Every finding on record at Above & Beyond Homecare Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: February 26, 27, and 28, and March 3 and 4, 2025 Active Census: 133 At this Emergency Preparedness survey, Above & Beyond Homecare was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. Abbreviations: EP Emergency Preparedness QR 3/7/25

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: February 26, 27, and 28, and March 3 and 4, 2025 12-Month Unduplicated Skilled Admissions: 2 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: RN Registered Nurse

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 and record review, the home health agency failed to ensure employees followed standards of practice for bag technique to reduce the spread of infections for 1 of 1 home visit observations with the alternate Clinical Manager. Findings include: 1. The agency policy “Bag Technique”, last updated 4/21/22, indicated the bag should be kept closed when not in use; soiled reusable items must be cleaned and disinfected prior to returning to the bag, per agency protocol with the one (1) minute dwell time per manufactures instructions on the disinfecting wipes and once reusable items are cleaned, place them on a clean surface. 2. During a home visit observation conducted with Patient #2 and Alternate CM on 2/28/25 beginning at 9:59 AM, Alternate CM cleaned the vitals equipment with a hydrogen peroxide disinfecting wipe and then sat the items on a clean barrier pocket of the nurse bag to air dry. The dirty paper barrier the nurse bag was sitting on draped over this clean area touching the blood pressure cuff. Later in the visit, Alternate CM cleaned the tablet and clipboard with a disinfecting wipe and placed the items immediately back into the nurse bag. Alternate CM failed to allow the items to air dry. 3. During an interview on 2/28/25 at 11:26 AM, Alternate CM relayed the dry time of the hydrogen peroxide disinfecting wipe was one minute. She relayed the nurse bag was sat on a different chair during the visit and she confirmed the dirty barrier touched the clean area of the nurse bag. 410 IAC 17-12-1(m)

This visit was for a federal Recertification and State Licensure Survey. Survey Dates: 3/29, 3/30, 3/31, and 4/1/2022. Above and Beyond Home Care was found to be in compliance with Emergency Preparedness at 42 CFR 484.102.

This visit was for a Recertification and State Licensure Survey. The survey was announced as partially extended on 3/31/2022 at 11:33 AM and was announced as fully extended on 4/1/2022 at 2:46 PM. Survey Dates: 3/29, 3/30, 3/31, and 4/1/2022. Census: 96 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State findings. Quality Review x2 completed on 5/13/22

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 home health agency failed to ensure the registered nurse [RN] accurately assessed blindness as a sensory loss, in 1 of 5 active clinical records reviewed (Patient #2). Findings include: An agency policy titled “Clinical Documentation,” undated, indicated but was not limited to “…to ensure there is an accurate record of all services provided ….” The clinical record of Patient #2, with start of care of 9/09/2020, was reviewed on 3/30/22. The comprehensive assessment dated 2/28/22, indicated “Neuro Assessment … WNL [within normal limits] / PERRLA [pupils, equal, round, reactive to light and accommodation] /: Yes … Motor / Gait: Unsteady gait, Loss of balance coordination … Other Neuro…Seizures … Sensory loss: No ….” The plan of care for the certification period 3/3/22 to 5/1/22 included the diagnoses, but not limited to, bipolar disorder and legal blindness. During an interview on 4/01/22 at 3:00 PM, RN #2 relayed, after review of the recertification assessment, “I guess I just never put two and two together on that one.” A skilled nurse visit note, dated 3/14/22, indicated “ … Neuro - Progress … WNL / PERRLA / A&O [alert and oriented]: Yes … Cognitive / Emotional Status: Forgetful…Motor / Gait: Unsteady gait, Loss of balance / coordination…Other Neuro: Seizures…” A skilled nurse visit note dated 3/28/22, indicated “ ... Neuro - Progress … WNL / PRRLA / A&O: Yes … Cognitive / Emotional Status: Forgetful … Motor / Gait: Unsteady gait, Loss of balance/ coordination … Other Neuro: Headaches, Seizures ….” During an interview on 4/1/22 beginning at 3:00 PM, RN #2 indicated they interpreted WNL as what was normal for the patient and indicated they struggled to answer that question in the assessment.

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 clinical record review and interview, the agency failed to ensure home health aide services were provided as ordered and services were not reduced or placed on hold due to lack of staffing in 3 of 5 active records reviewed with orders for home health aide services only (#7, 10, and 11). Findings include: The clinical record of Patient #7, with start of care 6/08/2021, was reviewed on 3/30/22. The record included a plan of care [POC] for the certification period 02/3/22 - 4/3/22 with patient diagnoses that included, but not limited to, autistic disorder, pervasive developmental disorder, attention deficit hyperactivity disorder, and urinary incontinence. The POC included the physician orders for home health aide (HHA) 3 visits per week for 1 week effective 02/03/22 and then 5-7 visits per week, 2-5 hours per visit (up to 24 hours per week) for 8 weeks. The home health agency failed to provide the minimum number of home health aide visits for first 8 weeks of the certification period. Week 1, the patient received 1 HHA visit for a total of 5 hours. Week 2, the patient received 3 visits for a total of 13 hours. Week 3, the patient received 3 visits for a total of 12 hours. Week 4, the patient received 3 visits for a total of 13.75 hours. Week 5, the patient received 4 visits for a total of 15.75 hours. Week 6, the patient received 4 visits for a total of 14 hours. Week 7, the patient received 4 visits for a total of 14.75 hours. Week 8, the patient received 3 visits for a total of 11.5 hours. An interview was conducted on 4/1/22 at 3:30 pm with the Clinical Manager. During the interview the Clinical Manager confirmed that when 5-7 home health aide visits per week are ordered in the plan of care, the agency should provide home health aide services for at least 5 visits per week “unless there is an interim order written specifying otherwise.” Clinical record review occurred on 3/31/2022, for Patient #10 for certification period 3/31/2022 to 5/29/2022. The agency’s electronic medical record revealed that Patient #10 was “on hold” and with an active certification period of 3/31/2022 to 5/29/22. Review of the assessment, completed on 3/28/2022 by Employee D a registered nurse, revealed the diagnoses / symptoms of lupus (the immune system attacks healthy tissue in many parts of the body), lymphedema (inability of the body to drain fluid which is normally drained through the lymphatic system) repeated falls, systemic involvement of connective tissue (damage to the connective tissue that holds the body structure together), fracture of the right ring finger, and chronic pain. The assessment revealed the associated symptoms were controlled with difficulty, affected daily functioning, and the need for ongoing monitoring. On the 4/01/2022, it was requested, of the clinical director, to provide the most recent home health aide visit notes. The clinical director provided, on 4/01/22 at 3 PM, home health aide visit notes which revealed Patient #10's last aide visit was completed on 02/07/2022. The clinical director confirmed, verbally, the last aide visit was provided on 02/07/22 and relayed they [the agency] was following the plan of care [POC] because the agency notified the physician and they had a physician order to place the patient's services on hold. The record evidenced a physician order, dated 02/08/22 to place the service on hold. Review of the record failed to evidence services were provided from 02/07/2022 through the end of the prior certification period ending 3/30/2022 nor were any services provided during the current certification period, which began on 3/31/2022, the patient remained "on hold." The record evidenced a recertification assessment was completed on 3/28/2022. The assessment identified Home Health Aide services of 3 - 5 days per week, for 1 – 3 hours per visit. Review of the plan of care for certification period 3/31/2022 – 5/29/2022, included physician orders for Home Health Aide services 3 – 5 days per week for 1 – 3 hours per visit for the assistance with showering, dressing, hair care, hand / foot care, skin care, meal preparation and set up. The plan of care revealed Patient #10 had no primary caregiver. Notes for Patient #10’s, within the electronic medical record, [EMR] revealed the patient’s representative (son / daughter) contacted the agency on 3/1/2022, and requested services to restart, that the patient's request to try to do as much as they could independently had failed, and indicated, “… starting up services again ….” Another EMR note, dated 3/29/2022, revealed a case conference note, which indicated Patient #10 wanted to try performing tasks on her own to see if he / she could be independent. The document also revealed Patient #10’s needs and deficits as “… decreased endurance, tires easily, has decreased participation in activities when [Patient #10’s] pain increases, continues to have increased risk for alteration in skin integrity due to incontinence and [Patient #10] is a fall risk due to unsteady gait with dependence on assistive device. [Patient #10] has no local family available for assistance.” The note revealed home health aide services of 3 – 5 days a week, 1 – 3 hours per visit. The note concluded “Will continue with services as ordered. [Patient #10] will be updated on new hire’s availability.” A phone interview was conducted with Patient #10 on 3/31/2022 at 1:05 p.m. Patient #10 confirmed he / she requested services on hold to try to see his / her level of independence, “but that was about 6 weeks ago.” Patient #10 indicated he / she could not be independent and required continued home health aide services. Patient #10 denied refusing replacement aides, and relayed “they don’t have anybody.” During an interview on 3/29/2022 at 10:45 a.m., Employee B, Clinical Supervisor, confirmed the agency had difficulty hiring home health aides and had to turn down referrals as the agency did not have available staff. During an interview on 4/1/2022 at 3:00 p.m., Employee B, asserted the agency was providing services to this patient per the plan of care or physician order. A clinical record review occurred on 4/1/2022 for Patient #11, for certification period 3/15/2022 – 5/13/2022. The agency’s electronic medical record revealed Patient #11 was “on hold.” Review of the assessment for the certification period 3/15/2022 to 5/13/2022, completed on 3/11/2022 by Employee D, Registered Nurse, revealed the diagnoses / symptoms of Multiple Sclerosis (damage to the insulating covers of nerve cells in the brain and spinal cord, disrupting in nerve damage that disrupts communication between the brain and body), high blood pressure, weakness, hypothyroidism (abnormally low activity of the thyroid gland), depression, and fatigue. The assessment revealed the associated symptoms were controlled with difficulty, affecting daily functioning, and the need for ongoing monitoring. The EMR evidenced the last date service were provided to patient 11 was on 02/15/2022; a recertification assessment was completed on 3/11/2022. Review of the plan of care for certification period 3/15/2022 to 5/13/2022, revealed the need for Home Health Aide services 1 – 3 days per week for 3 – 5 hours per visit. The plan of care revealed patient needed “… assistance with showering, dressing, skin care, and meal prep. [Patient #11] has started having difficulty with standing unassisted.” The plan of care also revealed Patient #11 had no caregiver (other than the agency). Review of a document titled “Aide Care Plan” for certification period 3/15/2022 – 5/13/2022, revealed aide tasks for assistance with shower, hair care, mouth care, hand/ foot care, skin care, shave, assist with clothing, toileting, mobility, use of a walker, wheelchair, or cane; getting in or out of bed or chair, meal preparation, medication reminder, change bed linens, laundry, clean up area, and offering fluids. When the last week of home health aide notes were requested, the agency provided notes which revealed Patient #11’s last aide visit was 2/15/2022. Review of the record revealed notification of missed visits on the following dates and included comments regarding the missed visits: 1/26/2022, 1/27/2022: “Aide called off; client did not want a replacement sent.” 2/3/2022, 2/4/2022: “Client cancelled visit for the day due to weather conditions.” 2/16/2022, 2/17/2022, 2/18/2022: “Aide requested out; client stated she is okay while looking for a different caregiver.” 2/21/2022, 2/22/2022, 2/23/2022, 2/24/2022, 2/25/2022: “Aide requested out; client states she does not need replacement until permanent aide placed.” 2/28/2022, 3/2/2022, 3/2/2022, 3/4/2022, 3/4/2022: “Regular aide not available and client refused replacement.” An additional physician order effective 2/28/2022, revealed “Physician Orders for Services – Addendum.” The home health aide order was reduced to 1 – 3 days a week, 1 visit per day for 3 – 5 hours. The agency failed to provide physician ordered services, based on the patient assessed needs and functional deficits. During an interview on 4/1/2022 at 3:00 p.m., Employee B, Clinical Supervisor, asserted the agency was providing services to this patient per the plan of care or physician order. 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 observation, agency document review, and interview, the home health agency failed to direct their staff on specific products to use in the home for the decontamination of reusable tools and equipment and failed to follow accepted standards of practice and their own policies to prevent the transmission of infections and communicable diseases for 2 of 2 skilled nursing visits observed [Registered nurse # 1 with patients # 7 and 8). Findings include: An undated agency policy titled “Bag Technique,” indicated, but not limited to, “… following care … soiled reusable items must be cleaned and disinfected prior to returning to the bag, per agency protocol … once reusable items are cleaned, place them on a clean surface … perform hand hygiene … replace items into bag ….” An undated agency policy titled “Bag Technique In-Service,” indicated, but not limited to “…,there exists the risk for transmission of infection from one patient to another via contaminated nursing bags … preventing transmission through bag technique ….” During a home visit observation, conducted on 3/30/2022 at 9:32 AM, with Patient #7 (start of care 6/08/21) and Registered Nurse [RN] #1, after the nurse used a disposable wipe on the items / tools she used during the home visit assessment, RN #1 failed to place the items on a clean surface and allow to dry and failed to perform hand hygiene prior to returning the items to her nurse bag. During a home visit observation, conducted on 3/30/22 at 11:03 AM with Patient #8 (start of care 9/20/21) and RN #1, after the nurse used a disposable wipe on the items / tools she used during the home visit assessment, RN #1 failed to place the items on a clean surface and allow to dry and failed to perform hand hygiene prior to returning the items to her nurse bag. 410 IAC 17-12-1(m) During an interview at the daily conference on 3/31/2022, Employee B, the alternate administrator / clinical supervisor, relayed that reusable disinfected equipment, should be dry, before returned to the nurse's supply bag. When asked which product was to be used for the decontamination of the agency staff's tools, used in a patient home during a visit, employee B relayed that the staff may use any product of their choosing, the agency does not provide the product, the product the staff choose to use is to be labeled to kill 99%. When asked if they have directions for the use of the products the staff are using, employee B relayed the agency did not as every product would be different. 410 IAC 17 - 12 - 1(m)

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the safety of ALL patients and employees in regards to the lack of enforcement of the additional precautions intended to mitigate the transmission and spread of COVID-19. Findings include: During an interview on 3/29/2022 at the entrance conference, Employee B, the Alternate Administrator and Clinical Supervisor, stated he / she “would have to check” what mitigation the agency had in place for unvaccinated personnel, and that Employee A, the Administrator had the COVID policies. On 3/29/2022 at 12:04 PM, the alternate administrator provided a list of the agency’s vaccinated and unvaccinated staff. The list evidenced of their 106 employees, 44 applied for and were given a religious exemption. Review of the agency’s January 2022 Quality Assessment and Performance Improvement (QAPI) Plan revealed the following objectives which include, but are not limited to, “To identify deviations from agency and professional standards and pursue improvement opportunities by assessment, planning and evaluation, “To meet state and federal regulatory requirements,” and “To reduce factors that contributes [sic] to unanticipated adverse events and/ or outcomes.” The QAPI January 2022 meeting agenda revealed a section to address each of the objectives in the QAPI plan. This revealed additional objectives of “To address hi- risk [sic], hi- volume[sic], or problem prone areas,” and “Address any identified concerns that lead to an immediate correction of any identified problem that directly or potentially threatens the health and safety of patients.” Review of the Centers for Disease Control and Prevention [CDC] revealed options to reduce the spread of COVID – 19 among or by healthcare providers, which include, but not limited to, “A NIOSH [National Institute for Occupational Safety and Health] – approved N95 or equivalent or higher – level respirator” or a “well – fitting facemask.” Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html During the end of day conference on 3/31/2022, Employee A, Administrator, stated, “I understand you don’t like it, but that is our policy.” During all interactions with Employee C, the Muncie Branch Manager on 3/29/22, 3/30/22, 3/31/22, and 4/01/22, he / she was observed to wear a cloth mask, while within 6 feet of other unvaccinated employees and the surveyors. During an interview on 3/30/2022 which began at 10 AM, the administrator relayed relayed he provided a N95 mask to each staff member. When asked, if the agency's unvaccinated staff were to be wearing the N95 mask during all patient contact and / or when in the office, the administrator relayed that they may remove the mask, if they have difficulty breathing, and wear a well fitting mask. When asked if the agency is tracking or monitoring their unvaccinated staff to determine or identify which unvaccinated staff are wearing which type of mask, the administrator relayed they were not monitoring. The administrator indicated verbally, several times during the conversation, that their unvaccinated staff may choose to wear a well fitting mask as mitigation for the spread of SARS CoV2 [COVID-19]. On 4/01/2022 at 11:18 AM, when asked, the administrator relayed that the agency did not have a mechanism in place to ensure the implementation of additional precautions, intended for the spread of COVID-19; the administrator relayed the agency did not a process in place for tracking the vaccinate status of staff that obtain a booster, the administrator relayed they did not require their unvaccinated staff to obtain COVID – 19 testing; and relayed that their contingency staffing plan for unvaccinated staff was to use their office staff to complete home visits, that the office staff are also home health aides.

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 home health agency failed to ensure that orders for home health aides (HHA) on the plan of care were present on the Aide Care Plan for 1 of 7 active records with HHA orders reviewed (Patient #2). Findings include: The clinical record of Patient #2, with start of care of 9/09/2022, was reviewed on 3/30/22. The record included a plan of care (POC) for the certification period 3/03/22 to 5/01/22 that included the diagnoses, but not limited to, bipolar disorder, bulimia nervosa, and legal blindness. The POC included physician orders for HHA [home health aide] services, 3 to 5 days per week, 3 to 5 hours per visit for 60 days, aide to offer fluids for hydration and to offer 1 to 2 high protein shakes per day. The record included an aide care plan [list of aide tasks] that failed to include the aide task to offer the patient the physician ordered 1 - 2 high protein shakes per day. An interview was conducted on 4/1/22, beginning at 3:00 pm with registered nurse [RN] # 2. During the interview, the RN confirmed the aide plan of care should include the physician ordered task to offer 1 - 2 high protein shakes per day. 410 IAC 17 - 14 - 1(m)

This was a Federal and state Home Health complaint survey. Survey Dates: 5/24/21-5/26/21 Complaint Numbers: IN00354187; Substantiated: Federal deficiencies were cited. IN00351609; Substantiated: Federal deficiencies were cited. Provider Number: 15K024 Medicaid ID: 200829700 Facility ID: 004808 Census: 106 This deficiency reflects State Findings cited in accordance with 410 IAC 17.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide all services outlined in the plan of care for 1 of 5 clinical records reviewed (#2). Findings include: An undated document titled "Confidential Admission Packet," stated " ...As a patient ... you have the right to the following ... participate in, be informed about, and consent or refuse care, in advance of. And during treatment where appropriate, with respect to ... the frequency of visits ... receive all services outlined in the Plan of Care ...." An undated document titled "Service Agreement/Plan," stated " ...The client shall be advised of any changes in type or frequency of services ...." An undated document titled "Clinical Documentation," stated " ...Agency will document each direct communication with the client ... Telephone or other communication with clients, physicians, families, or other members of the health care team will be documented in clinical progress notes or other interagency communication form ... Services not provided and the reason for the missed visits will be documented and reported to the physician ...." The clinical record of patient #2 was reviewed on 5/24/2021 at 2:31 PM and indicated a start of care date of 5/6/2020. The record contained a plan of care for the certification dates 3/2/2021 to 4/30/2021 and indicated orders for home health aide visits 5 to 7 days per week, 1 to 2 visits per day, 3 to 6 hours per visit, during weeks 3 and 4. The agency failed to provide all services outlined in the plan of care as evidenced by: A document titled "Schedules for [Patient #2] - Visits by All Caregivers May 2021," indicated the 2 seven-hour visits were made on 5/15/2021 and 5/16/2021 (week 3), and 2 seven-hour visits were made on 5/22/2021 and 5/23/2021 (week 4). During an interview on 5/26/2021 at 11:00 AM, when asked if the patient had a right to receive all care/treatments ordered on the plan of care, the Clinical Supervisor indicated "yes."

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to thoroughly investigate and document complaints for 1 of 1 patient complaints reviewed (#3). Findings include: An undated document titled "Complaint Policy," stated " ...The Administrator or designee shall investigate the complaint ... This investigation shall include interviewing the complainant, the employee who is subject of the complaint, and any other individual who the Administrator or designee believes may have knowledge of the complaint ... The Administrator shall document the investigation and any conclusion reached as a result of investigation ...." The clinical record of patient #3 was reviewed on 5/24/2021 at 2:45 PM and indicated a start of care date of 6/19/2019. The record contained a plan of care for the certification period 4/9/2021 to 6/7/2021. An agency complaint reviewed from the complaint log on 5/24/2021 at 11:20 AM indicated " ...Received phone call from [investigator for Indiana State Department of Health] [Home health aide (HHA) D] stated he was charge with inappropriate relationship with a minor on 5/18/2021 ... Spoke with [Patient #4's Mother] ... informed of call from investigator ... we were removing [aide] from home ... she stated she was aware of charges and didn't want any other caregiver ... services were to be put on hold ... spoke with home health aide ... stated we were removing from home because of charges ... would suspend until charges were resolved ... results of investigation: still awaiting outcome of pending charges ... the agency took the following immediate action: no allegations of inappropriate conduct ..." The complaint failed to evidence a thorough complaint investigation as the patient was not interviewed and no referrals to outside agencies were made (i.e., child protective services). During an interview on 5/26/2021 at 11:00 AM, when asked how the agency ensured that complaints were thoroughly investigated, the Administrator indicated "do more supervisory visits and follow up with other clients." When asked if this process if documented, the Clinical Supervisor indicated "yes, it would be on the complaint form."

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 comprehensive assessment failed to contain all information about the current health status for 1 of 5 records reviewed (#1). Findings include: An undated policy titled "Comprehensive Client Assessment," stated " ...The Comprehensive Assessment must accurately reflect the client's status ... Assessment strategies ... MD or facility information ...." The clinical record of patient #1 was 5/24/2021 at 1:00 PM and indicated a start of care date of 7/3/19. The record contained a plan of care for the certification dates 4/32/21 to 6/21/21. The clinical record contained a recertification comprehensive assessment completed on 4/24/2021, which indicated on page 10 of 29, M1306 indicated the patient had no unhealed pressure injuries/injury at stage 2 or higher. On page 12 of 29, the Briggs Integumentary Status Chart, indicated the patient had bilateral stump (the distal end of a limb left after amputation) pressure ulcers, and that the wounds were unable to be assessed, as they were covered. The comprehensive assessment failed to evidence an accurate non-conflicting wound assessment. During an interview on 5/26/2021 at 11:00 AM, when asked if all information on the comprehensive assessment needed to be accurate for that patient at the time of assessment, the Clinical Supervisor indicated "yes."

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 agency failed to ensure the Registered Nurse coordinated with other agencies providing care to their patients for 1 of 5 records reviewed (#2). Findings include: An undated document titled "Coordination of Client Services," stated " ...Coordination of care will include dealing with multiple programs for the complex clients [cardiology, wound care, diabetes, neuro, etc.] ... Documentation must address the coordination activities ... Coordination will include providers of care who are not part of the agency ... When and how communication happens must be documented ... The agency Clinical Manager [Supervisor] or their designee will develop and implement the coordination plan ...." During an interview on 5/24/2021 at 2:32 PM, Patient #2 indicated that she used another agency for care as well, that her spouse worked for, so he is able to take care of her, and she thought they were called "Care Homes." The clinical record of patient #2 was reviewed on 5/24/2021 at 2:31 PM and indicated a start of care date of 5/6/2020. The record contained a plan of care for the certification dates 3/2/21 to 4/30/21. The record failed to evidence documentation of coordination of care with the other home health agency involved in the care of the patient. During an interview on 5/26/2021 at 11 AM, when asked if the agency should document coordination of care with any other agency involved in a patient's care, the Clinical Supervisor indicated "yes, if it's a home health agency."

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide was providing services in accordance with the plan of care/aide care plan for 1 of 5 records reviewed (#1). Findings include: An undated document titled "Home Health Aide Care Plan," stated " ...The Home Health Aide cannot be responsible for performing any procedure that is beyond his/her ability ...." The clinical record of patient #1 was 5/24/2021 at 1:00 PM and indicated a start of care date of 7/3/19. The record contained a plan of care for the certification dates 4/32/21 to 6/21/21. The record contained a Home Health Aide Care Plan, completed on 4/10/2021, indicating " ...Chair Bath (at sink) ... 3/27/2021 until wounds are healed ... Skin Care: (Moisturize, Inspect) ... Check stumps [the distal end of a limb left after amputation] when putting on/taking of prosthetics ...." The record contained a document titled "Visit Record and Time Sheet," completed by Employee E (Home Health Aide), indicating the HHA completed Skin Care (Moisturize, Inspect) on 4/25/2021, 4/26/2021, 4/27/2021, 4/28/2021, 4/29/2021, 4/30/2021, 5/1/2021, 5/2/2021, 5/3/2021, 5/4/2021, 5/5/2021, 5/6/2021, 5/7/2021, 5/8/2021, 5/9/2021, 5/10/2021, 5/11/2021, 5/12/2021, 5/13/2021, 5/14/2021, and 5/15/2021. The record failed to evidence documentation of a home health aide care plan that ordered tasks within the employee's scope of practice, according to the state law. During an interview on 5/26/2021 at 11 AM, when asked if Home Health Aides were permitted by state law to perform skin assessments, the Clinical Supervisor indicated "yes."