Every finding on record at A W Holdings LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 11/21/24, 11/22/24, 11/25/24, 11/26/24, 11/27/24, 12/02/24, 12/03/24, 12/04/2024 Active Census: 49 At this Emergency Preparedness survey, Homepointe Healthcare 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: 11/21/24, 11/22/24, 11/25/24, 11/26/24, 11/27/24, 12/02/24, 12/03/24, 12/04/2024 The survey was announced as partially extended on 11/22/24 at 2:51 PM. 12-Month Unduplicated Skilled Admissions: 6 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse SN Skilled Nurse LPN Licensed Practical Nurse POC Plan of Care HHA Home Health Aide SOC Start of Care MD Medical Doctor CM Clinical Manager QR 12/11/24 A2

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence documentation of an initial assessment visit for 2 of 3 active records reviewed of patients admitted in 2024 (Patients #2, #4). Findings include: 1. An agency policy titled “Client Admission Process,” last revised 12/12/17, indicated the admission process included an evaluation by an RN “to determine the immediate care and support needs of the client,” which was to be completed by an initial assessment visit. 2. Patient #2’s clinical record indicated a referral date of 6/27/24 for skilled nursing services. The agency obtained an order to admit Patient to home health services on 9/06/24. RN 5 created and signed a plan of care on 9/06/24, pending insurance approval. Patient was admitted to the agency on 9/20/24. The record failed to evidence documentation of an initial assessment visit. During an interview with RN 4 and RN 5 on 11/26/24 beginning at 10:53 AM, RN 4 reported she and RN 5 conducted an initial “intake” assessment of Patient in-home prior to admission to the agency. The plan of care was then created based off identified needs from the initial assessment and other information obtained during the admission process. The nurses were unable to provide a date they performed Patient’s initial assessment. 3. Patient #4’s clinical record indicated Patient began receiving attendant care services from the agency on 8/17/23. The agency received a referral for skilled nursing and home health aide services on 1/05/24, and Patient’s start of care for SN and HHA services was 1/23/24. The record failed to evidence documentation of an initial assessment visit. During an interview with RN 5 on 12/02/24 beginning at 8:57 AM, she reported she was Patient’s nurse case manager. RN 5 stated after receiving the referral for SN and HHA services, she conducted an initial assessment visit with Patient, which included a “focused” physical assessment. RN 5 reported she did not document the initial assessment visit, as care needs identified during the visit were noted on Patient’s initial POC. 410 IAC 17-14-1(a)(1)(A)

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence documentation of the discharge comprehensive assessment for 1 of 1 closed record review of a patient discharged due to caregiver request (Patient #6). Findings include: 1. An agency policy titled “Client Discharge Process,” last revised 11/28/19, indicated the discharge process included completing a discharge assessment. 2. Patient #6’s clinical record included a discharge summary, dated 11/03/24, which indicated Patient was discharged from the agency effective 11/03/24 per caregiver request. The record failed to evidence documentation of a discharge comprehensive assessment. 3. During an interview with Clinical Manager and RN 4 on 12/02/24 beginning at 3:58 PM, the staff reported a discharge comprehensive assessment visit was conducted with Patient prior to discharge, however the staff was unsure of the date. When queried how the visit was documented, CM reported the agency had a discharge comprehensive assessment form, but she could not find documentation of the visit in Patient’s record.

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 home health agency failed to ensure the plan of care included all patient-specific interventions, for 5 of 5 complete active records reviewed (Patients #1, 2, 3, 4, 5). Findings include: 1. An agency policy titled “Nursing Care Plans Policy,” last revised 1/11/18, indicated nursing care plans would be developed by an RN and would “correspond to the problems identified” during an initial assessment, services needed, and goals for the patient. The nursing care plans were to include “a list of specific interventions with plans for implementation.” 2. Patient #1’s clinical record included a plan of care for the current recertification period of 11/18/24 – 1/16/25. The plan of care indicated Patient was to receive skilled nursing services. The record included nursing care plans for the problems of “Infection [related to] COVID-19 Pandemic … Alteration in Nutrition – Less Than Body Requirements … Communication, Impaired … Alteration in Cardiac Output … Activity Intolerance … Impaired Gas Exchange … Caregiver Role Strain … Newborn Care: Knowledge Deficit … Safety … Alteration in Comfort; Acute and Chronic Pain … Mobility Impairment … Skin Integrity Alteration …” which indicated nursing interventions to be performed routinely and as needed during visits. The plan of care failed to evidence all patient-specific interventions to be performed by nursing staff as indicated on the nursing care plans. During an interview with RN 4 on 11/22/24 beginning at 11:45 AM, she reported she was Patient’s nurse case manager. RN 4 stated the nursing interventions indicated on the nursing care plans were not included in the plan of care. 3. Patient #2’s clinical record included a plan of care for the current recertification period of 11/20/24 -1/16/25. The plan of care indicated Patient was to receive SN services. The record included nursing care plans for the problems of “Skin Integrity Alteration … Alteration in Nutrition – Less Than Body Requirements … Bowel Elimination – Diarrhea … Safety … Falls …” which indicated nursing interventions to be performed routinely and as needed during visits. The POC failed to evidence all patient-specific interventions to be performed by nursing staff as indicated on the nursing care plans. 4. Patient #3’s clinical record included a plan of care for the current recertification period of 10/18/24 – 12/16/24. The plan of care indicated Patient was to receive SN services. The record included nursing care plans for the problems of “Communication, Impaired … Safety … Alteration in Comfort; Acute and Chronic Pain … Activity Intolerance … Mobility Impairment … Infection r/t COVID-19 Pandemic … Skin Integrity Alteration …” which indicated nursing interventions to be performed routinely and as needed during visits. The POC failed to evidence all patient-specific interventions to be performed by nursing staff as indicated on the nursing care plans. During an interview with Clinical Manager on 12/02/24 beginning at 2:51 PM, she reported she was Patient’s nurse case manager. Clinical Manager reported all nursing interventions noted on Patient’s nursing care plans were not included on the POC. 5. Patient #4’s clinical record included a plan of care for the current recertification period of 11/18/24 – 1/16/25. The plan of care indicated Patient was to receive SN services. The record included nursing care plans for “Alteration in Comfort; Acute and Chronic Pain … Activity Intolerance … Caregiver Role Strain … Skin Integrity Alteration … Falls … Safety …” which indicated nursing interventions to be performed routinely and as needed during visits. The POC failed to evidence all patient-specific interventions to be performed by nursing staff as indicated on the nursing care plans. During an interview with RN 5 on 12/03/24 beginning at 8:57 AM, she reported she was Patient’s nurse case manager. RN 5 reported all nursing interventions noted on Patient’s nursing care plans were not included on the POC, as this was not the agency’s process. 6. Patient #5’s clinical record included a plan of care for the current recertification period of 11/22/24 – 1/20/25. The plan of care indicated Patient was to receive SN services. The record included nursing care plans for “Skin Integrity Alteration … Alteration in Comfort; Acute and Chronic Pain … Alteration in Nutrition – Less Than Body Requirements … Mobility Impairment … Safety … Infection … Caregiver Roll Strain … Activity Intolerance … Alteration in Cardiac Output …” which indicated nursing interventions to be performed routinely and as needed during visits. The POC failed to evidence all patient-specific interventions to be performed by nursing staff as indicated on the nursing care plans. During an interview with Clinical Manager on 12/04/24 beginning at 11:51 AM, she reported she was Patient’s nurse case manager. Clinical Manager reported all nursing interventions included within Patient’s nursing care plans were not included on the POC, as the POC was “physician driven.”

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 interview, the home health agency failed to ensure all care and services were provided according to physician orders for 2 of 5 active records reviewed (Patient #2, 5). Findings include: 1. Patient #2’s clinical record included a plan of care with a start of care date of 9/09/24, pending insurance approval. The plan of care indicated Patient was to receive skilled nursing services. Nursing interventions included “Ostomy [surgically created opening in abdominal wall] orders (poor seal, adaptive ring, pediatric bag): Dependent on surgery on 8/16/24.” The plan of care failed to evidence further instructions on ostomy care to be provided by nursing staff. The record indicated Patient was admitted to the home health agency on 9/20/24. RN 4 and RN 5 conducted an admission comprehensive assessment and RN 3 conducted a SN visit on 9/20/24. RN 3 documented she changed Patient’s ostomy appliance during the visit. The record failed to evidence physician orders for Patient’s ostomy care were obtained prior to RN 3 changing Patient’s ostomy appliance. During an interview with RN 3 on 11/25/24 beginning at 4:42 PM, she reported during her first visit with Patient on 9/20/24, RN 4 and RN 5 were working on the admission process, including creating the plan of care, while RN 3 was providing care to Patient. When queried how the nurse knew what tasks and interventions to perform, RN 3 reported care was provided according to Person A’s, primary caregiver to Patient, instructions. During an interview with RN 4 and RN 5 on 11/26/24 beginning at 2:56 PM, RN 4 reported the nurses did not obtain orders for Patient’s ostomy care during the admission comprehensive assessment visit on 9/20/24. RN 4 reported ostomy care provided by RN 3 during the 9/20/24 visit would have been per Person A’s instructions and/or hospital discharge instructions. The record failed to provide hospital discharge instructions with ostomy care orders dated prior to 9/20/24. The record included a physician order to check Patient’s blood sugar twice a day. SN visit notes, signed by RN 2 and dated 11/08/24, 11/11/24, 11/12/24, and 11/15/24, failed to evidence Patient’s blood sugar had been checked and documented twice a day according to physician’s orders. During an interview with RN 2 on 11/25/24 beginning at 3:04 PM, she reported Patient’s blood sugars were ordered to be checked twice a day, however Patient’s blood sugars were being checked only once a day per Person A, primary caregiver for Patient #2. The record failed to evidence Person A’s request nor physician orders to decrease the frequency of blood sugar checks. 2. Patient #5’s clinical record included a plan of care for the recertification period of 9/23/24 – 11/21/24 which indicated Patient was to receive SN services. Patient’s services were placed on hold by the agency on 11/05/24 due to hospitalization. The record included a written physician order, dated 11/11/24 and signed by Clinical Manager, to resume home health services, effective 11/11/24. The record failed to evidence a signed written order nor verbal order to resume services had been obtained by the agency prior to resuming home health services. The record indicated skilled nursing visits were conducted on 11/13/24, 11/14/24, 11/15/24, 11/16/24, 11/20/24, 11/21/24, and 11/22/24 without physician orders. During an interview with Clinical Manager on 12/04/24 beginning at 11:51 AM, she reported when Patient was discharged from the hospital, CM called Patient’s physician office and to notify the agency was resuming home health services, then sent a written physician order for signature. CM stated she was unsure if the physician office staff she spoke with were licensed, and indicated a verbal order to resume care was not obtained. 410 IAC 17-13-1(a)

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 promptly alert the physician of changes in the patient’s condition for 2 of 2 active records reviewed which evidenced a change in patient condition (Patients #1, 2) and failed to notify the physician of its inability to provide services as ordered for 1 of 4 active records reviewed with missed or shortened visits (Patient #3). Findings include: 1. An agency policy titled “Services Provided Policy,” last revised 9/08/23, indicated the agency would notify the patient’s physician if scheduled visits were unable to be performed or rescheduled. 2. Patient #1’s clinical record indicated Patient was to receive skilled nursing services. A SN visit note, dated 11/04/24 by LPN 3, indicated Patient had a rash to his/her hands, feet, nose, right cheek, and around the mouth. The record indicated LPN 3 suspected Patient had hand, foot, and mouth disease (a viral infection which causes a rash and/or sores). The record failed to evidence Patient’s physician was notified of Patient’s new rash. During an interview with LPN 3 on 11/26/24 beginning at 4:55 PM, she reported she was notified of the new rash by Patient’s primary caregiver on 11/03/24. After the nurse conducted her visit with Patient on 11/04/24, she notified RN 4, Patient’s nurse case manager, of the rash. LPN 3 reported she did not notify Patient’s physician of the change in Patient’s condition. During an interview with RN 4 and CM on 11/27/24 beginning at 9:30 AM, CM reported the nurse conducting the SN visit was responsible for communicating a change in patient condition to the patient’s physician. RN 4 reported she was unaware if LPN 3 or other staff notified Patient’s physician of the new rash. 3. Patient #2’s clinical record indicated Patient was to receive skilled nursing services. A SN visit note, dated 10/29/24 by RN 2, indicated Patient had a fever and potential seizure activity during the nurse’s visit. The record failed to evidence Patient’s physician was notified of the potential seizure activity. During an interview with RN 2 on 11/25/24 beginning at 3:04 PM, she reported during the 10/29/24 visit, Patient had “stiffened up” and “startled longer than normal.” RN 2 reported she did not notify Patient’s physician of the potential seizure activity. During an interview with RN 4 and Alternate Clinical Manager on 11/26/24 beginning at 10:53 AM, RN 4 reported she was Patient’s nurse case manager. RN 4 stated Patient had a previous diagnosis of a seizure disorder from when he/she was “younger,” but the nurse was unaware of Patient having any seizures since beginning care with the agency on 9/20/24. Alternate Clinical Manager stated RN 2 should have notified Patient’s physician of the potential seizure activity on 10/29/24. 4. Patient #3’s clinical record indicated Patient was to receive skilled nursing services, with visits to be 10-13 hours per day, 4-5 days per week, with 1 additional day per week for 5-8 hours. The record indicated SN visits conducted on 10/04/24, 10/11/24, 10/18/24, 10/25/24, 11/01/24, 11/08/24, and 11/15/24 did not meet the minimum ordered duration of visits. The record failed to evidence Patient’s physician was notified of the shortened visits. During an interview with Clinical Manager on 12/02/24 beginning at 2:51 PM, she reported she was Patient’s nurse case manager. CM stated Administrative Assistant 1 was responsible for notifying the physician of any missed or shortened visits. During an interview with Administrative Assistant 1 on 12/02/24 beginning at 2:57 PM, she reported she was unable to find evidence of physician notification regarding Patient’s shortened visits for the requested dates. 410 IAC 17-13-1(a)(2)

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to coordinate care with all outside entities providing home health services to 1 of 1 active record reviewed of a patient receiving home health services from an outside entity (Patient #2). Findings include: 1. Patient #2’s clinical record indicated a start of care date of 9/20/24. The record included a plan of care for the recertification period of 11/20/24 – 1/18/25. The POC indicated Patient was to have Total Parental Nutrition (TPN, a method of providing nutrition) administered thru a central line (a long IV placed into a large vein). The POC failed to evidence who was responsible for monitoring and changing Patient’s central line dressing. During an interview with Alternate Clinical Manager and RN 4 on 11/26/24 beginning at 10:53 AM, RN 4 reported she was Patient’s nurse case manager. RN 4 stated Patient’s central line was managed and dressing changes performed by Entity F, a home health agency. When queried how the agency coordinated care with Entity F, RN 4 reported she was unsure. Alternate Clinical Manager reported the agency should coordinate care with all agencies involved in a patient’s care by sending POCs to the other agency(ies). Later in the interview, RN 4 stated Person A, primary caregiver for Patient, had reported via text message that Entity D, a home health agency, was monitoring and changing Patient’s central line dressing once a week, as well as drawing blood work. During an interview with Person E, an employee of Entity F, on 11/26/24 beginning at 9:59 AM, he/she reported Patient had not received home health services from Entity F. Person E also stated Entity F did not service the county where Patient resided. During an interview with Person B, an employee of Entity C, a pharmacy, on 11/26/24 beginning at 10:40 AM, he/she confirmed the entity provided pharmacy services to Patient, which included preparing TPN. Person B stated per Entity C’s records, Patient’s central line was monitored and dressing changes performed by Entity D. 410 IAC 17-12-2(h)

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, policy review, and interview, the home health agency failed to ensure all staff followed standard precautions and agency policies/procedures for 2 of 3 home visit observations (Patients #2, 3). Findings include: 1. An agency policy titled “Standard Precautions Policy,” last reviewed 3/01/24, indicated when washing hands, staff should apply soap, rub hands “vigorously” for at least 30 seconds, then rinse off the soap. 2. An agency nurse competency form, titled “Central Line TPN Line Medication Administration and Flush Competency Evaluation,” indicated prior to preparing Total Parental Nutrition (TPN, a method of providing nutrition thru a central line), staff should apply disinfectant to the intended workstation. 3. The review of manufacturer’s instructions for Clorox disinfectant wipes, obtained 11/22/24 from www.clorox.com, indicated when using the wipe to disinfect, the surface should remain “visibly wet” for 4 minutes and should be allowed to dry. 4. During a home visit observation with Patient #2 on 11/22/24 beginning at 3:35 PM, RN 2 was observed preparing to administer Patient’s TPN. The nurse removed the TPN bag and holding case from a desk, cleaned the desk surface with a Clorox disinfectant wipe, then immediately placed the TPN bag, holding case, and other supplies onto the wet desk surface. After preparing the TPN, RN 2 went to Patient’s bedside. The nurse scrubbed the connection hub of Patient’s central line for 10 seconds, then connected a saline flush syringe. During an interview with RN 2 on 11/25/24 beginning at 3:04 PM, she reported on 11/22/24 she cleaned the desk surface with a Clorox wipe prior to preparing the TPN. The nurse was unsure of the dry time for the Clorox wipe, and could not recall if she allowed the desk surface to dry prior to returning items and beginning TPN preparation procedures. RN 2 stated the connection hub of a central lines should be scrubbed with an alcohol wipe for 15 seconds prior to connecting the saline syringe. During an interview with administrative staff on 11/25/24 beginning at 4:21 PM, Alternate Clinical Supervisor reported it would be “ideal” for staff to allow a surface wiped with a disinfectant wipe to dry prior to continuing with TPN preparation procedures. The administrative staff was unsure of the dry time of Clorox wipes. RN 4, nurse case manager for Patient #2, reported staff should scrub the hub of a central line for 30 seconds prior to connecting a syringe or tubing. 5. During a home visit observation with Patient #3 on 11/25/24 beginning at 8:58 AM. During the visit, LPN 1 was observed washing her hands prior to preparing and administering medications. The nurse scrubbed her hands outside of running water for 8 seconds, then scrubbed for the remaining time under running water. Soap was not observed on the nurse’s hands while she scrubbed under running water. During an interview with LPN 1 on 11/25/24, she reported when washing her hands, she would scrub for “15-20” seconds outside of running water, then repeat under running water. 410 IAC 17-12-1(m)

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review, agency nurse competency review, complaint log review, and interview, the home health agency failed to re-educate staff when a breach in infection control procedures was reported for 1 of 1 record reviewed of a patient with a central line (Patient #2). Findings include: 1. An agency nurse competency form, titled “Central Line TPN Line Medication Administration and Flush Competency Evaluation,” indicated prior to priming the IV tubing for Total Parental Nutrition (TPN, a method of providing nutrition thru a central line), staff should perform hand hygiene and apply non-sterile gloves. 2. An agency grievance form dated 10/14/24 and completed by RN 4, nurse case manager for Patient #2, indicated Person A, primary caregiver to Patient #2 and Patient #8, had notified RN 4 on 10/11/24 of RN 3’s potential breach in infection control procedures. The note indicated while RN 2 and Person A were priming Patient #2’s TPN tubing, RN 3 “came up and grabbed the end cap of the tubing for the TPN out of [Person A’s] hand. [Person A] was upset because [he/she] said [RN 3] did not have gloves on” while priming Patient #2’s TPN tubing. RN 4 documented she and Clinical Manager spoke with RN 3 regarding the alleged incident. RN 3 reportedly stated the priming of TPN tubing did not require a sterile setting and “nowhere [the nurse] touched was being contaminated ….” The complaint documentation failed to evidence the agency re-educated RN 3 on agency infection control procedures for priming TPN tubing. 3. Patient #2’s clinical record included a plan of care for the initial certification period of 9/20/24 – 11/19/24, which indicated Patient was to receive skilled nursing services. The POC indicated Patient had a central line (a long IV placed into a large vein) thru which staff were to administer TPN. The record indicated RN 2 conducted a SN visit on 10/11/24 from 8:30 AM – 4:30 PM, during which the nurse changed Patient’s TPN bag. Patient #8’s clinical record indicated Patient was to receive SN services, and Patient resided in the same location as Patient #2. The record indicated RN 3 conducted a SN visit with Patient #8 on 10/11/24 from 8:30 AM – 4:30 PM. During an interview with Person A on 11/22/24 beginning at 4:41 PM, he/she reported on 10/11/24, while RN 2 and Person A were priming Patient’s new TPN tubing, RN 3 removed the tubing end cap without performing hand hygiene and donning gloves. Person A stated he/she had previously been trained to perform hand hygiene then wear gloves when priming TPN tubing, including when removing the tubing’s end cap. Person A stated he/she reported the breach in infection control procedures to RN 4. During an interview with RN 2 on 11/25/24 beginning at 3:04 PM, she reported on 10/11/24, she observed RN 3 failing to wear gloves when priming TPN tubing. RN 2 reported she observed Person A report the breach in infection control procedures to RN 4. During an interview with RN 3 on 11/25/24 beginning at 4:42 PM, she reported on 10/11/24, while caring for Patient #8, she observed RN 2 and Person A priming Patient #2’s TPN tubing with the tubing end cap on. RN 3 reported the end cap of the TPN tubing needed to be removed in order for it to prime correctly, so she removed the cap. Person A reportedly told RN 3 this was a breach in infection control procedures, as hand hygiene should be performed and gloves worn prior to touching the tubing end cap. RN 3 was unable to recall if she had performed hand hygiene prior to removing the cap, and reported she did not wear gloves. The nurse stated when priming TPN tubing, she was to perform hand hygiene, but gloves were not required for this procedure. RN 3 reported she spoke with RN 4 and CM regarding the incident but had not received any re-education on agency procedures for priming TPN tubing. During an interview with RN 4 and CM on 11/26/24 beginning at 10:53 AM, the staff reported they spoke with Person A and RN 3 regarding the reported incident and had not identified any breaches in infection control procedures. The staff stated they had not performed any re-education with RN 3 regarding TPN priming procedures.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to supervise all HHAs to ensure the aide completed all tasks according to the aide care plan for 1 of 1 complete active record review of a patient receiving HHA services (Patient #4). Findings include: 1. Patient #4’s clinical record indicated Patient was to receive home health aide services. The record included an aide care plan which indicated tasks the aide was to perform at each visit included but were not limited to obtaining Patient’s temperature, pulse, and blood pressure; assisting with personal care, dressing, hair care, skin care, oral and gum care, elimination, and perineal care (cleaning the genital and rectal areas); checking pressure areas, medication reminders, transfer assistance, positioning, and meal preparation. The aide was also to assist Patient with showering and shampooing their hair “weekly.” The record indicated HHA 5 conducted an HHA visit on 10/14/24, which was the only aide visit for the week of 10/14/24 – 10/20/24. The visit flowsheet failed to evidence HHA 5 completed all tasks according to the aide care plan. The record indicated RN 5 conducted an HHA Supervisory Visit of HHA 5 on 10/15/24. The aide was not present for the visit. The supervisory visit note indicated HHA 5 had not “completed appropriate records in compliance with [the agency’s] policies and procedures … followed the client’s plan of care for the completion of tasks assigned ….” The record indicated HHA 5 conducted an HHA visit on 10/21/24, which was the only aide visit for the week of 10/21/24 – 10/27/24. The visit flowsheet failed to evidence HHA 5 completed all tasks according to the aide care plan. The record failed to evidence RN 5 followed up with HHA 5 regarding the aide’s continued failure to complete all tasks according to the aide care plan. During an interview with RN 5 on 12/03/24 beginning at 8:57 AM, she reported after the 10/15/24 aide supervisory visit, she discussed with HHA 5 how to document tasks performed. The nurse did not perform an in-person supervisory visit with Patient #4 and HHA 5 to ensure all tasks were performed according to the aide care plan. RN 5 reported that HHA 5’s documentation was “better” on 10/21/24, and the aide had documented that she had completed more, but not all, of the assigned tasks per the care plan. The nurse stated she had multiple follow-up conversations with HHA 5 regarding the requirements for following the aide care plan and documentation, however she was unable to provide documentation of these conversations. 410 IAC 17-14-1(n)

This visit was a federal recertification and state re-licensure of a home health provider with 1 complaint. The survey was announced as partially extended on 2/25/2022 at 9:21 a.m. Complaint Number 29472: Unsubstantiated: Lack of sufficient evidence. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. QA: 3/21/2022

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the agency failed to ensure a drug interaction review completed included all medications listed on the plan of care, for 1 of 5 active records reviewed (#7). Findings include: Review of an agency policy dated 03/06/20, titled “Client Comprehensive Assessment (C-145)” included, but not limited to, “… will accurately reflect and include … review of all medications the client is currently using in order to identify … adverse effects and drug reactions … ineffective drug therapy … significant side effects … significant drug interactions … duplicate drug therapy ….” A record review for Patient #7 was completed on 02/24/22, start of care date 11/25/20, and included a document titled “Home Health Certification and Plan of Care”, for certification period 01/19/22-03/19/22, with a primary diagnosis of feeding difficulties (difficulty swallowing), and, but not limited to, monoallelic mutation of CACNA1 (condition that causes movement disorder). This plan of care included the daily medications of Clonidine [used for movement disorder]. The most recent medication interaction review, was dated01/18/2022 and failed to evidence a drug interaction for clonidine. During an interview on 02/24/22 at 3:30 PM, Employee C, clinical supervisor, indicated there should be a drug regimen review for clonidine.

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 policy review, record review, and interview the agency failed to ensure all physician orders were executed in 1 of 5 active records reviewed (Patient #2). Findings include: 1. Review of an agency job description dated 01/18, titled “Registered Nurse” included, but not limited to, “… develops and/ or follows an individualized Plan of Care … that incorporates the individual client’s specific needs ….” Review of an agency policy dated 03/06/20, titled “Client Plan of Care (C-580)” stated, "C. The individualized Plan of Care must specify the care and services necessary to meet the client specific needs as identified in the comprehensive assessment, including identification of the responsible disciple." 2. Record review for Patient #2 was completed on 02/23/22, start of care date 10/17/18, included a document titled “Home Health Certification and Plan of Care,” for certification period 01/04/2022 to 03/04/2022, with primary diagnosis of Cerebral Palsy (damage that occurs to the immature, developing brain that affects movement and muscle tone or posture) and diagnosis of tracheostomy (a surgical opening made through the neck into the windpipe) with physician orders that included skilled nursing visits 6 to 16 hours per day, 4 to 7 days per week, throughout the certification period, and orders for the skilled nurse to change the patient's "trach" [tracheostomy] "every 1-2 weeks.” Review of skilled nurse visit notes, titled “Nursing Flow Sheet” for the dates 01/04/22 to 02/02/22 and 02/04/22 to 02/13/22 [There was no skilled nurse visit on 02/03/2022.] failed to evidence the tracheostomy change was completed by the skilled nurse from 01/04/2022 through 02/13/2022. During an interview on 02/24/22 at 3:00 PM, Employee C, clinical supervisor, indicated the patient’s mother changed the trach on Mondays.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the skilled nurse failed to ensure the comprehensive assessment included a complete cardiopulmonary assessment in 1 of 5 active records reviewed (Patient #2). Findings include: 1. The agency policy with a revision date of 4/14/2020, retroactive date of 3/06/20, titled “Client Comprehensive Assessment (C-145)” stated, “C. Comprehensive assessment will accurately reflect and include … current health … status.” The agency policy with revision date 4/14/2020 and retroactive date of 3/06/2020 titled, Client Plan of Care (C-580)" stated, "The plan of care is based on a comprehensive assessment." 2. Record review on 02/23/22 for patient #2, start of care10/17/18, included document titled “Home Health Certification and Plan of Care” for certification period 01/04/22 to 03/04/22, with diagnoses but not limited to, Chronic Obstructive Pulmonary Disease (inflammatory lung disease that causes obstructed airflow from the lungs), tracheostomy (surgical opening made through the neck into the windpipe), and Ventilator Dependence (requires a device to mechanically pump oxygen into the body). The record evidenced an agency document titled “Comprehensive Assessment” dated 01/03/22 which failed to evidence a complete cardiopulmonary assessment of heart sounds, edema, and pulses. During an interview on 02/24/22 at 3:00 PM, when queried as to the lack of a cardiopulmonary assessment, Employee C, the clinical supervisor, indicated the information would be documented in the physician summary in the plan of care.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the agency failed to follow their policy and ensure all visit notes were received by the agency office within 7 days for 2 of 5 active records reviewed (Patients #1 and 7). Findings include: Review of a policy titled “Clinical Records & Medical Record Retention (C – 450)," with a revision date of 11/13/2018, revealed documentation of services must “… be incorporated/ filed in the clinical record within fourteen (14) days.” A record review was completed on 2/23/2022 for Patient #3, start of care 2/8/2020, for the certification period 12/31/2021 – 2/28/2022. Review of the record revealed notes missing from the record for nursing services provided on 2/4/2022 and 2/6/2022. The note dated 2/4/2022 was received in the office on 2/14/2022, and the note dated 2/6/2022, was received in the office 2/9/2022. The notes were provided upon request on 2/23/2022. During an interview on 2/21/2022 at 9:20 p.m., Employee A, Administrator, indicated clinical notes should be incorporated into the chart within 14 days of the service. 410 IAC 17 - 15 - 1(a)(4) Review of an agency policy titled “Clinical Records & Medical Record Retention (C – 450)," with a revision date of 11/13/2018, indicated “… required documentation for each service must be … returned to the office within seven (7) [sic] of when services where [sic] provided and incorporated/ filed in the clinical record within fourteen (14) days ….” A record review was completed on 02/23/22 for Patient #1, start of care 08/05/21, for the certification period 02/01/22 – 04/01/22. Review of the record revealed nursing flow sheet notes missing from the record for services provided on 02/11/22, 02/15/22, 02/16/22, 02/17/22 and 02/18/22. The notes were provided upon request on 02/25/22. The notes for 02/16/22 and 02/17/22 were date stamped as received in the office on 02/23/22. Employee C, clinical supervisor indicated the notes for 02/11/22, 02/15/22 and 02/18/22 were received in the office on 02/25/22. The record failed to evidence the nursing flow sheet notes were returned to the office within 7 days of when services were provided and incorporated in the clinical record within 14 days. During an interview on 02/24/22 at 3:20 PM, Employee C, clinical supervisor, indicated would provide the missing records on 02/25/22. A record review was completed on 2/24/2022 for Patient #7, start of care 11/25/20, for the certification period 01/19/22 – 03/19/22. Review of the record revealed home health aide notes missing from the record for services provided on 02/10/22, 02/11/22 and 02/18/22. The notes were provided upon request on 02/25/22. The notes were date stamped as received in the office on 02/24/22. The record failed to evidence the home health aide visit notes were returned to the office within 7 days of when services were provided and incorporated in the clinical record within 14 days. During an interview on 02/24/22 at 3:30 PM, Employee C, clinical supervisor, indicated would provide the missing records on 02/25/22.