record review evidenced an agency document titled "Certified Home Health Aide and Personal Care Assistant Skills Check List," dated 11/16/20, signed by RN (Registered Nurse) C and home health aide E. This document indicated home health aide E met the demonstration of skills required to perform a bath at the bedside on 11/16/20. During a home visit on 5/4/21 at 11:18 a.m., home health aide E was observed while giving the patient a bed bath. The aide was observed filling two basins with clean water and cleaning the patient's face, arms, hands, chest, and abdominal area. The home health aide failed to be evidenced to have cleaned the two basins and add fresh water after cleaning each body section. The home health aide failed to follow standard / universal precautions. During an interview on 5/6/21 at 9:51 a.m., the administrator indicated in order to do a proper bed bath the clinician needs to prepare two basins, one with clean water and one with soap. She indicated the clinician should clean head to toe, starting with the head then obtains clean water and changes gloves. She indicated the clinician should then clean the armpits and get a new basin. She indicated the clinician should then clean the torso and private area and again obtain another clean basin. She indicated the clinician should then clean the extremities, turn the patient, and clean the back. The administrator indicated the basins should be cleaned after the clinician cleans the face, body, armpits, and private areas. She indicated the basins should be cleaned anytime the clinician moves to a new part of the body. The administrator also indicated the clinician that was observed giving the bed bath to patient #2 should have cleaned the basins after cleaning every section. 17-12-1(m)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse provided a complete care plan for the home health aide [HHA] in 1 of 1 active clinical records reviewed for patient's receiving wound care (#1). The findings include: Record review on 5/6/2021, evidenced an agency policy titled, "JOB DESCRIPTION - TITLE: HOME HEALTH NURSE (REGISTERED NURSE)", with copyright date 2004, which stated, "PRINCIPAL FUNCTION: Provides nursing care to assigned patients utilizing the Nursing Process to assess, plan, implement and evaluate patient service based upon a physician's plan of care. Coordinates care delivered by other health disciplines for assigned patients ... B. Planning ... 2. Develops nursing care lan for each assigned patient ... 3. Collaborates with other health disciplines in the development of a care plan, as indicated ... C. Implementation ... 5. Coordinates and supervises care delivery and patient status related to other health disciplines...." Record review on 5/6/2021, evidenced an agency policy titled, "JOB DESCRIPTION - TITLE: HOME HEALTH AIDE", with copyright date 2004, which stated, "PRINCIPAL FUNCTION: Provides personal care, physical assistance, therapeutic exercises, and nursing supervised procedures to patients with medical and nursing needs. Maintains a clean and safe environment for the patient. Care is provided under the supervision of a Registered Professional Nurse and in accordance with the physician's plan of care. RESPONSIBILITIES: 1. Provides patient care in accordance with the written care plan ... 10. Maintains patient safety ... 13. Documents patient care appropriately and completes necessary documentation according to agency policy...." Record review on 5/6/2021, evidenced an agency policy titled, "PATIENT CARE PLAN", with copyright date 2004, which stated, "1. The Patient care plan shall be written by appropriate member of the home health services team based upon plan of care and an assessment of the patient's needs, resources, family, environment, and goals. The initial assessment is to be made by a Registered Nurse...." Clinical record review on 5/3/2021 for patient #1, start of care 3/25/2021, certification period 3/25/2021 to 5/23/2021, and primary diagnosis of Pressure ulcer of right buttock, stage 2, evidenced an agency document titled, "Home Health Certification and Plan of Care", signed by the physician on 4/20/2021. The plan of care had a subcategory titled, "Safety Measures", which stated, "Keep pathway clear ... Anticoagulant Precautions. Safety in ADLs [activities of daily living] ... Fall Precautions...." Clinical record review evidenced an agency document titled "Aide Care Plan", dated 3/25/2021, and signed by the administrator. The aide care plan had a subcategory titled "Personal Care", which stated, " ... Back Rub / Massage PRN [as needed] ... Complete Bath PRN ... Oral Hygiene Denture Care PRN ... Partial Bath / Sponge PRN ... Shampoo Hair PRN ... Shower PRN....". The aide care plan had a subcategory titled "Activity", which stated, " ... Assist in Transfer Q [each] Visit PRN ... Range of Motion PRN ... Turn or Position PRN". The aide care plan failed to evidence anticoagulant precautions, fall precautions, or any safety measures. The skilled nurse failed to list the indications for when the home health aide was to perform the PRN tasks. During an interview on 5/6/2021 at 11:23 a.m., the administrator indicated the patient, family, and all disciplines of staff should be aware of and enforce fall and anticoagulant precautions. The administrator indicated safety precautions should be addressed by all disciplines of staff at each visit. When informed of the findings, the administrator indicated the skilled nurse failed to include safety precautions (anticoagulant precautions and fall precautions) in the aide care plan, and stated, "It needs to be revised". 17-13-2(a)

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the home health agency failed to ensure the home health aide reported changes in the patient's condition to a registered nurse or other appropriate skilled professional in 1 of 1 clinical records reviewed of patient's with a home visit. (#2) The findings include: Review of the agency job description copyrighted in 2004, titled "Job Description: Home Health Aide," stated "... Principal Function ... Provides personal care, physical assistance, therapeutic exercises, and nursing supervised procedures to patients with medical and nursing needs ... Care is provided under the supervision of a Registered Professional Nurse and in accordance with the physician's plan of care ... Responsibilities ... Recognizes and reports changes in client's condition to Nursing Supervisor and or Registered Nurse...." Clinical record review on 5/4/2021 for patient #2, primary diagnosis: Hemiplegia following cerebral infarction affecting left non dominant side (paralysis of one side of the body following a stroke), start of care 10/24/2019, evidenced an untitled agency aide care plan, dated 2/14/21, and signed by RN (Registered Nurse) D. This document stated "... Vital Sign Notification ... No Bowel Movement in 3 Days ...." A record review on 5/4/21 evidenced an agency document titled "HHA [Home Health Aide] Visit," dated 3/9/21, and signed by home health aide E. This document stated "... Last Bowel Movement ... 3/5/21 ...." Clinical record review failed to evidence the home health aide notified the nurse that the last bowel movement was 4 days prior. A record review on 5/4/21 evidenced an agency document titled "HHA [Home Health Aide] Visit," dated 4/9/21, and signed by home health aide E. This document stated "... Last Bowel Movement ... 4/1/21 ...." Clinical record review failed to evidence the home health aide notified the nurse that the last bowel movement was 8 days prior. During observation of a home visit on 5/4/21 at 11:07 a.m. for patient #2, the home health aide asked the family member when the patient last had a bowel movement. The family member indicated the patient last had a bowel movement on Friday 4/30/21. During observation of a home visit on 5/4/21 at 12:00 p.m. for patient #2, the home health aide was evidenced leaving the patient's home and indicated she was not going to notify the nurse about anything. The home health aide failed to notify the nurse about the patient not having a bowel movement for 4 days. During an interview on 5/6/21 at 9:55 a.m., the administrator indicated the aide should notify the nurse if the patient did not have a bowel movement after two days. She indicated if the aide was unable to get a hold of the nurse she has to call the administrator. She also indicated that during the home visit, the aide should have notified the nurse that the last bowel movement was on Friday.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure a registered nurse or other appropriately skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions made an onsite visit to the patient's home no less frequently than every 14 days in 1 of 1 clinical records reviewed of a patient with a home visit. (#2) The findings include: Review of the agency job description, copyrighted in 2004, titled "Job Description - Title: Nursing Supervisor," stated "... A Registered Professional Nurse who is responsible for supervision and coordination of field services in accordance with agency objectives, standards and policies. Assists with the development and implementation of home health services programs ... Responsibilities: ... Conducts supervision every 2 weeks for Home Health aide and in person supervisory visit every 60-day certification period to assess quality and appropriateness of service provision assess ongoing needs of client and caregivers. Assures documentation of assessment, intervention and plans...." Clinical record review on 5/4/2021 for patient #2, primary diagnosis: Hemiplegia following cerebral infarction affecting left non-dominate side (paralysis of one side of the body following a stroke), start of care 10/24/2019, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 2/15/21 - 4/15/21, and signed by RN (registered nurse) D. This document stated "... SN [Skilled Nursing]: 1x8 [once a week for 8 weeks] ... HHA [Home Health Aide]: 2x8 [twice a week for 8 weeks], 1x1 [then once a week for 1 week] ...." A record review evidenced an agency document titled "SNV[Skilled Nursing Visit] w/ [with] Aide Supervision," dated 4/6/21, and signed by RN D. This document indicated the home health aide was supervised while the aide was present. Clinical record review failed to evidence the agency made another supervisory visit of the aide within 14 days after this visit. During an interview on 5/6/21 at 10:12 a.m., the administrator indicated the aide should be supervised every 14 days, but the aide does not have to be there for the supervisory visit. She indicated after 4/6/21, the next supervisory visit was on 4/28/21 and they should have did an indirect supervisory visit on the recertification date of 4/11/21 and another one done before 4/25/21.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all entries were appropriately authenticated in 2 of 7 clinical records reviewed. (#2, #4) The findings include: 1. Clinical record review on 5/4/2021, for patient #2, primary diagnosis: Hemiplegia following cerebral infarction affecting left non-dominate side (paralysis of one side of the body following a stroke), start of care 10/24/2019, evidenced agency documents titled "SNV [Skilled Nursing Visit] w/ [with] Aide Supervision, " dated 2/22/21, 3/1/21, 3/8/21, 3/16/21, 3/23/21, 3/30/21, 4/6/21, and signed by RN (Registered Nurse) D. These documents had a subsection titled "Cardiovascular." These subsections indicated the peripheral pulses (pulses in the extremities) were weak. These same sections stated "... Cardiovascular ... WNL [within normal limits] ...." Clinical record review failed to evidence the clinician appropriately documented cardiovascular as outside normal limits as indicated by the weak pulses. During an interview on 5/6/21 at 10:18 a.m., the administrator indicated these documents should not be documented as WNL. 2. Clinical record review on 5/5/2021 for patient #4, primary diagnosis: Cellulitis (bacterial skin infection where the infected skin appears swollen and red and is typically painful and warm to the touch) of buttock, start of care 9/25/2020, evidenced an untitled agency comprehensive assessment, dated 10/12/2020, and signed by the administrator. This document had a subsection titled "Integumentary [skin] Status," which indicated there were 4 stage 2 pressure ulcers (shallow open ulcer with a red or pink wound bed) and none of them were present at the start of care. Clinical record review failed to evidence the clinician appropriately documented that 1 of the 4 stage 2 pressure ulcers were present on admission. During an interview on 5/5/21 at 10:52 a.m., the administrator indicated the document should state some of the stage 2 pressure ulcers were present on admission instead of saying none of the stage 2 pressure ulcers were present on admission, as it currently says. 17-15-1(a)(7)