Every finding on record at Adaptive Nursing and Healthcare Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Date: May 17th, 18th, and 19th of 2021 12 Month Unduplicated Census = 969 At this Emergency Preparedness survey, Adaptive Nursing and Healthcare Services Inc was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This survey was for a Federal recertification and State relicensure survey in conjunction with an infection control focused COVID-19 survey. Survey Dates: May 17th, 18th, and 19th of 2021 Facility ID: 012872 12 month unduplicated census: 969 Partially Extended Survey Announced 5/18/2021 at 4:52 p.m. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Quality Review completed on 5/27/2021 A4

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 provide services as written in the plan of care for 4 of 17 records reviewed. (Patients 5, 15, 20, and 25) Findings include: 1. An April 10, 2019 policy titled Plan of Treatment was provided by Operations Manager M on 5/18/2021 at 11:50 a.m. The policy indicated, but was not limited to, " ... patient's health needs can be adequately met by the home health agency ..." 2. The clinical record for patient 20 was reviewed on 5/17/2021. The record contained a plan of care for the certification period of 3/16/2021 to 5/14/2021, with orders for home health aide 3 days a week for 2 hours a day. The clinical record evidenced the following: Clinical record 20 evidenced documentation of a home health aide visit on 3/23/2021 from 1:15 p.m. to 3:00 p.m. for a total of 1.75 hours; 0.25 hours were missed for the week of 3/21/2021 to 3/27/2021. Clinical record 20 failed to evidence documentation of a home health aide visit on 4/3/2021 for a total of 2 hours missed for the week of 3/28/2021 to 4/3/2021. Clinical record 20 failed to evidence documentation of a home health aide visit on 4/10/2021 for a total of 2 hours missed for the week of 4/4/2021 to 4/10/2021. Clinical record 20 failed to evidence documentation of a home health aide visit on 4/17/2021 for a total of 2 hours missed for the week of 4/11/2021 to 4/17/2021. 3. During an interview on 5/17/2021 at 4:30 p.m. Operations Manager M acknowledged the shortage of hours and indicated there was a shortage of staff.4. The clinical record for patient 15 was reviewed on 5/17/2021. The record contained a plan of care for the certification period of 3/24/2021 to 5/22/2021, with orders for home health aide 5-7 days a week for 3 hours a day. The clinical record evidenced the following: Clinical record 15 failed to evidence documentation of home health aide visits on 5/10/2021 and on 5/11/2021 for a total of 6 missed hours for the week of 5/9/2021 to 5/15/2021.5. The clinical record for Patient 5 was reviewed on 5/19/2021. The record contained a plan of care for the certification period from 4/6/2021-6/4/2021, with orders for a home health aide " ... to observe for signs/symptoms of respiratory distress ... then notify office RN." Clinical record 5 indicated, but was not limited to, a note titled Daily Visit Sheet dated 4/12/2021 signed by HHA D. The visit sheet notes included "Unusual findings ... Slept with no oxygen last night. Extreme tiredness today due to it .... Had to wear oxygen on and off today." The record failed to indicate that the home health aide notified the office RN of the signs and symptoms of respiratory distress. During an interview with the administrator on 5/19//2021 at 10:31 a.m., the administrator was asked to provide proof of the home health aide notifying the office RN of changes in the patient's respiratory status. At 11:29 a.m. the administrator stated they were unable to find a note showing the home health aide notified the office RN, and that "they should have." 6. The clinical record for Patient 25 was reviewed on 5/17/2021. The record contained a plan of care for the certification period from 3/7/2021-5/5/2021, with orders for a home health aide 1-2 hours a day, 3-5 days a week, and orders for the home health aide to assist patient with a tub/shower bath 3 times a week and a partial bath 3 times a week. The clinical record evidenced the following: The Daily Visit Sheets on the following dates/times failed to evidence documentation of a bath being given or refused: 3/12/2021 timed 9:34 a.m., 3/19/2021 timed 10:02 a.m., 3/25/2021 timed 9:38 a.m., 4/02/2021 timed 9:34 a.m., 4/03/2021 timed 9:31 a.m., 4/08/2021 timed 9:33 a.m., 4/09/2021 timed 9:41 a.m., and 4/15/2021 timed 10:37 a.m. During an interview with the administrator on 5/18/2021 at 11:00 a.m., the administrator was asked to show where to find a note from the home health aide indicating if a bath was given or refused. The admin provided the steps to find the notes and stated "If the home health aide made a note, it should have been there." 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, record review, and interview, the agency failed to ensure hand hygiene was performed and failed to ensure accepted standards of practice were used when completing a bed bath. (Patient 15) Findings include: A 5/15/20 policy titled Handwashing was provided by Operations Manager M on 5/18/2021 at 11:50 a.m. The policy indicated, but was limited to, " ... use an alcohol rub ... after removing gloves" An undated document titled Home Health Aide Comps was provided by Operations Manager M on 5/18/2021 at 11:50 a.m. The document indicated, but was not limited to, " ... wash basin and a rinse basin and having separate cloths for each basin ... Wash, rinse and pat dry rest of face ... Arm farthest from you ... starting with top of the arm (including armpit) and washing down. Emphasize once the hand is washed do not go back up the arm. Repeat with other arm ... wash, rinse and pat dry. Chest (emphasize importance of lifting breasts and washing making sure areas are rinsed and dried thoroughly) ... rinse and pat dry. Stomach ... rinse and pat dry. Change Water & Gloves, wash hands ... Back of neck, behind the ears, back and buttocks ... Change Water, Cloths & Gloves, wash hands ... Peri-area ... Women ... wash between labia ... rinse and pat dry. REMOVE GLOVES and WASH HANDS ... Washing hair must be done in the bed, sink and tub ..." During a home visit on 5/17/2021 at 9:10 a.m. observed HHA (home health aide) C provide a bed bath for patient 15. HHA C filled one basin with warm water and another basin with water and Bed Bath Beyond soap. HHA C stated that he/she "does [patient name] bath different because the patient yells out and it was a family preference to give the bath starting with the feet and working all the way up the body. I don't place a towel down or on her because of a skin disorder". HHA C was observed washing patient 15's eyes out with a soapy cloth and pat dried the patient's face. HHA C failed to rinse the soap off the patient's eyes. HHA C proceeded to wash patient 15's feet and toes with a soapy cloth then dried areas with a new cloth. HHA C then washed patient 15's right upper and lower leg and left upper and lower leg with a soapy cloth then used a new cloth to dry both legs. HHA C proceeded to unfasten the patient's brief, used a soapy cloth to wash the vaginal area and pat dried using a new cloth, failing to rinse off the soap. HHA C then used a spray bottle solution filled with Soothe & Cool Cleanse Shampoo & Body Wash and sprayed the solution on patient 15's vaginal area and applied the brief without drying the area. HHA C failed to change the soapy water after cleaning the peri-area. HHA C used the same soapy cloth to wash the patient's chest and stomach. HHA C then washed the patient's back with a soapy cloth, failing to dry the back. HHA C then emptied the soapy water into the sink, removed gloves but failed to perform hand hygiene. HHA C completed the bed bath and dressed patient 15 and proceeded to use a hoyer lift to transfer the patient to a wheelchair. HHA C used the water in the second basin to wash patient 15's hair while in the wheelchair. HHA C stated it was a family preference to have his/her hair washed while sitting in the wheelchair. HHA C failed to follow the agency's Home Health Aide Comp guidance that was provided by Operations Manager M. Review of the Home Health Certification/Recertification Plan of Care Order dated 3/22/2021 indicated "HHA services would be extremely beneficial to help prevent skin breakdown by keeping client skin clean and dry." Review of the Plan of Care Service Plan dated 03/19/2021 failed to indicate the family preferences on bathing/hair washing and the use of a product provided by the family. During an interview on 5/17/2021 at 4:00 p.m. RN B was unaware of how HHA C was performing patient 15's bath from toe to head. During an interview on 5/18/2021 at 9:30 a.m. Operations Manager M provided a photo of the labels on the Soothe & Cool Cleanse Shampoo & Body Wash bottle indicating that it was a no rinse solution and did not think there was an issue with the spray being left on wet to the patient's skin and covered with a brief. At 3:00 p.m. Operations Manager M provided a copy of the Competency Assessment -HHA dated 2/13/2020 for HHA C. The bathing, bed/sponge, Tub, Shower, Shampoo/Hair washing in tub, bed, sink, shower section was left blank which indicated HHA C did not complete. 17-12-1(m)

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the agency provided services in accordance with current clinical practice guidelines and accepted professional standards of practice. (Patient 15) Findings include: Clinical Nursing Skills fourth edition indicated, but was not limited to, "Providing a Bed Bath ... 13. raise side rails. ... Rationale: Side rails maintain patient safety ..." The clinical record for patient 15 was reviewed on 5/17/2021, start of care date 1/29/2020, for the certification period of 3/24/2021 to 5/22/2021, which included a Home Health Certification/Recertification Plan of Care indicating "[patient name] remains high risk for falls ... " Patient 15's diagnoses were Spastic Diplegic Cerebral Palsy and mild autism. Patient 15 was completely dependant and non-weight bearing. During a home visit on 5/18/2021 at 9:10 a.m. observed HHA C washing patient 15's back using one hand to push the patient onto his/her side and the other hand to wash the patient's back while the 1/2 rail was left down increasing the risk for a fall. HHA C completed patient 15's bed bath and took the soapy water bath basin into the bathroom to empty. HHA C failed to raise the 1/2 rail on the bed before exiting the patient's room leaving the patient at an increased risk for a fall. During the home visit, patient 15's caregiver was interviewed and stated "She moves herself around in bed. I can go in there in the evening, and she will push herself up and to the side in her bed. The caregiver was asked if the patient moves in bed. The caregiver responded "Oh yeah, she moves side to side. I find she changed position." During an interview on 5/18/2021 at 4:00 p.m. RN B stated patient 15 was not at risk for falls and did not feel pulling the 1/2 rail up on the patient's bed while the HHA was not in the room and not in range to view the patient was an issue.

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 observation, record review, and interview, the agency failed to ensure care was provided prior to documenting in the clinical record for 1 of 7 home health aide visits. (Patient 15) Findings include: Review of a Documentation of Daily Visit Sheets In-Service dated 09/15/2020 signed by HHA C indicated "Check mark all tasks that have been completed for the shift ... " During a home visit on 5/18/2021 at 9:10 a.m. HHA C was observed providing a bed bath for patient 15. After the bed bath was completed HHA C was asked how he/she documents. HHA C first stated he/she doesn't document and then stated he/she documents using their personal cell phone. HHA C stated he/she already documented the bath was completed prior to giving the bath. During an interview on 5/18/2021 at 4:00 p.m. Operations Manager M stated the HHA was not to document that tasks were completed before doing the task. Operations Manager M stated the HHA thought once he/she opened the visit to chart, documentation had to occur at that time. Operations Manager M stated that documentation and editing can occur at anytime during the visit. 17-15-1(a)(7)