Every finding on record at Aged, LLC

This visit was for a Federal and State complaint survey of a Home Health Provider. Survey Date: 12/20/2023 Complaint: 102661 with unrelated deficiency cited. 12-Month Unduplicated Skilled Admissions: 9

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 agency failed to ensure that the initial assessment was completed within 48 hours of referral date in 2 of 5 clinical records reviewed (Patient #1, #3). Findings include: A document titled “Client Admission Process” was provided on 12/20/2023 at 4:39 PM by the Human Resources Manager. The document indicated but was not limited to: “To establish a consistent admission process for all clients admitted to Vertical…to ensure that client-identifying data is obtained and documented…Upon acceptance and admission of a client, all efforts will be made to provide continuity and limit the number of individuals providing care. Services will be initiated within 48 hours after the assessment, unless documentation supports an alternate plan based on client needs and wishes and caregiver availability…” The clinical record for Patient #1, Start of Care (SOC) 07/29/2021 and certification period 11/16/2023-01/14/2024, was reviewed on 12/20/2023. The record indicated that the date of referral for home health services was on 07/26/2021 and the date of initial RN visit was conducted on 07/29/2021. The record failed to include documentation of why the initial assessment was completed more than 48 hours after the referral date. The clinical record for Patient #3, Start of Care (SOC) 09/19/2022 and certification period 01/17/2023-03/17/2023, was reviewed on 12/20/2023. The record indicated that the date of referral for home health services was on 08/31/2022 and the date of initial RN visit was conducted on 09/19/2022. The record failed to include documentation of why the initial assessment was completed more than 48 hours after the referral date. During an interview on 12/20/23 at 3:55 PM with the Clinical Manager, he/she indicated that it was the agency’s policy and procedure to perform the initial assessment of a patient within 48 hours of the referral to home health services and to document the circumstances if the 48 hours can not be met. He/She indicated the inability to locate documentation of why the initial assessment was not completed within 48 hours of referral for Patients #1 and #3. IAC 17-14-1(a)(1)(A)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 09/18/2023 - 09/20/2023 Active Census: 148 At this Emergency Preparedness survey, Vertical Home Health 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: 09/18/2023 - 09/20/2023 12-Month Unduplicated Skilled Admissions: 177 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR Completed on 09/25/2023 by A4

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure medications, treatments, mental status, a diagnosis, communication ability, and therapy services were listed on the current plan of care for 3 of 5 active record reviews and 1 of 2 closed record reviews (Patients #2, #3, #7, #5) Findings include: 5. The clinical record for Patient #5, start of care date 07/28/2014, certification date 08/10/2023 through 10/08/2023, was reviewed on 09/18/2023 which included a POC that indicated the patient received 18 medications. LPN 1 was observed to perform a medication reconciliation and during interview indicated Patient #6 only had active physician orders for four routine medications and the POC had not been effectively updated to show 10 medications had been discontinued by the physician. During an interview, on 09/19/2023 at 9:55 AM, LPN 1 indicated Patient #5 was deaf, could not effectively communicate using sign language due to fine motor skill deficits and spasticity, and had not received PT (Physical Therapy) in more than two years. The POC did not include documentation to indicate Patient #5 was deaf and indicated the patient communicated using sign language and actively received PT services. 410 IAC 17-13-1(a)(1)(B) 410 IAC 17-13-1(a)(1)(C) 410 IAC 17-13-1(a)(1)(D)(i-xiii) 4. The clinical record for Patient #7, start of care date 12/21/2021, certification date 08/13/2023 to 10/11/2023, was reviewed on 09/19/2023 which included a POC that described Patient #7’s mental status, psychosocial, and cognitive status as “alert, cooperative”. The agency failed to specify Patient #7’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #7’s POC. 1. An undated policy titled “Plan of Care” was provided on 09/19/2023 at 2:22 PM. The policy indicated, but was not limited to, “…The Plan of Care shall be completed in full to include the following: c. Pertinent patient’s mental, psychosocial, and cognitive status … K. All medications and treatments …”. 2. The clinical record for Patient #2, the start of care (SOC) date 12/28/2020, certification date 02/16/2023 to 04/16/2023, was reviewed on 09/18/2023 which included a plan of care (POC) that described Patient #2’s mental status, psychosocial, and cognitive status as “oriented”. The agency failed to specify Patient #2’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #1’s POC. 3. The clinical record for Patient #3, the start of care (SOC) date 11/03/2021, certification date 08/25/2023 to 10/23/2023, was reviewed on 09/18/2023 which included a plan of care (POC) that described Patient #3’s mental status, psychosocial, and cognitive status as “oriented”. The agency failed to specify Patient #3’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #3’s POC. During an interview on 09/19/2023 at 10:55 PM, the Home Health Aide (HHA) 2 indicated the following medication on POC are not the correct dose being taken by patient #3: Carbidopa-Levodopa (to treat Parkinson's disease), Methotrexate (to treat arthritis) and Levothyroxine Sodium (to treat an underactive thyroid gland). He/She indicated that calcium (to treat low calcium) and Hydrocodone-Acetaminophen (to treat pain) frequency are not correct on POC. The HHA 2 indicated Nystatin (to treat fungal/yeast infection) and Hydrocortisone (to treat skin irritation) are being used but are not on POC and Atorvastatin (to treat high cholesterol) is no longer being taken but is still on the POC medication list. The agency failed to revise the POC to include patient #3’s medication changes. During an interview on 09/19/2023 at 3:20 PM the Administrator indicated medication reconciliations should be done on admission, resumption of care and recertification, and the medications orders that are received during the current POC certification period would not show on POC until the next admission, resumption of care and recertification.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the patient with revised written medication information for 1 of 3 home visit observations. (Patient #4) Findings include: An undated policy titled Coordination of Client Services was provided by the Alternate Administrator on 09/19/2023 at 2:22 PM. The policy indicated, but was not limited to, “All personnel furnishing services shall maintain a liaison to assure their efforts are coordinated effectively and support the objective outlined in the Plan of Care. This may be done through … maintaining complete, current Care Plans and written and verbal interaction. … Purpose … To establish effective interchange, reporting, and coordination of client care does occur. “ The clinical record for Patient #4, start of care (SOC) date 03/22/2023, certification period 09/13/2023 to 11/11/2023, included a plan of care (POC) listing the following five medications: Multivitamin (supplement), Spiriva (breathing medication), Albuterol (breathing medication), Proventil (breathing medication), and Tylenol (pain medication). During a home visit on 09/19/2023 at 10:00 AM, Patient #4’s medication list provided by the agency was reviewed along with the patient. The 07/12/2023 medication list included five medications they no longer took and were not listed on the plan of care for the certification period 09/13/2023 to 11/11/2023. During an interview on 09/19/2023 at 2:51 PM, the Alternate Administrator stated the expectation was for staff to provide the patient with a written copy of the current medication list. The Alternate Administrator said nursing staff would check this at recertification visits every 56-60 days. 410 IAC 17-13-1(a)(2)

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the patient with current written medication information for 1 of 3 home visit observations. (Patient #4) Findings include: An undated policy titled Coordination of Client Services was provided by the Alternate Administrator on 09/19/2023 at 2:22 PM. The policy indicated, but was not limited to, “All personnel furnishing services shall maintain a liaison to assure their efforts are coordinated effectively and support the objective outlined in the Plan of Care. This may be done through … maintaining complete, current Care Plans and written and verbal interaction. … Purpose … To establish effective interchange, reporting, and coordination of client care does occur. “ The clinical record for Patient #4, start of care (SOC) date 03/22/2023, certification period 09/13/2023 to 11/11/2023, included a plan of care (POC) listing the following five medications: Multivitamin (supplement), Spiriva (breathing medication), Albuterol (breathing medication), Proventil (breathing medication), and Tylenol (pain medication). During a home visit on 09/19/2023 at 10:00 AM, Patient #4’s medication list provided by the agency was reviewed along with the patient. The 07/12/2023 medication list included five medications they no longer took and were not listed on the plan of care for the certification period 09/13/2023 to 11/11/2023. During an interview on 09/19/2023 at 2:51 PM, the Alternate Administrator stated the expectation was for staff to provide the patient with a written copy of the current medication list. The Alternate Administrator said nursing staff would check this at recertification visits every 56-60 days.

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 standard infection control precautions were followed regarding hand hygiene for 1 of 2 home health aide observations. (HHA 2) Findings include: 410 IAC 17-12-1(m) 1. An undated policy titled “Infection Control Plan, Surveillance, Prevention and Control” was provided on 09/19/2023 at 2:22 PM. The policy indicated but was not limited to, “… Hand Hygiene should be performed at a minimum … after contact with the patient or objects in the immediate vicinity of the patient … after removal of personal protective equipment … Hand hygiene includes both handwashing … and use of alcohol-based product. 2. During a home visit observation on 09/19/23 at 10:55 AM, the Home Health Aide (HHA) 2 performed hand hygiene prior to starting but contaminated hands by touching facets after washing and drying hands, no other hand hygiene was performed during the home visit. He/She failed to perform hand hygiene 3 times between gloving, no hand hygiene was done at the end of the bathing procedure. The HHA 2 did not change/remove gloves after removing the sanitation pad from the undergarment, then touched multiple surfaces (door, sink, walker, patient) with contaminated gloves. During an interview on 09/19/2023 at 10:55 PM, the HHA 2 indicated gloving and hand hygiene procedures are different when comparing working in a facility to home health care, and the patient is your mother. During an interview on 09/19/2023 at 3:20 PM the Administrator indicated the agency expects HHA to perform hand hygiene (washing with soap or alcohol gel), between gloving and after patient contact.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide reported changes in the patient's condition to the nurse for 1 of 5 active records reviewed. (Patient #3) Findings include: 410 IAC 17-14-1 (1)(m) 1. An undated policy titled “Home Health Aide Services” was provided on 09/19/2023 at 2:22 PM. The policy indicated, but was not limited to, “… The home health aide is responsible for observing patients, reporting these observations … Reporting on patient’s condition and significant changes to the assigned nurse…”. 2. The clinical record for Patient #3, start of care (SOC) date 11/03/2021, certification date 08/25/2023 to 10/23/2023, was reviewed on 09/18/2023. No documentation was found in Patient #3’s clinical record indicating any form of communication between HHA 2 and the RN case manager regarding the change in the patient’s skin to buttocks and coccyx, nor the medication (Levothyroxine) dose change that took effect on the week of 9/11/2023. During an interview on 09/19/2023 at 10:55 PM, the HHA 2 indicated Patient #3 had a pressure ulcer on the buttocks and coccyx and the HHA 2 had not reported skin change to the RN case manager/physician since the skin was still intact over reddened area. During an interview on 09/19/2023 at 10:07 AM the Administrator indicated communication between the HHA and RN case manager is required when there is a change in the home, a fall happens, and when the HHA is aware of medication changes.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure personnel records were kept current and included documentation of orientation, competencies, and job descriptions for 4 of 5 personnel record reviews. (LPN 1, Alternate Clinical Manager, HHA 1, HHA 2) Findings include: 1. The policy and procedure for Personnel Records provided by the DON, on 09/20/2023 at 11:51 AM, indicated the purpose of the policy, "...To provide a mechanism for maintaining accurate, complete, and current personnel information..." 2. The personnel file of LPN 1 was reviewed, on 09/20/2023 at 9:00 AM, and indicated the employee hire date was 09/15/2016. The record did not include documentation of show LPN 1 was oriented to job responsibilities or agency policies. During an interview, the Human Resources Manager indicated the employment of LPN 1 was acquired with the purchase of the agency in 2017 and orientation documentation could not be provided. 3. The personnel file of the alternate clinical manager was reviewed, on 09/20/2023 at 9:15 AM, and indicated the employee hire date was 02/26/2018. A SN (Skilled Nurse) competency checklist, dated 08/09/2018, indicated 27 skills of the alternate clinical manager were evaluated. The checklist indicated handwashing skills were validated using a verbal method of evaluation and competency was identified; the competency, method, initials, and date of the 26 subsequent skills were documented with a down arrow through the column. 4. The personnel file of HHA 1 was reviewed, on 09/20/2023 at 9:20 AM, and indicated the employee hire date was 06/13/2022. A, "...Personal [sic] Orientation Checklist", dated 06/13/2022, included three columns titled, "Date completed", "Orientation by Whom", and "Notes" The first column indicated, "6/13/22", the second column indicated "6/28/22", and a down arrow was drawn through each column. 5. The personnel file of HHA 2 was reviewed, on 09/20/2023 at 9:25 AM, and indicated the employee hire date was 10/19/2021. A, "...Personal [sic] Orientation Checklist", dated 10/19/2021, included three columns titled, "Date completed", "Orientation by Whom", and "Notes" The first and second columns indicated, "10/19/21" and a down arrow was drawn through both columns. During an interview, on 09/19/2023 at 9:30 AM, the Human Resources Manager indicated it was the usual practice of the agency to draw down arrows through checklists to indicate each task is complete.

This visit was for a complaint investigation of a Home Health Agency.Complaint 32025 - substantiated with findingsFacility #: 012617Dates of Survey: 11/8/2021--11/9/2021 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. QR completed 11/22/2021 A4

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure an individualized plan of care was developed in 1 of 5 patients reviewed. (Patient 4) Findings include: 1. An undated policy titled, “Plan of Care,” was provided by Employee C on 11/8/2021 at 1:05 p.m. The policy indicated, but was not limited to, “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. (Periodically reviewed means every 60 days or more frequently when indicated by changes in the patient’s condition.)” … “The client and/or representative shall be informed of any changes in the Plan of Care.” … “Any revision to the Plan of Care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the HHA (Home Health Agency) Plan of Care.” 2. A record review on Patient 4 was completed on 11/9/2021 for certification period 7/23/2021—9/20/2021, start of care date 10/12/2017. Physician orders are as follows: Home health aide visits 3-5 hours, 5-7 days a week, The record for Patient 4 indicated an incomplete Plan of Care for certification period 7/23/2021—9/20/2021. Missing DME (Durable Medical Equipment) and Supplies, Safety Measures, Nutritional Requirements, Functional Limitations, Activities Permitted, Mental Status, Prognosis, Problems and Interventions, Goals/Rehabilitation Potential/Discharge Plans and 60-day summary. 3. An interview on 11/9/2021 at 10:25 a.m. with Employee B was completed. Inquired about the plan of care being incomplete, missing several key elements including the DME (durable medical equipment) and supplies, safety measures, nutritional requirements, functional limitations, activities permitted, mental status, prognosis, problems and interventions, goals/rehabilitation, potential discharge plans, and 60-day summary. Employee B could not provide any explanation as to why this information was not included in the plan of care for the certification period reviewed. Employee B was able to provide a complete plan of care for the certification period prior to and immediately after this particular certification period. 17-13-1(a)(1)(D)

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that home health aide visits were completed as ordered by the physician in the plan of care in 2 of 5 sampled patients reviewed. (Patient 3 and 4) Findings Include: 1. An undated policy titled, “Plan of Care,” was provided by Employee C on 11/8/2021 at 1:05 p.m. The policy indicated, but was not limited to, “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. (Periodically reviewed means every 60 days or more frequently when indicated by changes in the patient’s condition.)” … “The client and/or representative shall be informed of any changes in the Plan of Care.” … “Any revision to the Plan of Care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the HHA (Home Health Agency) Plan of Care.” 2. An undated policy titled, “Clinical Documentation,” was provided by Employee C on 11/8/2021 at 1:05 p.m. The policy indicated but was not limited to, “Agency will document each direct contact with the client. This documentation will be completed by the direct caregivers and monitored by the skilled professional responsible for managing the client’s care.” … “Purpose: To ensure that there is an accurate record of the services provided, client response, and ongoing need for care. To document conformance with the Plan of Care, modifications to the plan, and interdisciplinary involvement.” … “Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record within seven (7) days after the care has been provided. Services not provided and the reason for missed visits will be documented and reported to the physician.” 3. A record review on Patient 3 was completed on 11/8/2021 for certification period 8/30/2021—10/28/2021, SOC (start of care) date 7/27/2016. Physician orders are as follows: Home health aide visits for 1-2 hours 1-2 days a week. The record indicated that no home health aide visits were completed the week of 9/5/2021—9/11/2021, 9/19/2021—9/25/2021, 9/26/2021—10/2/2021, 10/3/2021—10/9/2021, 10/10/2021—10/16/2021, and 10/17/2021—10/23/2021. An interview on 11/8/2021 at 4:15 p.m. with Employee B was completed. Upon review of clinical record 3, it was noted multiple missed home health aide visits. Employee B indicated that most visits were missed due to a staffing shortage. Documentation in the medical record indicated patient refusal, not staff unavailable. Indicated that this area of the state is hard to staff. Confirmed that Patient 3 was receiving bi-weekly skilled nursing visits as ordered, just not the home health aide visits. 4. A record review on Patient 4 was completed on 11/9/2021 for certification period 7/23/2021—9/20/2021, SOC date 10/12/2017. Physician orders are as follows: Home health aide visits 3-5 hours, 5-7 days a week, The record for Patient 4 indicated missed home health aide visits the week of 7/25/2021—7/31/2021. One visit documented by a home health aide on 7/31/2021 for 1 hour. The record also indicated home health aide visits exceeding the 3-5 hour daily home health aide visit during the certification period of 9/10/2021—9/20/2021. Home health aide visit hours varied from 6 hours a day to 16 hours a day. An interview on 11/9/2021 at 10:25 a.m. with Employee B was completed. Employee B was unable to provide an explanation as to why there were increased home health aide hours daily from 9/10/2021—9/30/2021 with Patient 4. Confirmed the physician order in the plan of care indicated home health aide visits every 5-7 days, 3-5 hours daily. Employee B then confirmed the increase in hours daily during the above time period of 6-16 hours a day. Employee B also confirmed the missed home health aide visits during the week of 7/25/2021—7/30/2021. Unable to provide any further documentation. 17-14-1(a)(1)(H)