Every finding on record at Alliance Home Health Services LLC

Indianapolis, Indiana · CCN 157252

37 findings across 3 surveys, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of July 10, 2026

22 findings

E0000

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 07/07, 07/08/, 07/09, and 07/10/2026. Active Census: 621 At this Emergency Preparedness survey, Purposecare of Indiana was found out of compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 7/17/2026.

E0001

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interviews, the agency failed to maintain a comprehensive emergency preparedness program. The agency did not evidence an emergency plan had been developed, reviewed, and updated at least every two years (E0004); a facility-based and community-based, all-hazards risk assessment had been updated every two years (E0006); attempts were made to collaborate with local, regional, state, and federal officials (E0009); emergency preparedness policies and procedures had been reviewed and updated every two years (E0013); a communication plan addressing procedures to follow up with on-duty staff and patients had been developed (E0021); volunteers had been included in the communication plan (E0024); contact information for staff, patients, contracted service entities, physicians, and volunteers had been maintained (E0030); regional and state official contact information had been included (E0031); and the agency participated in a community-based full-scale exercise every two years with analysis of its response (E0039). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment and resulted in the agency being found out of compliance with condition 42 CFR §484.102 Emergency preparedness. Findings include: 1. On 07/07/2026 at 12:03 PM, upon request for the agency’s emergency preparedness program, the agency provided an undated and unreviewed policy titled “Emergency Preparedness Management Policy.” When asked about the remainder of the program, Admin 1 and Admin 2 stated, “We are trying to locate it.” 2. On 07/07/2026 at 12:47 PM, Admin 1 stated, “I cannot provide anything. There is nothing in the binder; it is empty.”

G0000

This visit was for a Federal Complaint survey of a Deemed HHA provider. Survey Dates: 07/07, 07/08/, 07/09, and 07/10/2026. Complaint: IN003066725 with related and unrelated deficiencies cited. 12 Month Unduplicated Admissions: 2,061 Fully Extended Survey was announced on 07/07/2026 at 4:25PM During this Initial Medicaid survey, Purposecare of Indiana was found to be out of compliance with Condition of Participation 42 CFR 484.60, Care Planning. Based on the Condition-level deficiencies during the 07/02/2026 survey, your agency was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency, and/or competency evaluation programs for a period of two years beginning 07/10/2026 and continuing through 07/09/2028. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide POC Plan of Care SN Skilled Nurse SOC Start of Care RN Registered Nurse DC Discharge LPN Licensed Practical Nurse ADON Assistant Director of Nursing DON Director of Nursing ADL Activities of Daily Living DME Durable Medical Equipment ROC Resumption of Care QAPI Quality Assurance Performance Improvement OASIS Outcome and Assessment Information Set QR completed by Area 3 on 7/17/2026.

G0372

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to electronically transmit the completed OASIS assessments to the CMS (Centers for Medicare & Medicaid Services) system within 30 days of completing the patient assessments in 18 of 18 focused clinical records reviewed. (Patients: #15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32) The findings include: 1. A review of an undated agency policy titled “Encoding and Reporting OASIS Data” indicated, but was not limited to, “ … 1. Agency will encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment … ” 2. A review of the agency’s report titled “HHA Error Summary by Agency,” dated 07/01/2025 to 07/06/2026, evidenced error number 3330 with the description “records submitted late: The submission date is more than 30 days after the M0090.” The report showed 1,907 assessments with this error, representing 36.91% of all assessments reviewed. 3. A focused review of the active clinical record for Patient #15 evidenced the SOC OASIS assessment had an M0090 date of 05/06/2026. The agency submitted the SOC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 4. A focused review of the active clinical record for Patient #23 evidenced the SOC OASIS assessment had an M0090 date of 05/06/2026. The agency submitted the SOC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 5. A focused review of the active clinical record for Patient #24 evidenced the SOC OASIS assessment had an M0090 date of 05/16/2026. The agency submitted the SOC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 6. A focused review of the active clinical record for Patient #25 evidenced the SOC OASIS assessment had an M0090 date of 05/21/2026. The agency submitted the SOC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 7. A focused review of the active clinical record for Patient #26 evidenced the SOC OASIS assessment had an M0090 date of 05/31/2026. The agency submitted the SOC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 8. A focused review of the active clinical record for Patient #27 evidenced the SOC OASIS assessment had an M0090 date of 05/19/2026. The agency submitted the SOC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 9. A focused review of the discharged clinical record for Patient #16 evidenced a SOC date of 01/11/2024 and a DC date of 05/22/2026. The DC OASIS assessment had an M0090 date of 05/22/2026. The agency submitted the DC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 10. A focused review of the discharged clinical record for Patient #17 evidenced a SOC date of 03/25/2026 and a DC date of 05/20/2026. The DC OASIS assessment had an M0090 date of 05/20/2026. The agency submitted the DC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 11. A focused review of the discharged clinical record for Patient #18 evidenced a SOC date of 02/04/2026 and a DC date of 05/25/2026. The DC OASIS assessment had an M0090 date of 05/25/2026. The agency submitted the DC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 12. A focused review of the discharged clinical record for Patient #19 evidenced a SOC date of 04/30/2026 and a DC date of 05/28/2026. The DC OASIS assessment had an M0090 date of 05/28/2026. The agency submitted the DC OASIS on 07/06/2026, which exceeded 30 days from the M0090 assessment completion date. 13. A focused review of the discharged clinical record for Patient #20 evidenced a SOC date of 03/02/2026 and a DC date of 05/31/2026. The DC OASIS assessment had an M0090 date of 05/31/2026. The agency submitted the DC OASIS on 07/06/2026, which exceeded 30 days from the M0090 assessment completion date. 14. A focused review of the discharged clinical record for Patient #21 evidenced a SOC date of 03/26/2026 and a DC date of 05/28/2026. The DC OASIS assessment had an M0090 date of 05/28/2026. The agency submitted the DC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 15. A focused review of the discharged clinical record for Patient #22 evidenced a SOC date of 03/25/2026 and a DC date of 05/21/2026. The DC OASIS assessment had an M0090 date of 05/21/2026. The agency submitted the DC OASIS on 07/01/2026, which exceeded 30 days from the M0090 assessment completion date. 16. A focused review of the discharged clinical record for Patient #28 evidenced a SOC date of 02/09/2026 and a DC date of 05/28/2026. The DC OASIS assessment had an M0090 date of 05/28/2026. The agency submitted the DC OASIS on 07/06/2026, which exceeded 30 days from the M0090 assessment completion date. 17. A focused review of the discharged clinical record for Patient #29 evidenced a SOC date of 04/03/2026 and a DC date of 05/28/2026. The DC OASIS assessment had an M0090 date of 05/28/2026. The agency submitted the DC OASIS on 07/06/2026, which exceeded 30 days from the M0090 assessment completion date. 18. A focused review of the discharged clinical record for Patient #30 evidenced a SOC date of 03/23/2026 and a DC date of 05/11/2026. The DC OASIS assessment had an M0090 date of 05/11/2026. The agency submitted the DC OASIS on 07/02/2026, which exceeded 30 days from the M0090 assessment completion date. 19. A focused review of the discharged clinical record for Patient #31 evidenced a SOC date of 04/01/2026 and a DC date of 05/28/2026. The DC OASIS assessment had an M0090 date of 05/28/2026. The agency submitted the DC OASIS on 07/02/2026, which exceeded 30 days from the M0090 assessment completion date. 20. A focused review of the discharged clinical record for Patient #32 evidenced a SOC date of 04/01/2026 and a DC date of 05/28/2026. The DC OASIS assessment had an M0090 date of 05/28/2026. The agency submitted the DC OASIS on 07/02/2026, which exceeded 30 days from the M0090 assessment completion date. During an interview on 07/07/2026 at 1:37 PM, when asked about the agency’s submission reports, untimely submission process, and who submits OASIS assessments to CMS, Admin 4 communicated they submitted OASIS reports in IQIES. Admin 2, the Care Transition Coordinator, stated the agency had issues with untimely submissions due to branch and parent identifiers that needed to be changed for both the Indianapolis and Ft. Wayne locations. IQIES identified this issue on April 8, 2026. The Indianapolis office identifier was corrected on April 16, 2026, and the Ft Wayne branch identifier was corrected on May 5, 2026. Admin 2 further stated, “They sent the agency’s error reports to the Administrator for follow‑up.” During an interview on 07/10/2026 at 10:52 AM, when asked about the untimely OASIS submissions, Corporate Staff 1, the Vice President of Quality and Compliance, and governing body member stated, “The DON/Administrator had not reported out any errors in OASIS submissions to the governing body.” Corporate Staff 1 further communicated the QAPI program had not contained an updated performance improvement plan to address the ongoing problem of untimely OASIS.

G0514

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 observation, record review, and interviews, the agency failed to ensure the RN completed the initial assessment to determine home care needs within 48 hours of receiving the referral for 1 of 1 SOC observations. (Patient: #2) Findings Include: 1. A review of an undated agency policy titled “Comprehensive Client Assessment” indicated, but was not limited to, “The initial assessment visit must be held either within 48 hours of referral or within 48 hours of the client’s return home, or on the physician-ordered start of care date ….” 2. During a home visit at Patient #2’s residence on 07/08/2026 at 8:05 AM, observed RN 1 completing an initial comprehensive assessment for Patient #2. When asked when they returned home from Entity 7, the rehabilitation facility, Patient #2 stated, “I came home from the hospital Friday, July 3, 2026.” A review of the clinical record for Patient #2 contained faxed referral documents from Person 6, the Medical Social Worker and Case Manager of Entity 7. The documents contained a document dated 06/25/2026 and signed by Person 8, a physician at Entity 7, titled “Home Health Care Face-To-Face Encounter Form and Orders.” The Face-to-Face Encounter Form indicated Patient #2 had orders for skilled nursing, physical therapy, occupational therapy, and speech therapy. On 07/08/2026 at 8:40 AM, when asked about the referral and SOC process timeline, RN 1 stated, “The office sends out the referral and sends it out for us to schedule with the patient. I review the referral and then call the patient to schedule an appointment. I do not call the physician after my assessment unless the patient needs physical therapy or something else. I just go by the referral information.” During an interview on 07/09/2026 at 2:07 AM, when asked Person 8 about when they had sent the referral to Purposecare of Indiana for Patient #2, they stated, “Patient #2 discharged on 07/03/2026, and I sent the referral information and orders on 06/25/2026, our first care conference.” During an interview on 07/09/2026 at 2:10 PM, when asked about any calls received to Person 3, Patient #2’s primary care provider, Person 5, an office nurse, stated, “The only note in [Patient #2’s] chart is from yesterday from a [RN1] who contacted us regarding skilled nursing and physical therapy started yesterday.” When asked if there were any other orders or communication regarding a delay in Patient #2’s start of care for home care needs after their rehabilitation stay, Person 5 stated, “No.” 410 IAC 17-14-1(a)(1)(A)

G0536

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 observation, record review, and interview, the agency failed to ensure the RN reconciled all medication with the patient, and the ordering physician in 1 of 1 SOC observed. (Patient #2) Findings Include: 1. A review of an undated agency policy titled “Medication Reconciliation” indicated but was not limited to, “ … Agency will reconcile all medications taken by the client prior to admission to home care with those ordered at the time of admission … 1. At the time of admission to the home care agency, the admitting professional will document a complete list of medications taken by the client … 2. The information will be obtained from the client … Medications will be reviewed with the client on each home visit … ” 2. On 07/08/2026 at 8:05 AM, RN 1 was observed completing Patient #2’s SOC assessment. Patient #2 showed RN 1 the medication bottles located on the kitchen countertop. RN 1 glanced at the medication bottles but failed to compare the medication labels with the medication list obtained from Entity 7, the rehabilitation facility from which Patient #2 had been discharged. RN 1 failed to complete a medication reconciliation during the SOC. During an interview on 07/08/2026 at 8:40 AM, when asked about medication reconciliation, RN 1 stated, “Medications are to be reviewed and compared to the list we received.” 410 IAC17-14-1(a)(1)(B)

G0564

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the transfer/discharge summaries were sent to the receiving healthcare providers 1 of 1 active records reviewed transferred to an in-center acute care facility (Patient: #9), and for 2 of 2 inactive records reviewed, patients transferred to a hospice provider. (Patients: #12 and 13) Findings Include: 1. A review of an undated agency policy titled “Client Transfer” indicated but was not limited to, “ … To assure continuity of care by providing pertinent information to another … The original Transfer Summary form shall be sent to the new provider of facility … ” 2. A review of an undated agency policy titled “Client Discharge Process” indicated but was not limited to, “ … A completed discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care services to the client after discharge within 5 business days of the client’s discharge … ” 3. A review of the active record for Patient #9 SOC date of 05/18/2026, evidenced the patient had been transferred to Entity 9, an acute care facility on 06/17/2026. The record contained a transfer summary dated 06/17/2026, signed by RN 3. The transfer summary indicated PT 5’s last home visit occurred 06/10/2026. The record failed to contain evidence the transfer summary had been sent to Entity 6, the provider assuming Patient #9’s care. 4. A review of the inactive clinical record for Patient #12 evidenced the patient had been transferred to hospice on 03/01/2026. The record contained a discharge summary dated 03/03/2026, signed by RN 2. The discharge summary indicated RN 2’s last skilled visit occurred on 02/26/2026, and Patient #12 experienced a decline in condition, prompting discharge so hospice could admit the patient on 03/02/2026. The record failed to contain evidence that the transfer/discharge summary was sent to the hospice provider assuming Patient #12’s care. 5. A review of the inactive record for Patient #13 evidenced the patient had been transferred to hospice on 01/21/2026. The record contained a discharge summary dated 01/21/2026, signed by PT 4. The discharge summary indicated PT 4’s last skilled visit occurred on 01/21/2026, and Patient #12 experienced a decline in condition, prompting discharge so hospice. The record failed to contain evidence that the transfer/discharge summary was sent to the hospice provider assuming Patient #13’s care. During an interview on 07/07/2026 at 4:03 PM, when asked to provide documentation of the discharge orders and evidence that the transfer/discharge summaries for Patients #12 and #13 had been sent to the hospice providers resuming their care, LPN 1, the LPN Clinical Supervisor, stated, “There’s nothing in [Patient #12’s or 13’s] record showing coordination of care or that the transfer/discharge summary was sent to the hospice provider resuming care. There’s also no discharge order.” When asked if transfer and discharge summaries were to be sent to healthcare provider assuming care for the patients and coordination of care documented, LPN 1 communicated the transfer and discharge summaries had only been sent to the primary care provider of the patients while under care of the agency. 410 IAC 17-13-2(a)(b)(9)

G0570

G0574

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the POC contained all of the elements, including mental/cognitive status, psychosocial status, safety, seizure plans, nutritional information, DME and Supplies, discipline orders with frequency and duration, for 4 of 8 active clinical records reviewed (Patient #1, 2, 3, and 7) Findings Include: 1. A review of an undated agency policy titled "Care Plans" indicated, but was not limited to, " … The Care Plan shall include, but not limited to: Nursing diagnosis(es)/problems and needs identified … Reasonable, measurable, and realistic goals … A list of specific interventions with plans for implementation … " 2. During a home visit at Patient #1’s residence, a group home, on 07/08/2026 at 12:00 PM, observed HHA 1 providing a shower using a handheld shower to Patient #1. Observed a grab rail in the shower that Patient #1 held onto for balance during their shower. Person 10, the group home manager and caregiver for Patient #1, encouraged Patient #1’s participation with the reward of going to Olive Garden for lunch, and stated: “He loves their breadsticks.” Person 10 had to remind Patient #1 several times to stop scratching their left leg and picking at their skin during the home visit observation. Person #10 stated, “[Patient #1] picks at their left leg and causes open areas needing wound care.” A review of the active clinical record for Patient #1, with a SOC date of 02/18/2026, contained a POC for the certification period of 02/18/2026 to 06/17/2026. The POC included but was not limited to the following diagnoses: Unspecified open wound to the left lower leg, Excoriation (skin-picking) Disorder, Cerebral Palsy (a neurological disorder affecting movement, posture, and muscle coordination due to abnormal brain development), and Anxiety Disorder. The section titled “Nutrition Requirements” noted supplements (Boost), but failed to evidence Patient #1 being on a regular diet. The section titled “Psychosocial Status” noted no problems identified, but failed to address Patient #1’s anxiety and picking at their lower extremities, causing open areas. The section titled “DME and Supplies” noted “None,” failed to list grab bars in the shower, and a handheld shower. 3. A review of the active clinical record for Patient #2 with a SOC date of 07/08/2026, contained a POC for the certification period of 07/08/2026 to 09/05/2026. The POC included but was not limited to the following diagnoses: Epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), Type 2 Diabetes Mellitus (a condition of the body’s inability to produce insulin to process blood sugar levels), Long Term Use of Insulin, Essential Hypertension (High blood pressure), and Muscle Weakness. The section titled “Safety” listed Diabetic: Do not cut nails, fall precautions, emergency/disaster plan development, keep pathways clear, safety in ADLS, slow position changes, standard precautions/infection control, support during transfer and ambulation, use of assistive device, but failed to list seizure precautions and bleeding precautions. The section titled “DME and Supplies” listed grab bars, care, tub/shower bench, but failed to list glucometer, lancets, and pen needles for diabetic supplies. Patient #2’s medications listed but were not limited to the following; Eliquis (a medication used to prevent blood clotting) 5 milligram (mg) oral tablet BID (twice) by mouth, and Tirzepatide (a medication used to regulate blood sugar levels and appetite) 5mg/0.5 milliliters (ml) subcutaneous auto injector every (Q) 7 days, and Levetiracetam (a medication used in the treatment of seizures) 1,000 mg oral twice daily. During an interview at Patient #2’s residence on 07/08/2026 at 8:05 AM, Patient #2 reported they were on seizure medication for seizures due to seizures. Patient #1 confirmed they have given their own weekly injection if their family member is available, to help with their diabetes. 4. During a home visit at Patient #3’s residence on 07/08/2026 at 2:00 PM, observed Patient #3 sitting on a Hoyer lift pad in a motorized wheelchair in the living area. Observed on Patient #3’s left leg a catheter leg bag, and the patient had blue chucks in the chair and had a blue brief on. LPN 2 provided a tour of all the special equipment in the back area, a living space, and the bathroom Patient #3 had, which included: a hospital bed with an over-the-bed triangle, another motorized wheelchair, incontinence supplies of briefs and chucks, a Hoyer lift, and rails in the bathroom and shower area with a specially designed shower chair. Patient #3 stated, “My daughter checks my sugar and gives me my insulin every morning. A review of the active clinical record for Patient #3 with a SOC date of 02/141/2026, contained a POC for the certification period of 06/11/2026 to 08/09/2026. The POC included but was not limited to the following diagnoses: Type 2 Diabetes, Long Term Use of Insulin, and Paraplegia (paralysis of the legs and lower body caused by a spinal injury or disease). The section titled “Mental/Cognitive Status” had been left blank. The section titled “DME and Supplies” listed a wheelchair and a tub/shower bench, but failed to list a glucometer and diabetic supplies, a Hoyer lift, a hospital bed, a catheter, and catheter supplies. 5. A review of the active clinical record for Patient #7, SOC date of 02/05/2026, and a Resumption of care (ROC) date of 06/02/2026 contained a POC for the recertification period of 06/05/2026 to 08/03/2026. The POC noted that Patient #7 had orders for SN once a week for 6 weeks, with each visit to include a physical assessment emphasizing the disease process, minimizing the risk of rehospitalization, and addressing high-risk medications and compliance. The POC noted orders for HHA but failed to evidence frequency, provide personal care, and document ADLs. During an interview on 07/10/2026 at 9:44 AM, when asked about the process documentation for DME, supplies, and other required elements on the POC, RN 4 indicated that the POC sections came from the comprehensive assessment and that all DME and Supplies should be on the POC. 410 IAC 17-13-1(a)(1)(D)(i-xiii)

G0584

G0608

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care had been completed with other entities providing services for 3 of 4 active clinical records reviewed. (Patients: #5, 7, and 8) Findings Include: 1. A review of an undated agency policy titled “Coordination of Client Services” indicated, but was not limited to, “ … Coordination will include providers of care who are not part of the agency … ” 2. A review of the clinical record for Patient #5 contained a POC for the initial certification period 05/18/2026 to 07/16/2026. The POC noted in the section titled “Caregiver Status” Patient #5 lived in Entity 15, an assisted living facility. A review of the SOC OASIS dated 05/18/2026 and signed by PT 2, noted in the section titled “Care Coordination,” the physician had been checked only. The Clinical record failed to evidence coordination of care with Entity 15, the assisted living facility. No communication notes had been documented in the clinical record. During an interview on 07/10/2026 at 12:06 PM, when asked about coordination of care and where it would be located, PT 2 stated, “Coordination of care would be documented in the communication notes.” 3. A review of the clinical record for Patient #7 contained a resumption of care (ROC) POC for the recertification period 06/05/2026 to 08/03/2026. The POC noted in the section titled “Caregiver Status,” Patient #7 had around-the-clock care. The POC failed to provide evidence of coordination of care with Entity 16, the group home, or Person 17, the group home manager. A review of an updated resumption of care, adding the PT POC signed by PT 3, and dated 06/19/2026, noted in the section titled “Living Arrangements,” Patient #7 lived in a congregate situation around the clock. The POC failed to provide evidence of coordination of care with Entity 16, the group home, or Person 17, the group home manager. A review of the ROC OASIS dated 06/02/2026 and signed by Admin 4, the Quality Assurance RN, and Interim DON, noted in the section titled “Care Coordination” that the physician had been checked only. The Clinical record failed to evidence coordination of care with Entity 16, the group home, or Person 17, the group home manager. During an interview on 07/10/2026 at 1:40 PM, PT 3 indicated coordination of care should be documented in communication notes or on the visit notes. 4. A review of the clinical record for Patient #8 contained a POC for the initial certification period 06/05/2026 to 08/03/2026. The POC noted in the section titled “Caregiver Status,” Patient #8 resides in Entity 13, an assisted living facility. A review of the SOC OASIS dated 06/1052026 and signed by RN 5, noted in the section titled “Care Coordination,” the physician had been checked only. The Clinical record failed to evidence coordination of care with Entity 13, the assisted living facility. The clinical record failed to evidence communication notes. During an interview on 07/10/2026 at 12:40 PM, when asked about documenting coordination of care with other healthcare providers, RN 2 indicated coordination of care would be documented in the communication notes or on the visit notes. 410 IAC 17-14-1(a)(1)(F)

G0612

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide the patient or caregiver with written instructions regarding the home health services to be provided and the plan of care for 2 of 2 patients (Patients: #1 and 3) during home visits conducted, receiving ongoing continued care. Findings Include: 1. During a home visit at Patient #1’s residence, a group home, on 07/08/2026 at 12:00 PM, Person 10, the group home manager and caregiver for Patient #1, provided the agency folder for review. The agency folder contained an agency booklet but failed to include a plan of care or written instructions regarding the home health services being provided. During an interview on 07/08/2026 at 12:09 PM, when asked about written instructions or the plan of care describing the services to be provided to Patient #1, Person 10 stated, “No, that booklet is all that has been provided.” 2. During a home visit at Patient #3’s residence on 07/08/2026 at 2:00 PM, LPN 2 was observed performing wound care for Patient #3. When asked for the agency folder for review, Patient #3 was unable to provide one. When asked whether they had been provided with a plan of care containing instructions and information regarding the services the home health agency was providing, Patient #3 shook their head no. During an interview on 07/08/2026 at 2:45 PM, when asked about the plan of care in the home and the medication list, LPN 2 reported they used the tablet to review Patient #3’s chart and were unaware of the plan of care being provided to the patients.

G0614

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the patient and caregiver in writing with a copy of the visit schedule in 2 of 2 home visits conducted with patients receiving ongoing services. (Patients: #1 and 3) Findings Include: 1. During a home visit at Patient #1’s residence, a group home, on 07/08/2026 at 12:00 PM, Person 10, the group home manager and caregiver for Patient #1, provided the agency folder for review. The agency folder contained an agency booklet with blank calendars at the back. No visit schedules were found in Patient #1’s home. During an interview on 07/08/2026 at 12:09 PM, when asked about a schedule or plan of care being provided to Patient #1, Person 10 stated, “No, that booklet is all that has been provided. They just call the day of the visit.” 2. During a home visit at Patient #3’s residence on 07/08/2026 at 2:00 PM, LPN 2 was observed performing wound care for Patient #3. When asked for the agency folder for review, Patient #3 was unable to provide one. No written schedules could be found in Patient #3’s home. During an interview on 07/08/2026 at 2:45 PM, when asked about the plan of care in the home and the medication list, written schedules, LPN 2 reported they used the tablet to review Patient #3’s chart and were unaware of the plan of care or written schedules being provided to the patients.

G0616

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 or caregiver with a medication schedule and instructions for 2 of 2 patients (Patients: #1 and 3), during home visits conducted, receiving ongoing continued care. Findings Include: 1. During a home visit at Patient #1’s residence, a group home, on 07/08/2026 at 12:00 PM, Person 10, the group home manager and caregiver for Patient #1, provided the agency folder for review. The agency folder contained an agency booklet, but failed to include a medication schedule with written instructions. During an interview on 07/08/2026 at 12:09 PM, when asked about the medication list with written instructions or the plan of care being provided to Patient #1, Person 10 stated, “No, that booklet is all that has been provided.” 2. During a home visit at Patient #3’s residence on 07/08/2026 at 2:00 PM, LPN 2 was observed performing wound care for Patient #3. When asked for the agency folder for review, Patient #3 was unable to provide one. When asked whether they had been provided with a plan of care or a medication list, Patient #3 shook their head no. During an interview on 07/08/2026 at 2:45 PM, when asked about the plan of care in the home and the medication list, LPN 2 reported they used the tablet to review Patient #3’s chart and the patient’s medications, and were unaware of a medication list being provided to the patients.

G0622

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the name and contact information for the clinical manager for 2 of 2 home visits conducted with patients with ongoing needs. (Patients #1, 3) Findings Include: 1. During a home visit at Patient #1’s residence, a group home, on 07/08/2026 at 12:00 PM, Person 10, the group home manager and caregiver for Patient #1, provided the agency folder for review. The agency folder contained an agency booklet that listed Former Employee 9 as the Administrator/DON. During an interview on 07/08/2026 at 12:09 PM, when asked about getting hold of the Clinical Manager in case of need, Person 10 stated, “No, do not know how to reach them. Just the shower aide test and calls.” 2. During a home visit at Patient #3’s residence on 07/08/2026 at 2:00 PM, LPN 2 was observed performing wound care for Patient #3. When asked for the agency folder for review, Patient #3 was unable to provide one. No contact information was in the home. During an interview on 07/08/2026 at 2:45 PM, when asked about contacting the Clinical Manager, LPN 2 indicated the office has had many changes lately, and the family and patients had their phone numbers.

G0682

G0726

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure nursing services were provided under RN supervision for 4 of 9 active clinical records reviewed. (Patients: #1, 3, 5, and 6) Findings Include: 1. A review of an undated agency policy titled “Physician Orders” indicated but is not limited to, “ … To assure accurate and complete orders are obtained and verified … When a nurse or therapist receives a verbal order form the physician, he/she shall write the order as given then read the order back to the physician verifying that the person receiving the order heard it correctly and interpreted the order correctly …The verbal order shall verify that the order was taken and verified by documenting this on the form … Verbal orders are accepted by authorized, licensed agency personnel in accordance with applicable law … ” 2. A review of the active clinical record for Patient #1, with a SOC date of 02/18/2026, contained a physician order dated 02/18/2026 and signed by Former Employee 2, a previous LPN. The order stated, “Ok for SN to evaluate for home health services related to wound care,” and indicated that the order had been read back and verified. The order failed to identify from whom Former Employee 2 received the verbal order and did not include the time the order was read back and verified. In addition, the order was obtained and documented by an LPN, rather than an RN, as required for SOC orders for home health services. 3. A review of the active clinical record for Patient #3, with a SOC date of 02/11/2026, contained a physician order dated 07/02/2026 and signed by LPN 1. The order indicated Patient #3 had new wound‑care directions, including a change in frequency for skilled nursing services to two times per week for five weeks, effective 07/05/2026. The order further noted the wound would be changed by the skilled nurse on Mondays and Wednesdays, and the wound Nurse Practitioner would see the patient on Fridays. The wound‑care instructions for the left heel included: cleanse with normal saline, pat dry, apply Medihoney to the wound bed, cover with alginate, secure with a foam heel cup, and wrap with roll gauze and Coban. The clinical record failed to evidence RN direction or collaboration with LPN 1 in obtaining or writing the physician order for Patient #3’s care. During an interview on 07/09/2026 at 10:21 AM, when asked about the orders found in charts obtained by LPN 1 and Former Employee, an LPN for the agency, LPN 1 stated, “We rewrite all the orders in the electronic health record that come in, and they are sent out to the physician for signature.” 4. A review of the active clinical record for Patient #5, with a SOC date of 05/18/2026, contained a physician order dated 05/18/2026 and signed by Former Employee 2, a previous LPN. The order stated, “Ok for PT to evaluate for home health services related to generalized weakness/pain,” and indicated that the order had been read back and verified. The order failed to identify from whom Former Employee 2 received the verbal order, which had been read back and verified. In addition, the order was obtained and documented by an LPN, rather than an RN, as required for SOC orders for home health services. 5. A review of the active clinical record for Patient #6, with a SOC date of 02/02/2026, contained a POC for the recertification period 06/02/2026 to 07/31/2026. The POC noted Patient #6 had orders for SN one time a week for 1 week and 2 times a week for 8 weeks for wound care to a sacral pressure ulcer. Review of the 07/03/2026 LPN visit note, signed by LPN 2, noted in the “Visit Narrative” section the LPN reported contacting Patient #6’s healthcare provider, Person 12 regarding a significant change in the patient’s sacral wound. Verbal wound care orders were obtained and implemented. The LPN reassessed and remeasured the wound and provided education to the patient and caregiver on monitoring drainage, comfort, and potential side effects related to anticoagulation therapy. The visit note failed to evidence the RN case manager was notified of the significant change in the wound, or LPN 2 had been directed to contact the healthcare provider. Review of the 07/03/2026 physician order, signed by LPN 2, showed Patient #6’s nursing visit frequency was changed to twice weekly for four weeks. The order also added sacral pressure ulcer care for the skilled nurse on Mondays and Fridays, with the nurse practitioner scheduled on Wednesdays. Wound care included cleansing with Vashe (a wound wash), applying alginate (an absorbent wound dressing), lightly filling the tunnel and wound with Hydrofera Blue Classic (a wound foam dressing), and covering with bordered foam using aseptic technique. The clinical record failed to evidence LPN 2 had notified the RN case manager, or had been directed to contact Person 12, Patient #6’s healthcare provider. During an interview on 07/08/2026at 2:45 PM, when asked about significant changes in wounds and the process for calling the healthcare providers for orders, LPN 2 stated, “I call and get orders if there are changes in the patient’s wounds or condition. I do not go through a RN. I just called on [Patient #6] last week due to a significant change in their wound, and I received new orders for wound care.” 6. A review of Personnel records and agency job descriptions for nursing staff evidenced the following: A review of the personnel file for LPN 2 contained an agency document dated 03/25/2025, and signed by LPN 2, titled “Licensed Practical Nurse (LPN) Job Description.” The LPN job description indicated but was limited to, “The Licensed Practical Nurse (LPN) is responsible for ensuring quality home health care services to the Agency’s clients. In addition, to perform other duties as required by the Case Manager … Essential Duties and Responsibilities: Develops and implements client home health care plans … Discusses client plans of care with supervising Case Manager … Reports observations of client conditions to Case Manager … ” A review of the personnel file for LPN 1/Nursing Supervisor contained an agency document dated 10/15/2025 and electronically signed by LPN 1, titled “LPN Clinical Supervisor Job Description.” The LPN Clinical Supervisor job description indicated but was limited to, “The LPN Clinical Supervisor assists, establishes, implements, and evaluates goals and objectives for home health services … Essential Duties and Responsibilities: Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel … Completes plan-of-care with other agencies … Completes documentation/physician orders for changes in patient care … Monitoring clinical compliance … ” A review of the personnel file for RN 1 contained an agency document dated 11/18/2024 and electronically signed by RN 1, titled “Registered Nurse Job Description.” The RN job description indicated, but was not limited to, “ … The Registered Professional Nurse is responsible to apple professional knowledge and skill, in accordance with State and Federal guidelines and professional standards of practice … Essential Duties and Responsibilities: Demonstrates leadership and provides direction to members of the patient care team through case management … Provide supervision of LPN’s assigned to patient caseload, through directing the implementation and evaluating the effectiveness of the nursing … Documents direct patient services, coordination, and collaboration with physician and other disciplines … ” 7. Interviews with other nursing staff evidenced the following: During an interview on 07/10/2026 at 11:53 AM, when asked about being employed with Purposecare of Indiana, RN 3 and Former ADON, stated, “Yes, I work there PRN now. They eliminated my ADON position and offered me a QA role, and I resigned on 06/01/2026. I am only PRN now.” RN 3 further indicated they had received no training and expressed concerns about the training clinicians received, noting the need for RN support. During an interview on 07/10/2026 at 12:00 PM, LPN 4 confirmed they had been employed by Purposcare of Indiana for approximately 1.5 years. When asked about what they did when a patient had a change in condition, or for example, wound deterioration, LPN 4 stated, “If the patient has a change in their condition, I call the physician, then let the office know.” When asked who they reported to at the office, they stated: “[LPN 1].” During an interview on 07/10/2026 at 12:31 PM, LPN 5 confirmed they had been employed with Purposcare of Indiana for a few months. When asked about the training they had received, LPN 6 stated, “They had me go out for a few days with an LPN.” LPN 5 further communicated LPN1 is the one who responds when they have issues. During an interview on 07/10/2026 at 12:40 PM, RN 2 confirmed they had been employed with Purposcare of Indiana for about 10 months. When asked about who they reported to, they stated, “I report to [LPN1] the ADON.” 410 IAC 17-14-1(a)(1)(J)

G0798

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure Home Health Aides (HHAs) were assigned and provided appropriate instruction in 2 of 2 active clinical records reviewed for patients receiving HHA services. (Patients: # 1 and 7) Findings Include: 1. A review of an undated agency policy titled “Clinical Supervision” indicated but was not limited to, “Skilled Nursing and other therapeutic services are provided under the supervision of a Registered Nurse … To meet the requirements of state/federal guidelines and provide supervision and direction to all staff delivering home health services … ” 2. A review of the active clinical record for Patient #1, SOC date of 02/18/2026, contained a POC for the certification period of 02/18/2026 to 06/17/2026. The POC noted Patient #1 had orders for SN one time a week for 9 weeks to perform wound care to the distal lower left extremity, and HHA 3 times a week for one week, and 5 times a week for 8 weeks, to provide personal care and ADLs. During an interview on 07/08/2026 at 12:45 PM, when asked about the RN oversight and supervision, HHA 1, the HHA for Patient #1 stated, “I am on my own out here. I do not ever see a nurse out here. No one has shown me or tells me what the patients’ needs.” 3. A review of the active clinical record for Patient #7, SOC date of 02/05/2026, and a Resumption of care (ROC) date of 06/02/2026 contained a POC for the recertification period of 06/05/2026 to 08/03/2026. The POC noted that Patient #7 had orders for SN once a week for 6 weeks, with each visit to include a physical assessment emphasizing the disease process, minimizing the risk of rehospitalization, and addressing high-risk medications and compliance. The POC noted orders for HHA, but failed to evidence frequency, to provide personal care and ADLs. A review of a HHA visit note dated 06/08/2026 noted in comments “No care plan available.” During an interview on 07/10/2026 at 11:49 AM, when asked about the oversight of the HHA and care plans, RN 4 stated, “The RNs were to complete the care plan in and then the patients were assigned to the HHAs by the schedulers.”

G0808

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure RN supervisory visits were completed at least every 14 days for 2 of 2 active clinical records reviewed, with patients receiving skilled services and HHA services. (Patients: #1 and 7) Findings Include: 1. A review of an undated agency policy titled “Clinical Supervision” indicated but was not limited to, “Skilled nursing and other therapeutic services are provided under the supervision of a Registered Nurs … When clients are receiving skilled nursing services in addition to personal care, the Registered Nurse will make a supervisory visit to the client’s residence no less frequently than every 14 days … the supervisory visit may be conducted by the Therapist in place of the Registered Nurse … ” 2. A review of the active clinical record for Patient #1, SOC date of 02/18/2026, contained a POC for the certification period of 02/18/2026 to 06/17/2026. The POC noted Patient #1 had orders for SN one time a week for 9 weeks to perform wound care to the distal lower left extremity, and HHA 3 times a week for one week and 5 times a week for 8 weeks to provide personal care and ADLs. A review of the HHA visit notes the week of 05/31/2026 through 06/06/2026 evidenced Patient #1 had HHA visits 06/01, 06/02, 06/03, 06/04, and 06/05/2026. A review of the HHA Supervisory Visit notes from 05/05/2026 through 06/15/2026, evidenced Patient #1 received RN visits and Supervisory visits on 05/05, 05/19, 06/09, and 06/15/2026. The record failed to evidence a HHA Supervisory visit 14 days after the Supervisory visit dated 05/19/2026. The week of 05/31/2026 through 06/06/2026, no SN visits were conducted. During an interview on 07/08/2026 at 12:45 PM, when asked about the RN oversight and supervisory visits, HHA 1, the HHA for Patient #1, stated, “I am on my own out here. I have never seen a nurse out here. No one has shown me or told me what the patients’ needs are.” During an interview on 07/10/2026 at 11:50 AM, when asked about HHA supervisory visits, RN 4, the RN for Patient #1, confirmed supervisory visits were to be completed every 14 days. 3. A review of the active clinical record for Patient #7, SOC date of 02/05/2026, and a Resumption of care (ROC) date of 06/02/2026 contained a POC for the recertification period of 06/05/2026 to 08/03/2026. The POC noted Patient #7 had orders for SN one time per week for 6 weeks, with each visit to include a physical assessment emphasizing the disease process, minimizing the risk of rehospitalization, high-risk medications, and compliance. The POC noted orders for HHA, failing to evidence frequency, to provide personal care and ADLs. A review of a PT updated POC dated 06/19/2026, and signed by PT 3, for the certification period 06/05/2026 through 08/03/2026, noted Patient #7 had orders for PT one time a week for 7 weeks, effective 06/19/2026. A review of the HHA visit notes for the week of 06/28/2026 through 07/04/2026 indicates that Patient #7 had HHA visits on 06/29, 06/30, 07/01, 07/03, and 07/04/2026. A review of the HHA 2’s visit notes the week of 07/05/2026 through 07/10/2026 evidenced Patient #7 had HHA visits 07/05, 07/06, 07/08, 07/09, and 07/10/2026. A review of the HHA Supervisory Visit notes from 06/21/2026 through 07/10/2026, evidenced Patient #7 received a PT visit and Supervisory visit on 06/24/2026. The clinical record failed to evidence any other supervisory visits had been conducted. During an interview on 07/10/2026 at 1:44 PM, when asked about the HHA supervisory visits for Patient #7 being missed, PT 3 stated, “I don’t know how that was missed. Yes, every 14 days, HHA supervisory visits are to be completed.” 4. A review of HHA 1’s and HHA 3’s personnel files evidenced the following: A review of the personnel file to HHA 1 contained an agency document dated 11/27/2024 and electronically signed by HHA 1, titled “Home Health Aide (HHA) Job Description.” The HHA job description indicated, but was not limited to, “The home health aide is a member of the home care team who works under the supervision of a registered nurse ... ” A review of the personnel file to HHA 3 contained an agency document dated 01/26/2026 and electronically signed by HHA 3, titled “Home Health Aide (HHA) Job Description.” The HHA job description indicated, but was not limited to, “The home health aide is a member of the home care team who works under the supervision of a registered nurse ... ”

G0952

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 follow its policy to ensure hired staff were qualified to provide services for 1 of 1 agency. Findings Include: 1. Review of an undated agency policy titled “Clinical Supervision” indicated but was not limited to, “ … The Director of Nursing or a designated qualified Registered Nurse will be available to provide ongoing supervision … The Director of Nursing/Nursing Supervisor shall be responsible for the quality of care provided and supervision of all staff providing therapeutic services, including contract staff … The Nursing Supervision or designated Registered Nurse will give the Licensed Practical Nurse direction for client care …A copy of this written plan of care is to be left in the client’s home … When skilled services are being provided to a client, Registered Nurse/Therapist must make a supervisory visit to the client’s residence no later than 14 days … ” 2. A review of the personnel files for Admin 4, Quality Assurance RN, and Interim DON, LPN 2, RN 1, and Former Employees 1 and 2 failed to evidence documentation of job orientations or a nursing skills list. 3. Review of the clinical records for Patients #3 and #6 showed both had complex wounds with multiple wound‑order changes, episodes of wound deterioration, and use of wound VAC therapy (a treatment using a vacuum-assisted closure providing negative pressure). 4. A review of the personnel file for LPN 1/Nursing Supervisor contained an agency document dated 10/15/2025 and electronically signed by LPN 1, titled “LPN Clinical Supervisor Job Description.” The LPN Clinical Supervisor job description indicated but was limited to, “The LPN Clinical Supervisor assists, establishes, implements, and evaluates goals and objectives for home health services … Essential Duties and Responsibilities: Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel … Completes plan-of-care with other agencies … Completes documentation/physician orders for changes in patient care … Monitoring clinical compliance …" LPN 1, personnel record failed to contain a RN license. During an interview on 07/10/2026 at 11:53 AM, when asked about being employed with Purposecare of Indiana, RN 3 and Former ADON, stated, “Yes, I work there PRN now. They eliminated my ADON position and offered me a QA role, and I resigned on 06/01/2026. I am only PRN now.” RN 3 further indicated they had received no training and expressed concerns about the training clinicians received, noting the need for RN support. During an interview on 07/10/2026 at 12:00 PM, LPN 4 confirmed they had been employed by Purposcare of Indiana for approximately 1.5 years. When asked about what they did when a patient had a change in condition, or for example, wound deterioration, LPN 4 stated, “If the patient has a change in their condition, I call the physician, then let the office know.” When asked who they reported to at the office, they stated: “[LPN 1].” During an interview on 07/10/2026 at 12:40 PM, RN 2 confirmed they had been employed with Purposcare of Indiana for about 10 months. When asked about who they reported to, they stated, “I report to [LPN1] the ADON.” During an interview on 07/08/2026 at 12:45 PM, when asked about the RN oversight and supervisory, HHA 1, a contracted employee with Entity 18, a Personal Services Agency, stated, “I am on my own out here. I do not ever see a nurse out here. No one has shown me or tells me what the patients’ needs.” During an interview on 07/10/2026 at 9:58 AM, when asked about the missing personnel documents, Corporate Staff 1, the Vice President of Quality and Compliance, and a member of the governing body, stated, “We do not do specific job descriptions on staff, only general orientation. The only specific skills and orientation are for Home Health Aides (HHAs). It is not required for the skill checklist or specific orientation.” When asked about how the agency can determine the level of skill and knowledge of the nursing staff and need for further education or training, for example, a new nurse experienced only in a non-skilled facility and the nurse assigned to a wound vac who had never done wounds, the Corporate Staff 1 stated, “We do not do skills lists it is not required.” 410 IAC 17-12-1(d)(8)

G0984

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 RN appropriately and accurately assessed patients according to professional standards for 1 of 1 RN home visits completed. (Patients: #2) Findings Include: 1. A review of an undated agency policy titled “Comprehensive Client Assessment” indicated but is not limited to, “ … The Comprehensive Assessment must accurately reflect the client’s status, and must include … The client’s current health, psychosocial, functional, and cognitive status … ” 2. Constantine, L., MSN, RN, C-FNP. (2004, June 15). Overview of Nursing Health Assessment. Retrieved January 16, 2019, from rn.com " ... PULMONARY ASSESSMENT: When examining the pulmonary system ... Inspect the thoracic cage, palpate the thoracic cage, Auscultate the anterior and posterior chest: Have patient breath slightly deeper than normal through their mouth, Auscultate from C-7 to approximately T-8, in a left to right comparative sequence. You should auscultate between every rib ... Identify any adventitious breath sounds. .... " 3. Nurse.org, dated April 7, 2020, indicated: "How to Conduct a Head-to-Toe Assessment : ... LENGTH OF ASSESSMENT ... the duration of the exam is directly in correlation to the patient's overall health status. Health patients with limited health histories may be completed in less than 30 minutes" … The Order of a Head-to-Toe Assessment: 1. GENERAL STATUS: Vital signs; ... Temperature; ... Pain. 2. HEAD, EARS, EYES, NOSE, THROAT ... 3. NECK ... 4. RESPIRATORY: Listen to lung sounds front and back; Assess respiratory expansion level; Ask about coughing; Palpate thorax. 5. CARDIAC: Palpate the carotid and temporal pulses bilaterally; Listen to heartbeat. 6. ABDOMEN: ... Ask about problems with bowel or bladder. 7. PULSES: Check pulses in arms/legs/feet including, Radial, Femora, Posterior tibial, Dorsalis pedis. 8. EXTREMITIES: ... Check capillary refill on fingernails/toenails. 9. SKIN: Check skin turgor; Check for lesions, abrasions, rashes; Check for tenderness, lumps, lesions; Check if patient is pale, clammy, dry, cold, hot, flushed. 10. NEUROLOGICAL: Oriented x3; Assess gait; Check coordination; Assess reflexes; Check Glasgow Coma Scale." 4. During a home‑visit observation at Patient #2’s residence on 07/08/2026, from 8:05 AM to 8:37 AM, RN 1 was observed completing a SOC comprehensive assessment for Patient #2. RN 1 obtained vital signs and asked Patient #2 about shortness of breath, diabetes, oxygen equipment or needs, urinary continence issues, bowel movements and last date of movement, and appetite. RN 1 auscultated only the upper two posterior lung fields and failed to assess all posterior fields and anterior lung sounds. RN 1 auscultated the upper two abdominal quadrants for bowel sounds but failed to assess the lower two quadrants. RN 1 then auscultated the patient’s apical heart. RN 1 asked cognitive memory words, questions about bathing and daily activities, and caregiver assistance. RN 1 examined Patient #2’s skin on the back, buttocks, legs, and feet. Patient #2 reported they had fallen and awakened in the hospital with double‑vision changes and inability to walk. Patient #2 further indicated they had been hospitalized the prior fall for a brain bleed and now had to take medication to prevent seizures, as well as one as‑needed medication for nighttime hiccups following the seizure. Patient #2 stated they had received speech therapy to help with vision and word expression, occupational therapy, and physical therapy, and now could walk with a cane but was instructed to use a walker. Patient #2 became tearful and expressed experiencing suicidal ideation during hospitalization due to the lengthy stay and inability to attend a special event with friends and family, and was placed on close observation. RN 1 failed to complete a depression scale test and failed to complete a neurological exam. A review of the clinical record for Patient #2 contained referral documents from Entity 7, the rehabilitation facility dated 06/25/2026. The referral documents contained a document titled “Home Health Care Face-To-Face Encounter Form and Orders.” The face to face and orders form dated 06/25/2026, and signed by Person 8, a physician at Entity 7, noted Patient #2 had a Cerebral Vascular Accident (CVA) (commonly known as a stroke that happens when there is a loss of blood flow to part of the brain causing brain cells to die) and based on the physician’s findings Patient #2 required skilled nursing care for skin assessment and medication management, physical therapy, occupational therapy, and speech therapy. A review of the referral documents contained a document titled “History & Physical,” electronically signed by Person 11, a physician at Entity 7, and dated 06/21/2026. The assessment noted Patient #2 had been admitted to Entity 7 for a multifocal stroke with associated balance and vision impairments and was receiving comprehensive physical therapy, occupational therapy, and speech therapy. The assessment further documented that Patient #2 had a history of a cerebral aneurysm (a bulging or ballooning blood vessel in the brain that can rupture or leak, causing damage to brain cells), seizures treated with Keppra (a medication used to treat various types of seizures), depression currently managed with medication therapy, and Parkinson’s disease (a progressive nervous system disorder characterized by tremor, muscular rigidity, and slowed, imprecise movement). During an interview on 07/08/2026 at 8:40 AM, when asked about neuro checks being completed due to blurred vision and post CVA for Patient #2’s initial SOC assessment, RN 1 stated, “No, I didn’t need to do that. I do the basics for an assessment. I go home and put the rest of the information in using the referral information.” 5. A review of the personnel file for RN 1 contained an agency document dated 11/18/2024 and electronically signed by RN 1, titled “Registered Nurse Job Description.” The RN job description indicated, but was not limited to, “ … The Registered Professional Nurse is responsible to apple professional knowledge and skill, in accordance with State and Federal guidelines and professional standards of practice … " During a review of the home‑visit observations on 07/09/2026 at 9:34 AM with the management team—Corporate Staff 1, the Vice President of Quality & Compliance and governing body; LPN 1, the Clinical Supervisor; Admin 3, the Director of Operations and Interim Administrator; and Admin 4, the Quality Assurance RN and Interim DON—management was asked about the agency’s process and expectations for a SOC initial assessment completed by an RN. The management team communicated that a full head‑to‑toe assessment should be completed. When asked what should be assessed for a post‑CVA patient, the management team stated that both a head‑to‑toe assessment and a neurological assessment should have been completed.

G1024

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Resumption of care (ROC) assessment had been authenticated and completed for 1 of 1 clinical records reviewed, with a ROC being completed. (Patient #7) Findings Include: 1. A review of an undated agency policy titled “Clinical Documentation” indicated, but was not limited to, “Agency will document each direct contact with the client. This documentation will be completed by the direct caregivers … Purpose: To ensure there is an accurate record of the services provided … ” 2. A review of the clinical record for Patient #7 contained a ROC OASIS dated 06/02/2026 with a visit start time of 4:49 PM and visit end time of 5:32 PM, and electronically signed by Admin 4, the Quality Assurance RN and Interim DON. During an interview on 07/09/2026 at 3:35 PM, Corporate Staff 1, the Vice President of Quality and Compliance, stated, “[Admin 4] does not see patients, and she is not required to see patients in the field. She works remotely.” The Governing Body/agency failed to ensure the proper process for a resumption of care as Admin 4 does not see the patient. 410 IAC 17-15-1(b)

Survey of April 8, 2022

1 finding

G0802

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the home health aide failed to follow the aide care plan of care for 1 of 2 home health aide home visits. (Patient #1) Findings include: 1. A review of an agency policy titled, 'STANDARDS OF PRACTICE C-110' dated 11/17/21, stated, "POLICY Alliance Home Health Services will provide services that are in compliance with professional standards of practice for the home health care industry as well as all state and federal laws and identified agency performance improvement standards. PURPOSE To identify and define the accepted standards of practice Alliance Home Health Services is committed to following in the provision of home care services to our clients. SPECIAL INSTRUCTIONS 1. Alliance Home Health Services staff will practice within the guidelines of their stated discipline. 2. Staff will be knowledgeable regarding laws and regulations governing home health care. 3. Client care will be provided under the Plan of Care established by a PCP [primary care physician] ..." A Review of an agency policy titled, 'SERVICES PROVIDED C-100' dated 11/17/2021 stated, "...Services will be coordinated by the Registered Nurse...managing the care. This will include implementing...” 2. A review of Patient #1 undated document titled,” Aide Care Plan,” for the certification period of 3/18/22 to 5/16/22 revealed the HHA (home health aide) was to "1. Assist with positioning, repositioning, alignment, 2. Assist with transfers, 3. ROM (range of motion) exercises, 4. Transfer to bed/chair with assistance-use Hoyer lift, 5. Diabetic Precautions, 6. Assist with meal preparation, 7. Dusting, 8. Document bowel movements, 9. Incontinent Care, 10. Change patient linen, 11. Clean bathroom after patient care, 12. Clean living area of the patient, 13. Clean up kitchen after meal preparation, 14. Do patient laundry, 15. Make patient bed, 16. Assist patient with dressing, 17. Bath-Bed, 18. Shampoo, 19. Fall precautions”. A home visit was conducted on 4/6/22 from 8:15 AM to 9:05 AM, with employee B, a home health aide, after the patient’s bed bath, employee B applied nystatin powder to the patient’s abdominal folds and applied a mixture of calmoseptine and Vaseline onto the patient’s buttocks. A review of Patient #1 home health aide visit note for 4/6/22, failed to document the HHA had applied the nystatin powder and the mixture of calmoseptine and Vaseline onto the patient’s buttocks and failed to document ROM (range of motion) exercises, failed to document bowel movements, failed to have changed the patient linens, clean the patient’s bathroom, and clean the living area of Patient 1. During an interview with the clinical supervisor on 4/7/22 at 3:40 PM, when informed of the home health aide visit, the clinical supervisor stated employee B knows that's a prescription (referring to the nystatin powder) and the HHA was not permitted to apply medicated lotions. 410 IAC 17-14-1(h)(1)-(14)

Survey of February 23, 2022

14 findings

E0000

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 2/15, 2/16, 2/17, 2/21. 2/22, 2/23 At this Emergency Preparedness survey, Home Health Care Solutions, LLC., was found to have been in compliance with the Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, including staffing and the implementation of staffing during a pandemic at 42 CFR 484.102. QR by Area 3 on 3-8-2022

G0000

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Care Provider. Survey Dates: 2/15, 2/16/22, 2/17/22, 2/21/22, 2/22/22, and 2/23/22. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Based on the Condition-level deficiencies during the 2/24/22 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 2/24/22. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation program for a period of two years beginning 2/24/22 and continuing through 2/23/24. QR by Area 3 on 3-8-2022

G0436

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 ensure they adhered to patient rights and provide all services as outlined on the patient's plan of care in 1 of 7 active records (Patient #4) and 1 of 3 closed records. (Patient #5) Findings include: 1. A review of the clinical record of patient #4, revealed a “Home Health Care Certification and Plan of Care,” dated 1/19/22, for the certification period of 1/19/22 to 3/19/22, which evidenced diagnoses, but not limited to, Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time,) Scoliosis (a sideways curvature of the spine,) and Intervertebral Disc Disorders with radiculopathy (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, that can cause pain, numbness, and/or leg weakness,) with SN (skilled nursing) 1 x month for 2 months, and HHA (home health aide) services 7 x week for 1st week, then 12 times a week for 8 weeks. Review of the Aide Visit Notes for the certification period of 1/19/22 to 3/19/22 evidenced home health aide missed visits on 1/23/22, both AM and PM, 1/30/22 AM, 2/2/22 PM, 2/3/22 PM, 2/4/22 AM and PM, 2/6/22 AM, and 2/13/22 AM. During a home visit on 2/17/22 at 8:20 AM with patient #4, when a family member was queried if the patient/family had been notified in advance if the HHA was not coming for an ordered visit, they stated "sometimes." The family member stated the staff is usually late. The Agency failed to provide all services outlined in the Plan of Care. 2. A review of the closed clinical record of patient #5, revealed a “Home Health Care Certification and Plan of Care,” dated 7/29/21, for the certification period of 7/29/21 to 9/26/21, which evidenced diagnoses but not limited to Hypertensive Kidney Disease Stage 4 (moderate to severe damage to your kidneys, not filtering waste out of your blood, causing a buildup in your body causing other health issues,) Intervertebral Disc Degeneration Lumbar Region (the breakdown of one or more of the discs that separate the bones of the spine, lower back,) and a History of Falls. Patient #5 was ordered to receive SN (skilled nursing) 2 times a week for 2 weeks, then 1 time a week for 4 weeks, PT (physical therapy) 2 times a week for 6 weeks, OT (occupational therapy) 2 times a week for 6 weeks, and HHA (home health aide) 2 times a week for 8 weeks. A review of skilled and therapy notes revealed there was a missed skilled nursing visits the week of 8/1/21 to 8/7/21, and 1 missed visit the week of 8/8/21 to 8/14/21; missed PT visits were 1 the week of 8/15/21 and 2 the week of 9/5/21 to 9/11/21; and missed OT visits were 1 the week of 8/1/21 to 8/7/21 and 1 the week of 8/15/21 to 8/21/21. The clinical record failed to evidence any documentation of HHA care visits. The Agency failed to provide Patient #5 all services that were ordered/outlined in the Plan of Care. During an interview with the clinical manager on 2/22/22 at 12:05, when made aware of these patients' missed visits, stated they were not able to provide missed visit communication notes to the physician, and had no explanation for how care needs and goals could be met in the absence of ordered care visits.

G0570

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, interview, and observation, the agency failed to ensure ordered care visits were provided according to the written plan of care (See G572); failed to ensure the plan of care was created in conjunction with the ordering physician by having failed to obtain verbal orders before furnishing care, resumption of care, and/or recertification assessments were performed by agency clinicians (See G580); failed to ensure verbal orders were obtained and documented in the clinical record and contained signature, date, and time the verbal orders were received from the physician (See G584); the agency failed to ensure the individualized plan of care was reviewed by the physician who was responsible for the home health plan of care, no less frequently than every 60 days from the start of care (See G588). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation 42CFR 484.60 Care Planning, Coordination of Care, and Quality of Care. A deficient practice citation was also evidenced at this standard as follows: These practices impacted 7 (patients 2, 4, 5, 6, 7, 8, and 10) out of 10 sampled records reviewed. Findings Include: 1. A review of an agency undated policy, "Electronic Visit Verification Submission," revealed, "POLICY ... services furnished under waivers or "home health service" or "personal care service"... even if they are bundled into a different service ... SPECIAL INSTRUCTIONS 1 ... a. the type of service performed; which must match the are plan or explain why it did not ... 6. All services are provided under a physician plan of care ... If any services are not provided, it must be documented as to exactly why they were not provided ..." 2. A review of an agency's policy dated 11/20/2017, titled, "Clinical Documentation C-680," revealed; "POLICY Alliance Home Health Care will document each direct contract 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 ... SPECIAL INSTRUCTIONS...6. Services not provided and the reason for the missed visits will be documented." 3. In an undated agency policy titled 'Plan of Care C-580,' a section titled 'Policy' stated, "Home Services are furnished under the supervision and direction of the client's physician.' A section titled 'Special Instruction' stated, "3. If a physician refers client under a Plan of Care that cannot be completed until after an assessment visit, the physician shall be consulted to approve additions or modifications to the original plan ... 8. The total Plan of Care shall be reviewed by the attending physician and agency personnel as often as the severity of the client's condition requires but at least one time every 60 days ...10. Verbal/ telephone orders shall be obtained from the client's physician for changes in the plan of care." 4. A review of an Agency's policy, dated 10/22/21, titled 'Physician Orders C-635,' a section titled 'POLICY CDT 4.D - 5.1.M.2 revealed "all medications, treatments and services provided to clients must be ordered by a physician ... The orders may be initiated via telephone or in writing and must be countersigned by the allowed prescribing practices within 30 days...PURPOSE To document verification that orders for services have been obtained in accordance with 410 IAC 17-31-1 Medical Plan of Care...SPECIAL INSTRUCTION 1. When the nurse or therapist receives a verbal order from the allowable prescribing practitioner, he/she shall write the order as given and then read the order back to the allowable subscriber verifying that the person receiving the order heard it correctly and interpreted the order correctly. The verbal order shall verify that the order was taken and verified by documenting this in the EMR {electronic medical record} form and signing the form. The order must include the time, date, specific order, be signed with the full name and title of the person receiving the order and be sent to the allowable prescriber for signature ... " 5. A review of an Agency's policy titled, "Client Reassessment/Update of Comprehensive Assessment," dated 10/22/21, revealed, "POLICY The Comprehensive Assessment will be up dated and revised as often as the client's condition warrants ... 1. Every second calendar month beginning with the start of care ... including day sixty ... PURPOSE To identify decline or improvement in health ... To verify appropriate use of home care services ...To identify progress toward goals ... SPECIAL INSTRUCTION ... 12. Reassessments are conducted every visit based on physician orders, client conditions ..." 6. A review of an Agency's undated policy titled, "Plan of Care C580," revealed, "POLICY Home care services are furnished under the supervision and direction of the client's physician ... PURPOSE To assure that the plan meets state/federal guidelines, and all applicable laws and regulations ... SPECIAL INSTRUCTIONS 1. An individualized Plan of Care signed by a physician shall be required for each client receiving home health and personal care services. 2. The Pan of Care shall be completed in full to include: … 3. If a physician refers a client under a Plan of Care that cannot be completed until after an assessment visit, the physician shall be consulted to approve additions or modifications to the original plan. The Skilled assessment visit order will be documented on a Doctor’s Order Form and mailed to the physician for signature … 9. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care. 10. Verbal/telephone orders shall be obtained from the client’s physician for changes in the Plan of Care …" 7. A review of the clinical record of patient #2, revealed a document titled, “Home Health Care Certification and Plan of Care,” evidenced a SOC (start of care) of 2/5/22, for the certification period of 2/5/22 to 4/5/22, and revealed Physical Therapy 2 times a week, for 3 weeks, then 1 time a week for 3 weeks, beginning the week of 2/7/22 through 3/19/22, which was signed by the RN (registered nurse) on 2/14/22, and the physician on 2/15/22. The clinical record revealed PT visits were made on 2/10/22 and 2/14/22. A review of the clinical record failed to evidence a verbal order for therapy visits, or a returned physician authenticated plan of care had been obtained prior to having furnished the above care visits. During a telephone interview on 2/17/22 at 3:59 PM, Person B from entity A (for patient 2), stated the agency never calls for verbal orders, they will send orders through Right Fax, but let me check the patient's record to verify what I'm telling you is right, to make sure someone hasn't left out a communication note in the chart for verbal orders. Person B placed the surveyor on hold momentarily, then came back to the state, "there are no communication notes for verbal orders in the patient's medical record." 8. A review of the clinical record of patient #4, revealed a “Home Health Care Certification and Plan of Care,” dated 1/19/22, for the certification period of 1/19/22 to 3/19/22, evidenced diagnoses, but not limited to, Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time,) Scoliosis (a sideways curvature of the spine,) and Intervertebral Disc Disorders with radiculopathy (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, that can cause pain, numbness, and/or leg weakness,) with SN (skilled nursing) 1 x month for 2 months, and HHA (home health aide) services 7 x week for 1st week, then 12 times a week for 8 weeks. This document was signed by MD on 2/10/22. Review of the Aide Visit Notes for the certification period of 1/19/22 to 3/19/22 evidenced missed visits on 1/23/22, both AM and PM, 1/30/22 AM, 2/2/22 PM, 2/3/22 PM, 2/4/22 AM and PM, 2/6/22 AM, and 2/13/22 AM. Review of Patients #4 clinical record failed to evidence documentation that explained the reason for missed visits, how care needs were met in the absence of ordered care visits, failed to document attempts to make up missed visits, and failed to evidence documentation the ordering physician was notified of same. A review of HHA care visits during the certification period of 1/19/22 to 3/19/22, were made on 1/19/22, AM and PM visits; 1/20/22 PM visit; 1/21/22 AM and PM visits; 1/22/22 AM and PM visits; 1/24/22, AM and PM visits; 1/25/22 PM visit; 1/26/22, AM and PM visits; 1/27/22 PM visit; 1/28/22 AM and PM visits; 1/29/22, AM and PM visits; 1/30/22 PM visit; 1/31/22, AM and PM visits; 2/1/22 PM visit; 2/2/22 AM visit; 2//5/22, AM and PM visits; 2/6/22 PM visit; 2/7/22 AM and PM visits; 2/8/22 PM visit; and 2/9/22, AM and PM visits. A review of the clinical record failed to evidence documentation of receipt of a verbal order for care visits, or attempt to obtain a verbal order, complete with date and time of receipt, from the signing physician (2/10/22) before service visits were provided from 1/19/22 to 2/10/2022. A review of the clinical record of patient #4, revealed a “Skilled Nursing Visit” note for Home Health Plan of Care recertification, dated 1/14/22, for the certification period of 1/19/22 to 3/19/22; with a start of care date of 5/24/21, and revealed the RN (registered nurse), employee H, indicated in the narrative note a verbal recertification order was received. A review of the clinical record failed to evidence documentation of the contents of the order, or evidence a verbal order had been sent to the physician for counter-signature. The clinical record failed to evidence verbal orders for recertification before the new certification period and failed to evidence the Primary Clinician (employee H) with the physician following the recertification assessment dated 1/14/22, to obtain approval for recertification. During a telephone interview on 2/23/22 at 3:14 PM, Person J from entity K stated (for patient 4), "we never give out verbal orders for home care services. It's all handled by fax." 9. A review of the closed clinical record of patient #5, revealed a “Home Health Care Certification and Plan of Care,” dated 7/29/21, for the certification period of 7/29/21 to 9/26/21, which evidenced diagnoses, but not limited to, Hypertensive Kidney Disease Stage 4 (moderate to severe damage to your kidneys, not filtering waste out of your blood, causing a buildup in your body causing other health issues,) Intervertebral Disc Degeneration Lumbar Region (the breakdown of one or more of the discs that separate the bones of the spine, lower back,) and History of Falls. Patient #5 was to receive SN (skilled nursing) 2 times a week for 2 weeks, then 1 time a week for 4 weeks, PT (physical therapy) 2 times a week for 6 weeks. OT (occupational therapy) 2 times a week for 6 weeks, and HHA (home health aide) 2 times a week for 8 weeks, signed by the physician on 8/18/21. A review of SN care visits during the certification period of 7/29/21 to 9/26/21, were made on 8/10/21, 8/17/21, 8/20/21, 8/23/21, 8/26/21, 8/30/21, and 9/2/21. A review of PT visits during the certification period of 7/29/21 to 9/26/21, were made on 8/3/21, 8/17/21, 8/25/21, 8/27/21. 8/31/21, and 9/1/21. A review of OT visits during the certification period of 7/29/21 to 9/26/21, were made on 8/4/21, 8/14/21, 8/16/21, 8/25/21, 8/27/21, 9/1/21, 9/3/21, and 9/8/21. A review of the clinical record failed to evidence documentation of receipt of a verbal order, or attempt to obtain verbal order, complete with date and time of receipt, or content of the orders for care, from the signing physician before service visits after the evaluation visits were provided from 7/29/21 to 8/18/21. Missed SN visits: there were no visits made the week of 8/1/21 to 8/7/21, and 1 missed visit the week of 8/8/21 to 8/14/21. Missed PT visits were 1 missed visit the week of 8/15/21 and 2 missed visits the week of 9/5/21 to 9/11/21. Missed OT visits were 1 missed visit the week of 8/1/21 to 8/7/21, 1 missed visit the week of 8/15/21 to 8/21/21. All HHA's visits were missed. There was no documentation of HHA care visits in the clinical record. During an interview with the clinical manager on 2/22/22 at 12:05, stated they are not able to provide missed visits report and missed visits communication notes to physician, or verbal orders identifying missed visits. The clinical manager could not explain how the patients' needs were met or progress towards goals was maintained in the absence of ordered visits. The clinical record failed to evidence documentation that explained the reason for missed visits, failed to document attempts to make up missed visits, and failed to evidence documentation that the ordering physician was notified of same. A further review of the closed clinical record of patient #5, revealed SN care visits during the certification period of 7/29/21 to 9/26/21, were made on 8/10/21, 8/17/21, 8/20/21, 8/23/21, 8/26/21, 8/30/21, and 9/2/21. A review of PT visits during the certification period of 7/29/21 to 9/26/21, were made on 8/3/21, 8/17/21, 8/25/21, 8/27/21. 8/31/21, and 9/1/21. A review of OT visits during the certification period of 7/29/21 to 9/26/21, were made on 8/4/21, 8/14/21, 8/16/21, 8/25/21, 8/27/21, 9/1/21, 9/3/21, and 9/8/21. A review of the clinical record failed to evidence documentation of receipt of a verbal order, or attempt to obtain verbal order, complete with date and time of receipt, the content of the care orders, from the signing physician before service visits after the evaluation visits were provided from 7/29/21 to 8/18/21. 10. A review of the clinical record of patient #6, revealed a “Home Health Care Certification and Plan of Care,” dated 1/11/22, for the certification period of 1/9/22 to 3/9/22, with SN (skilled nursing) 3 times a week for 8 weeks, then 2 times a week for 1 week for wound care. The Plan of Care was signed by the physician on 1/27/22. A review of skilled nursing visits revealed visits were 1/10/22, 1/14/22, 1/17/22, 1/19/22, 1/21/22, 1/24/22, 1/26/22. A review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care, had not been obtained before furnishing the SN visits above, made prior to 1/27/22. A further review of the clinical record of patient #6, revealed a document titled, ROC OASIS (resumption of care) Assessment”, dated 1/7/22; which evidenced diagnoses, but not limited to ,Type 2 Diabetes mellitus ( the body either doesn't produce enough insulin, or it resists insulin,) with foot ulcer (an open sore or wound that may occur with diabetes, and is commonly located on the bottom of the foot,) Malignant neoplasm of the colon (cancer colon,) and Colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen.) The record failed to evidence verbal orders for the resumption of care and any changed orders based on the resumption of care assessment. A review of the clinical record of patient #6, revealed a “Home Health Care Certification and Plan of Care,” dated 1/11/22, for the certification period of 1/9/22 to 3/9/22. Patient #6 orders included SN (skilled nursing) 3 times a week for 8 weeks, then 2 times a week for 1 week for wound care. The Plan of Care was signed by the physician on 1/27/22. The clinical record for patient #6 failed to evidence verbal orders for the resumption care, before the start of the certification period, and failed to evidence the Primary Clinician (employee letter 'I') conferred with the physician following the resumption assessment dated 1/7/22, to determine approval for resumption/recertification. 11. A review of the clinical record of Patient 7, with a start of care date of 1/14/22, contained a plan of care for the certification period of 1/14/22 to 3/14/22, with the resumption of care orders effective 1/21/22, and contained PT (physical therapy) visit orders effective 1/24/22: 1 time per week for 1 week, 2 times per week for 5 weeks, and OT (occupational therapy) visit orders effective 1/24/22: 1 time per week for 1 week, 2 times per week for 6 weeks. The record revealed the physician signed the resumption plan of care on 2/14/22. A review of the visit notes evidenced PT visits were made on 1/26/22, 2/5/22, 2/7/22, and 2/9/22, and visit notes from OT evidenced visits were made on 1/28/22, /31/22, 2/8/22, and 2/10/22. A review of the clinical record failed to evidence documentation of receipt of verbal order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician before service visits were provided. In an interview on 2/23/22 at 10:55 AM, Nurse F with Doctor G (for patient 7) indicated that in their documentation he/she could not find any phone calls or messages received from Physical Therapy, nor Occupational Therapy attempting to obtain verbal orders for Home Health services. Nurse F stated, "not for October, not for November... fax in December...I do not see phone orders." 12. A review of the clinical record for patient 8, with a start of care date of 1/6/22 and a certification period of 1/6/22 to 3/6/22, contained a plan of care which included PT (physical therapy) visit orders for: 2 times per week for 2 weeks, and OT (occupational therapy) visit orders for: 2 times per week for 4 weeks. The record revealed the physician signed the plan of care orders on 1/19/22. A review of visit notes from PT evidenced visits were made on 1/11/22, 1/13/22, and 1/18/20, and visit notes from OT evidenced visits were made on 1/10/22, 1/12/22, and 1/17/22. A review of the clinical record failed to evidence documentation of receipt of verbal order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician before service visits and after the evaluation visit. In an interview on 2/24/22 at 2:30 PM, Nurse D with Doctor E (for patient 8) returned the call and the indicated that according to their records, as of 1/6/22 they have no record of representatives from the agency calling to obtain verbal orders. Stated, "they are definitely fax-ers." When queried further, Nurse D indicated she was the one who usually gave verbal orders and stated, "I would remember (giving verbal orders)". 13. A review of the clinical record for patient 10, with a start of care date of 10/26/21 and a certification period of 10/26/21 to 12/24/21, which contained a plan of care that included PT (physical therapy) visit orders for: 1 time per week for 1 week, 2 times per week for 5 weeks, and OT (occupational therapy) visit orders for: 2 times per week for 4 weeks. The record revealed the physician signed the plan of care orders on 12/1/21. A review of visit notes from PT evidenced visits were made on 10/30/21, 11/2/21, 11/4/21, 11/9/21, 11/11/21, 11/23/21, and 11/29/21, and visit notes from OT evidenced visits were made on 11/1/21, 11/3/21, 11/8/21, 11/10/22, 11/15/21, 11/17/21, 11/22/21 and 11/24/21. A review of the clinical record failed to evidence documentation of receipt of verbal order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician before service visits after the evaluation visits, were provided. In an interview on 2/23/22 at 11:03 AM, Nurse H with Doctor I (for patient 10) indicated there were no calls made from the agency for verbal orders for therapy services, but indicated they have received faxes titled, "Verbal Order" but there were no corresponding phone calls. 14. In an interview on 2/23/22 at 1:30 PM, the Clinical Manager indicated the process for obtaining verbal orders for a plan of care (at admission, resumption, or recertification) was to have the Admitting Nurse, when nursing was involved, to contact physicians for all verbal orders for the plan of care, including requesting orders for therapists on behalf of the Physical and Occupational Therapists. 15. In an interview on 2/23/22 at 2:22 PM, Nurse #C indicated during or after a start of care, resumption of care, or recertification, the admitting nurse was supposed to call the ordering physician for nursing orders, and the therapists were to call the physician during or after their therapy evaluations to obtain their own verbal orders for therapy frequencies and orders. 410 IAC 17-13-1(a)

G0572

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure care visits for skilled nursing, therapy and aides were provided according to the written plan of care for 1 of 8 active records and 1 of 2 closed records reviewed. (Patients #4, and 5) Findings Include: 1. A review of an agency undated policy, "Electronic Visit Verification Submission" revealed, "POLICY...services furnished under waivers or "home health service" or "personal care service"...even if they are bundled into a different service ... SPECIAL INSTRUCTIONS 1... a. the type of service performed; which must match the are plan or explain why it did not...6. All services are provided under a physician plan of care ... If any services are not provided, it must be documented as to exactly why they were not provided ..." A review of an agency's policy dated 11/20/2017, titled, "Clinical Documentation C-680" revealed; POLICY Alliance Home Health Care will document each direct contract 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 ... SPECIAL INSTRUCTIONS ... 6. Services not provided and the reason for the missed visits will be documented. 2. A review of the clinical record of patient #4, revealed a “Home Health Care Certification and Plan of Care”, dated 1/19/22 for the certification period of 1/19/22 to 3/19/22 which evidenced diagnoses, but not limited to, Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time), Scoliosis (a sideways curvature of the spine), and Intervertebral Disc Disorders with radiculopathy (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, that can cause pain, numbness, and/or leg weakness) with SN (skilled nursing) 1 x month for 2 months, and HHA (home health aide) services 7 x week for 1st week, then 12 times a week for 8 weeks. Review of the Aide Visit Notes for the certification period of 1/19/22 to 3/19/22 evidenced missed visits on 1/23/22, both AM and PM, 1/30/22 AM, 2/2/22 PM, 2/3/22 PM, 2/4/22 AM and PM, 2/6/22 AM, and 2/13/22 AM. The agency failed to ensure the patient received the services as outlined in their plan of care and failed to document missed visits. 3. A review of the closed clinical record of patient #5, revealed a “Home Health Care Certification and Plan of Care”, dated 7/29/21, for the certification period of 7/29/21 to 9/26/21, which evidenced diagnoses but not limited to Hypertensive Kidney Disease Stage 4 (moderate to severe damage to your kidneys, not filtering waste out of your blood, causing a buildup in your body causing other health issues), Intervertebral Disc Degeneration Lumbar Region (the breakdown of one or more of the discs that separate the bones of the spine, lower back), and History of Falls. The patient was to receive SN (skilled nursing) 2 times a week for 2 weeks, then 1 time a week for 4 weeks, PT (physical therapy) 2 times a week for 6 weeks. OT (occupational therapy) 2 times a week for 6 weeks, and HHA (home health aide) 2 times a week for 8 weeks. Missed SN visits: there were no visits made the week of 8/1/21 to 8/7/21, and 1 missed visit the week of 8/8/21 to 8/14/21. Missed PT visits were 1 missed visit the week of 8/15/21 and 2 missed visits the week of 9/5/21 to 9/11/21. Missed OT visits were 1 missed visit the week of 8/1/21 to 8/7/21, 1 missed visit the week of 8/15/21 to 8/21/21. All HHA's visits were missed. Review of the clinical record failed to evidence documentation of any HHA care visits. The agency failed to ensure the patient received the services as outlined in their plan of care and failed to document missed visits. 4. During an interview with the clinical manager on 2/22/22 at 12:05, stating they are not able to provide missed visits report and missed visits communication notes to physician, or verbal orders identifying missed visits. 410 IAC 17-13-1(a)

G0580

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 agency failed to ensure the plan of care was created in conjunction with the ordering physician by having failed to obtain verbal orders after the initial comprehensive assessment, at the time of resumption of care, and at recertification in 6 (Patients #2, 4, 6, 7, 8 and 10) out of 10 clinical records reviewed. Findings include: 5. A review of the clinical record of patient #2, revealed an document titled, “Home Health Care Certification and Plan of Care” evidenced a SOC (start of care) of 2/5/22 for the certification period of 2/5/22 to 4/5/22, revealed Physical Therapy 2 times a week, for 3 weeks, then 1 time a week for 3 weeks, beginning the week of 2/7/22 through 3/19/22, which was signed by the RN (registered nurse) on 2/14/22 and the physician on 2/15/22. The clinical record revealed PT visits were made on 2/10/22 and 2/14/22. A review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care had been obtained prior furnished the above care visits. 6. A review of the clinical record of patient #4, revealed a “Home Health Care Certification and Plan of Care”, dated 1/19/22 for the certification period of 1/19/22 to 3/19/22 with SN (skilled nursing) 1 x month for 2 months, and HHA (home health aide) services 7 x week for 1st week, then 12 times a week for 8 weeks; which evidenced the MD signature on 2/10/22. A review of HHA care visits during the certification period of 1/19/22 to 3/19/22, were made on 1/19/22, AM and PM visits; 1/20/22 PM visit; 1/21/22 AM and PM visits; 1/22/22 AM and PM visits; 1/24/22, AM and PM visits; 1/25/22 PM visit; 1/26/22, AM and PM visits; 1/27/22 PM visit; 1/28/22 AM and PM visits; 1/29/22, AM and PM visits; 1/30/22 PM visit; 1/31/22, AM and PM visits; 2/1/22 PM visit; 2/2/22 AM visit; 2//5/22, AM and PM visits; 2/6/22 PM visit; 2/7/22 AM and PM visits; 2/8/22 PM visit; 2/9/22, AM and PM visits; 2/10/22 PM visit; 2/11/22, AM and PM visits; 2/12/22, AM and PM visits; 2/13/22 PM visit; 2/14/22, AM and PM visits; 2/15/22 PM visit; 2/16/22, AM and PM visits; 2/17/22 AM visit. A review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care, had been obtained before furnishing the HHA visits made prior to 2/10/22. 7. A review of the clinical record of patient #6, revealed a “Home Health Care Certification and Plan of Care”, dated 1/11/22, for the certification period of 1/9/22 to 3/9/22, with SN (skilled nursing) 3 times a week for 8 weeks, then 2 times a week for 1 week for wound care, which evidenced the MD signature on 1/27/22. A review of skilled nursing visits revealed visits were 1/10/22, 1/14/22, 1/17/22, 1/19/22, 1/21/22, 1/24/22, 1/26/22, 1/31/22, 2/2/22, 2/7/22, 2/9/22, 2/11/22, 2/14/22, 2/16/22, 2/21/22. A review of the clinical record failed to evidence a verbal order or a returned physician authenticated plan of care, had been obtained before furnishing the SN visits made prior to 1/27/22. 8. During a telephone interview on 2/17/22 at 3:59 PM, Person B from entity A, a physician's office, stated the agency never calls for verbal orders, they will send orders through Right Fax, but let me check the patient's record to verify what I'm telling you is right, to make sure someone hasn't out a communication note in the chart for verbal orders. Person B placed this writer on hold momentarily, then came back to indicate there are no communication notes for verbal orders in the patient's medical record. During a telephone interview on 2/23/22 at 3:14 PM, Person J from entity K stated, we never give out verbal orders for home care services. It's all handled by fax. In an interview on 2/23/22 at 1:30 PM, the Clinical Manager indicated the process for obtaining verbal orders for a plan of care (at Admission, resumption, or recertification) was to have the Admitting Nurse, when nursing is involved, contact physicians for all verbal orders for the plan of care, including requesting for therapy orders on behalf of the Physical and Occupational Therapists. 410 IAC 17-13-1(a) 1. In an undated agency policy titled 'Plan of Care C-580', a section titled 'Policy' stated, "Home Services are furnished under the supervision and direction of the client's physician.' A section titled 'Special Instruction' stated, "3. If a physician refers client under a Plan of Care that cannot be completed until after an assessment visit, the physician shall be consulted to approve additions or modifications to the original plan...8. The total Plan of Care shall be reviewed by the attending physician and agency personnel as often as the severity of the client's condition requires but at least one time every 60 days...10. Verbal/ telephone orders shall be obtained from the client's physician for changes in the plan of care." In an agency policy dated 10/22/21, titled 'Physician Orders C-635' a section titled 'Policy CDT 4.D - 5.1.M.2 stated, "all medications, treatments and services provided to clients must be ordered by a physician....The orders may be initiated via telephone or in writing and must be countersigned by the allowed prescribing practices within 30 days." A section titled 'Purpose' stated, "To document verification that orders for services have been obtained in accordance with 410 IAC 17-31-1 Medical Plan of Care." A section titled 'Special Instruction' stated, "1. When the nurse or therapist receives a verbal order form the allowable prescribing practitioner, he/she shall write the order as given and then read the order back to the allowable subscriber verifying that the person receiving the order heard it correctly and interpreted the order correctly. The verbal order shall verify that the order was taken and verified by documenting this in the EMR {electronic medical record} form and signing the form. The order must include the time, date, specific order, be signed with the full name and title of the person receiving the order and be sent to the allowable prescriber for for signature." 2. A review of the clinical record of Patient 7, with a start of care date of 1/14/22, which contained a plan of care for the certification period of 1/14/22 to 3/14/22, with resumption of care orders effective 1/21/22 and contained PT (physical therapy) visit orders effective 1/24/22: 1 time per week for 1 week, 2 times per week for 5 weeks, and OT (occupational therapy) visit orders effective 1/24/22: 1 time per week for 1 week, 2 times per week for 6 weeks. The record revealed the physician signed the resumption plan of care on 2/14/22. A review of visit notes from PT evidenced visits were made on 1/26/22, 2/5/22, 2/7/22, and 2/9/22, and visit notes from OT evidenced visits were made on 1/28/22, 1/31/22, 2/8/22, and 2/10/22. A review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care, had not been obtained before furnishing the above care visits. A review of the clinical record for Patient 8, with a start of care date of 1/6/22 and a certification period of 1/6/22 to 3/6/22, contained a plan of care which included PT (physical therapy) visit orders for: 2 times per week for 2 weeks, and OT (occupational therapy) visit orders for: 2 times per week for 4 weeks. The record revealed the physician signed the plan of care orders on 1/19/22. A review of visit notes from PT evidenced visits were made on 1/11/22, 1/13/22, and 1/18/20, and visit notes from OT evidenced visits were made on 1/10/22, 1/12/22, and 1/17/22. A review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care, had been obtained before furnishing the above care visits. A review of the clinical record for Patient 10, with a start of care date of 10/26/21 and a certification period of 10/26/21 to 12/24/21, which contained a plan of care that included PT (physical therapy) visit orders for: 1 time per week for 1 week, 2 times per week for 5 weeks, and OT (occupational therapy) visit orders for: 2 times per week for 4 weeks. The record revealed the physician signed the plan of care orders on 12/1/21. A review of visit notes from PT evidenced visits were made on 10/30/21, 11/2/21, 11/4/21, 11/9/21, 11/11/21, 11/23/21, and 11/29/21, and visit notes from OT evidenced visits were made on 11/1/21, 11/3/21, 11/8/21, 11/10/22, 11/15/21, 11/17/21, 11/22/21 and 11/24/21. A review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care, had been obtained before furnishing the above care visits. 3. In an interview on 2/23/22 at 10:55 AM, Nurse F with Doctor G (for Patient 7) indicated that in their documentation he/she could not find any phone calls or messages received from Physical Therapy, nor Occupational Therapy attempting to obtain verbal orders for Home Health services. Nurse F stated, "not for October, not for November...a fax in December...I do not see phone orders." In an interview on 2/23/22 at 11:03 AM, Nurse H with Doctor I (for Patient 10) indicated there were no calls made from the agency for verbal orders for therapy services, but indicated they had received faxes titled, "Verbal Order" but there were no corresponding phone calls. In an interview on 2/24/22 at 2:30 PM, Nurse D with Doctor E (for Patient 8) returned call and indicated according to their records, as of 1/6/22 they have no record of representatives from the agency calling to obtain verbal orders. Stated, "they are definitely fax-ers." When queried further, Nurse D indicated she was the one who usually gave verbal orders and stated, "I would remember (giving verbal orders.)" In an interview on 2/23/22 at 1:30 PM, the Clinical Manager indicated the process for obtaining verbal orders for a plan of care (at Admission, resumption or recertification) was to have the Admitting Nurse, when nursing is involved, to contact physician for all verbal orders for the plan of care, including requesting for therapy orders on behalf of the Physical and Occupational Therapists. In an interview on 2/23/22 at 2:22 PM, Nurse #C indicated that during or after a start of care, resumption of care, or recertification, the admitting nurse is supposed to call the ordering physician for nursing orders, and the therapists are to call the physician during or after their therapy evaluations to obtain their own verbal orders for therapy frequencies, modalities, and duration. 410 IAC 17-13-1(a)

G0584

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were obtained and documented in the clinical and included signature, date, and time the verbal orders were received from the physician in 5 (Patients 4, 5, 7, 8, 10) of a total sample of 10 active and 1 closed clinical record (Patient #5) reviewed. Finding include: 6. A review of the clinical record of Patient 7, evidenced a start of care date of 1/14/22, and contained a plan of care for the certification period of 1/14/22 to 3/14/22, with resumption of care orders effective 1/21/22, for PT (physical therapy) visit orders effective 1/24/22: 1 time per week for 1 week, 2 times per week for 5 weeks, and OT (occupational therapy) visit orders effective 1/24/22: 1 time per week for 1 week, 2 times per week for 6 weeks. The record revealed the physician signed the resumption plan of care on 2/14/22. A review of the visit notes evidenced PT visits were made on 1/26/22, 2/5/22, 2/7/22, and 2/9/22, and visit notes from OT evidenced visits were made on 1/28/22, 1/31/22, 2/8/22, and 2/10/22. A review of the clinical record failed to evidence documentation of receipt of a verbal order, contents of an order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician before care visits were provided after the assessment. 7. A review of the clinical record for Patient 8, with a start of care date of 1/6/22 and a certification period of 1/6/22 to 3/6/22, contained a plan of care which included PT (physical therapy) visit orders for: 2 times per week for 2 weeks, and OT (occupational therapy) visit orders for: 2 times per week for 4 weeks. The record revealed the physician signed the plan of care orders on 1/19/22. A review of visit notes from PT evidenced visits were made on 1/11/22, 1/13/22, and 1/18/20, and visit notes from OT evidenced visits were made on 1/10/22, 1/12/22, and 1/17/22. A review of the clinical record failed to evidence documentation of receipt of verbal order, contents of a verbal order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician before care visits were provided after the assessment. 8. A review of the clinical record for Patient 10, with a start of care date of 10/26/21 and a certification period of 10/26/21 to 12/24/21, which contained a plan of care that included PT (physical therapy) visit orders for: 1 time per week for 1 week, 2 times per week for 5 weeks, and OT (occupational therapy) visit orders for: 2 times per week for 4 weeks. The record revealed the physician signed the plan of care orders on 12/1/21. A review of visit notes from PT evidenced visits were made on 10/30/21, 11/2/21, 11/4/21, 11/9/21, 11/11/21, 11/23/21, and 11/29/21, and visit notes from OT evidenced visits were made on 11/1/21, 11/3/21, 11/8/21, 11/10/22, 11/15/21, 11/17/21, 11/22/21 and 11/24/21. A review of the clinical record failed to evidence documentation of receipt of verbal order, contents of a verbal order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician before service visits subsequent to the evaluation visits were provided. 9. In an interview on 2/23/22 at 10:55 AM, Nurse F with Doctor G (for Patient 7) indicated that in their documentation he/she could not find any phone calls or messages received from Physical Therapy, nor Occupational Therapy having attempted to obtain verbal orders for Home Health services. Nurse F stated, "not for October, not for November...a fax in December...I do not see phone orders." In an interview on 2/23/22 at 11:03 AM, Nurse H with Doctor I (for Patient 10) indicated there were no calls made from the agency for verbal orders for therapy services, but indicated they had received faxes titled, "Verbal Order" but there were no corresponding phone calls. In an interview on 2/24/22 at 2:30 PM, Nurse D with Doctor E (for Patient 8) returned the call and indicated according to their records, as of 1/6/22 they had no record of representatives from the agency calling to obtain verbal orders. Stated, "they are definitely fax-ers." When queried further, Nurse D indicated she was the one who usually gave verbal orders and stated, "I would remember (giving verbal orders.)" In an interview on 2/23/22 at 1:30 PM, the Clinical Manager indicated the process for obtaining verbal orders for a plan of care (at admission, resumption or recertification) was to have the Admitting Nurse, when nursing was involved, to contact the physician for all verbal orders for the plan of care, including requesting for therapist's frequency and plan of care orders on behalf of the Physical and Occupational Therapists. In an interview on 2/23/22 at 2:22 PM, Nurse #C, team lead, indicated that during or after a start of care, resumption of care, or recertification, the admitting nurse on the case was supposed to call the ordering physician for nursing orders, and the therapists were supposed to call the physician, during or after their therapy evaluations, to obtain their own verbal orders for therapy frequencies and modalities. 410 IAC 17-14-1(a)(H) 1. A review of an Agency's policy, dated 10/22/21, titled 'Physician Orders C-635' a section titled 'POLICY CDT 4.D - 5.1.M.2 revealed "all medications, treatments and services provided to clients must be ordered by a physician ... The orders may be initiated via telephone or in writing and must be countersigned by the allowed prescribing practices within 30 days ... PURPOSE To document verification that orders for services have been obtained in accordance with 410 IAC 17-31-1 Medical Plan of Care ... SPECIAL INSTRUCTION 1. When the nurse or therapist receives a verbal order form the allowable prescribing practitioner, he/she shall write the order as given and then read the order back to the allowable subscriber verifying that the person receiving the order heard it correctly and interpreted the order correctly. The verbal order shall verify that the order was taken and verified by documenting this in the EMR {electronic medical record} form and signing the form. The order must include the time, date, specific order, be signed with the full name and title of the person receiving the order and be sent to the allowable prescriber for for signature ..." 2. A review of the clinical record of patient #2 revealed a document titled, “Home Health Care Certification and Plan of Care,” and evidenced a SOC of 2/5/22, for the certification period of 2/5/22 to 4/5/22. The plan of care revealed orders for Physical Therapy 2 times a week, for 3 weeks, then 1 time a week for 3 weeks, beginning the week of 2/7/22 through 3/19/22, which evidenced signatures by the RN (registered nurse) on 2/14/22 and the physician on 2/15/22. The clinical record revealed PT visits were made on 2/10/22 and 2/14/22. A review of the clinical record failed to evidence documentation of receipt of verbal order, contents of a verbal order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician before service visits subsequent to the evaluation visits were provided on 2/10/22 and 2/14/22. 3. A review of the clinical record of patient #4, revealed a “Home Health Care Certification and Plan of Care,” dated 1/19/22 for the certification period of 1/19/22 to 3/19/22, which evidenced diagnoses, but not limited to, Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time), Scoliosis (a sideways curvature of the spine), and Intervertebral Disc Disorders with radiculopathy (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, that can cause pain, numbness, and/or leg weakness) with SN (skilled nursing) 1 x month for 2 months, and HHA (home health aide) services 7 x week for 1st week, then 12 times a week for 8 weeks, which evidenced the physician's signature on 2/10/22. A review of HHA care visits during the certification period of 1/19/22 to 3/19/22, were made on 1/19/22, AM and PM visits; 1/20/22 PM visit; 1/21/22 AM and PM visits; 1/22/22 AM and PM visits; 1/24/22, AM and PM visits; 1/25/22 PM visit; 1/26/22, AM and PM visits; 1/27/22 PM visit; 1/28/22 AM and PM visits; 1/29/22, AM and PM visits; 1/30/22 PM visit; 1/31/22, AM and PM visits; 2/1/22 PM visit; 2/2/22 AM visit; 2//5/22, AM and PM visits; 2/6/22 PM visit; 2/7/22 AM and PM visits; 2/8/22 PM visit; 2/9/22, AM and PM visits, which had been furnished prior to having obtained a physician's verbal order or the return of a signed plan of care. A review of the clinical record failed to evidence documentation of receipt of a verbal order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician before care visits were made after the assessment, but prior to the date the physician signed the plan of care (2/10/22.) 4. A review of the closed clinical record of patient #5, revealed a “Home Health Care Certification and Plan of Care,” dated 7/29/21, for the certification period of 7/29/21 to 9/26/21, which evidenced diagnoses, but not limited to, Hypertensive Kidney Disease Stage 4 (moderate to severe damage to your kidneys, not filtering waste out of your blood, causing a buildup in your body causing other health issues), Intervertebral Disc Degeneration Lumbar Region (the breakdown of one or more of the discs that separate the bones of the spine, lower back), and History of Falls. The patient's orders were to receive SN (skilled nursing) 2 times a week for 2 weeks, then 1 time a week for 4 weeks, PT (physical therapy) 2 times a week for 6 weeks. OT (occupational therapy) 2 times a week for 6 weeks, and HHA (home health aide) 2 times a week for 8 weeks; which evidenced the physician's signature on 8/18/21. A review of SN care visits during the certification period of 7/29/21 to 9/26/21, were made on 8/10/21, 8/17/21, prior to having obtained physician authorization. A review of PT visits during the certification period of 7/29/21 to 9/26/21, were made on 8/3/21, 8/17/21, prior to having obtained physician authorization. A review of OT visits during the certification period of 7/29/21 to 9/26/21, were made on 8/4/21, 8/14/21, 8/16/21, prior to having obtained physician authorization. A review of the clinical record failed to evidence documentation of receipt of verbal order, contents of a verbal order, or attempt to obtain verbal order, complete with date and time of receipt, from the signing physician prior to furnishing care visits after the assessment and before return of a physician signed plan of care (8/18/2021.) 5. In an interview on 2/23/22 at 1:30 PM, the Clinical Manager indicated the process for obtaining verbal orders for a plan of care (at Admission, resumption, or recertification) was to have the Admitting Nurse, when nursing was involved, to contact physicians for all verbal orders for the plan of care, including requesting orders for therapy frequency and modalities.

G0588

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 ensure the individualized Plan of Care was reviewed and revised by the allowable prescriber who was responsible for the Home Health Plan of Carex, no less frequently than every 60 days from the start of care date in 2 (Patients 4 and 6) of a total sample of 10 clinical records reviewed. Findings include: 1. A review of an Agency's policy titled, "Client Reassessment/Update of Comprehensive Assessment", dated 10/22/21, revealed, "POLICY The Comprehensive Assessment will be updated and revised as often as the client's condition warrants ...1. Every second calendar month beginning with the start of care ... including day sixty ... PURPOSE To identify decline or improvement in health ... To verify appropriate use of home care services ... To identify progress toward goals ... SPECIAL INSTRUCTION ...12. Reassessments are conducted every visit based on physician orders, client conditions ..." A review of an Agency's undated policy titled, "Plan of Care C580", revealed, "POLICY Home care services are furnished under the supervision and direction of the client's physician...PURPOSE To assure that the plan meets state/federal guidelines, and all applicable laws and regulations ... SPECIAL INSTRUCTIONS 1. An individualized Plan of Care signed by a physician shall be required for each client receiving home health and personal care services. 2. The Pan of Care shall be completed in full to include … 3. If a physician refers a client under a Plan of Care that cannot be completed until after an assessment visit, the physician shall be consulted to approve additions or modifications to the original plan. The Skilled assessment visit order will be documented on a Doctor’s Order Form and mailed to the physician for signature … 8. The total Plan of Care shall be reviewed by the attending physician and agency personnel as often as the severity of the client's condition requires but at least one time every 60 days ... 9. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care. 10. Verbal/telephone orders shall be obtained from the client’s physician for changes in the Plan of Care…" In an agency policy dated 10/22/21, titled 'Physician Orders C-635,' a section titled 'Policy CDT 4.D - 5.1.M.2 stated, "all medications, treatments and services provided to clients must be ordered by a physician ....The orders may be initiated via telephone or in writing and must be countersigned by the allowed prescribing practices within 30 days." A section titled 'Purpose' stated, "To document verification that orders for services have been obtained in accordance with 410 IAC 17-31-1 Medical Plan of Care." A section titled 'Special Instruction' stated, "1. When the nurse or therapist receives a verbal order form the allowable prescribing practitioner, he/she shall write the order as given and then read the order back to the allowable subscriber verifying that the person receiving the order heard it correctly and interpreted the order correctly. The verbal order shall verify that the order was taken and verified by documenting this in the EMR {electronic medical record} form and signing the form. The order must include the time, date, specific order, be signed with the full name and title of the person receiving the order and be sent to the allowable prescriber for signature." 2. A review of the clinical record of patient #4, revealed a “Skilled Nursing Visit” note for Home Health Plan of Care recertification, dated 1/14/22 for the certification period of 1/19/22 to 3/19/22; with a start of care date of 5/24/21, revealed the RN (registered nurse) indicated in the narrative note a verbal recertification order was received. A review of the clinical record of patient #4, revealed a “Home Health Care Certification and Plan of Care,” dated 1/19/22, for the certification period of 1/19/22 to 3/19/22, which evidenced diagnoses, but not limited to, Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time), Scoliosis (a sideways curvature of the spine), and Intervertebral Disc Disorders with radiculopathy (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, that can cause pain, numbness, and/or leg weakness) with orders for SN (skilled nursing) 1 x month for 2 months, and HHA (home health aide) services 7 x week for 1st week, then 12 times a week for 8 weeks; which evidenced the physician's signature on 2/10/22. The clinical record failed to evidence verbal orders for recertification prior to the start of the certification period and failed to evidence the Primary Clinician H had conferred with the physician following the recertification assessment dated 1/14/22, to determine approval for recertification. 3. A review of the clinical record of patient #6, revealed a document titled, ROC OASIS (resumption of care) Assessment,” dated 1/7/22; which evidenced diagnoses but not limited Type 2 Diabetes Mellitus ( the body either doesn't produce enough insulin, or it resists insulin) with foot ulcer (an open sore or wound that may occur with diabetes, and is commonly located on the bottom of the foot), Malignant neoplasm of colon (cancer colon), and Colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen.) A review of the clinical record of patient #6, revealed a “Home Health Care Certification and Plan of Care,” dated 1/11/22, for the certification period of 1/9/22 to 3/9/22, The patient orders included SN (skilled nursing) 3 times a week for 8 weeks, then 2 times a week for 1 week for wound care. Wound Care orders: Cleanse RLE (right lower extremity) with saline or wound cleanser. Pat dry with gauze. Apply Ammonium Lactate 12% lotion. Apply knee-hi compression socks, then Circaid wrap. Don surgical shoe. Cleanse LLE (left lower extremity) with saline or wound cleanser. Pat dry with gauze. Apply Ammonium Lactate 12% lotion. Apply Blast X gel to wound bed. Cover with a silver foam pad. Secure with tape. Apply compression stocking, then Circaid wrap, don surgical shoe; which evidenced the physician's signature on 1/27/22. The clinical record failed to evidence verbal orders for the resumption care prior to date of the recertification period, and failed to evidence the Primary Clinician had conferred with the physician following the patient in relation to the resumption assessment dated 1/7/22, to determine approval for resumption/recertification. 4. During an interview on 2/23/22 at 1:30 PM, the Clinical Manager indicated the process for obtaining verbal orders for a plan of care (at Admission, resumption, or recertification) was to have the Admitting Nurse, when nursing was involved, to contact physicians for all verbal orders for the plan of care, including requesting therapy orders on behalf of the Physical and Occupational Therapists. 410 IAC 17-13-1(a)(2)

G0682

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 all staff followed infection control policies for 3 of 4 home visits observed (Patients #4, 6, and 11). Findings include: 4. A review of the clinical record of patient #11, revealed a “Home Health Care Certification and Plan of Care”, dated 12/30/21 for the certification period of 1/2/22 to 3/2/22 which evidenced diagnoses but not limited to Cerebral Palsy unspecified (a group of disorders that cause problems with movement, balance and posture and affects the cerebral motor cortex), generalized muscle weakness, dysphasia (a language disorder marked by deficiency in the generation of speech, and sometimes also in comprehension, due to brain disease or damage), history of falling, dependence of wheel chair, mild intellectual disabilities (individuals are slower in all areas of conceptual development and social and daily living skills) with SN (skilled nursing) 1 time per month for 3 months, and HHA (home health aide) services 7 times per 8 weeks, then 4 times per week for 1 week. The document also included aide 'Interventions' which included but was not limited to, "assist with transfers...bathing/showering...do patient laundry...standard precautions." On a home visit conducted on 2/21/22 at 10:05 AM, HHA (Home Health Aide) G attended to patient 11 in their wheelchair, and assisted patient down the hallway to a newly refurbished bathroom. HHA G positioned patient 11 near handicapped accessible sink and proceeded to perform hand hygiene at the sink with soap and water, scrubbing all surfaces of hands for at least 20 seconds, then shut off faucet bare-handed and reached for a cloth towel to dry hands and explained to surveyor that the family kept a fresh stack of towels for her use today, but that normally the front bathroom is where the bathing activities are performed and that paper towels are available to him\/her there and in the kitchen as well. The aide then needed to step out of the bathroom to obtain gloves from a box of gloves located on a dresser in the adjacent bedroom, then donned gloves. Then assisted the patient in undressing to prepare for bathing. Hand hygiene was not performed after turning off the faucet bare handed and was not performed before returning to patient to provide personal cares. The HHA failed to ensure hand hygiene was maintained by failing to ensure the faucet was turned off utilizing a disposable barrier (such as a paper towel), thereby failing to reducing exposure to microorganisms in any subsequent contact made with patient. In an interview on 2/21/22 at 3:39 PM, during end of day conference, with Administrator and Clinical Manager, the visit with HHA G and Patient 11, the breech of infection control was discussed. When queried the Clinical Manager explained that a family member had requested that the nicer, newer bathroom be utilized for the surveyor's visit, which was not the normal routine for the aide, but could not offer explanation for the breech in hand hygiene itself. 410 IAC 17-12-1(m) 1. A review of an Agency’s policy titled, “OSHA Infection Control/Exposure Plan I-213”, revealed POLICY Alliance Home Health Services shall maintain policies and procedures for the care of clients …. and for infection control practices by employees … SPECIAL INSTRUCTION … a. Adhering to standard precautions as outlined by the CDC. b. Wearing and changing gloves as necessary during the delivery of client care. c. Appropriate wound and skin care … g. Frequent hand washing or use of hand sanitizer by home health care employees before and after the provision of direct care … After handling soiled or contaminated materials … Before dawning gloves, After removing gloves.” A review of an Agency’s policy titled, “Infection Prevention/Control I-214,” revealed POLICY Alliance Home Health will observe the recommended precautions for home care as identified by the Centers for Disease Control and Prevention … PURPOSE To ensure employee and client safety. To reduce the risk of transmission of microbes … STANDARD PRECAUTIONS – TIER ONE 1. Standard precautions apply to blood, all body fluids…All are to be treated as a potential source of infection … 2. Hands are washed before donning gloves and immediately after gloves are removed, between client contacts … 3. Gloves are worn when touching blood, body fluids, secretions … contaminated items … DISEASE-SPECIFIC STANDARD PRECAUTIONS – TIER TWO This approach provides … 3. Contact Precautions: Use gowns, gloves … SPECIAL INSTRUCTIONS Alliance Home Health has a process in place to identify the need for infection prevention control activities …T ypes of care that may place clients at risk for infection …Wound care…” Review of a Centers for Disease Control document, "Standard Precautions...IV. A. Hand Hygiene. IV. A. 1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces... Perform hand hygiene: IV. A. 3. a. Before having direct contact with blood, body fluids or excretions, mucus membranes, non-intact skin, or wound dressings. IV. A. 3. b. After contact with blood, body fluids or excretions, mucus membranes, non-intact skin, or wound dressings... IV. A. 3. d. If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV. A. 3. e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. IV. A. 3. f. After removing gloves … IV. B. Personal Protective equipment (PPE) … IV. B. 2. Gloves. IV. B. 2. a. Wear gloves when it can be reasonably anticipated that contact with blood or potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin … could occur." 2. A review of the clinical record of patient #4, revealed a “Home Health Care Certification and Plan of Care,” dated 1/19/22 for the certification period of 1/19/22 to 3/19/22, which evidenced diagnoses, but not limited to, Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time), Scoliosis (a sideways curvature of the spine), and Intervertebral Disc Disorders with radiculopathy (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, that can cause pain, numbness, and/or leg weakness) with orders for SN (skilled nursing) 1 x month for 2 months, and HHA (home health aide) services 7 x week for 1st week, then 12 times a week for 8 weeks. A review of an undated document titled,” Aide Care Plan,” revealed the HHA was to "1. Ambulate only with assistance 2. Ambulate patient using assistive device … 3. Assist with transfer 4. Up in chair 5. Assist to BSC (bedside commode)/toilet 6. Assist patient with dressing 7. Bath-Shower 8. Shampoo 9. Shave 10. Remind patient to take medications 11. Fall precautions 12. Standard precautions 13. Universal precautions." A home visit conducted on 2/17/22 at 8:28 AM to 9:05 AM, employee D, HHA, entered the apartment at 8:28 am, immediately put on/donned gloves, assisted the patient out of their bed and into the bathroom using a walker, removed the patient’s brief prior to sitting on the toilet (with raised toilet seat). Employee D removed the patient’s t-shirt, then left the bathroom to the bedroom to retrieve the clean t-shirt and necklace alarm, placing them on top of the clothes hamper. Employee D turned the water on, wetted the washcloth, using bar soap, turned the water off, gave the washcloth to the patient for the patient to wash their face, moved a curtain to retrieve a clean towel, placed the towel on the patient’s wheelchair; turned the water on, rinsed the washcloth, turned the water off, used bar soap to wash back and arms, turned the water on, then rinsed washcloth, turned the water off, rinsed off back and arms, placing washcloth on the sink, then drying patient’s back and arms. The HHA, employee D, retrieved the t-shirt and a sweatshirt off the clothes hamper and dressed the patient’s upper body. Employee D placed the alarm necklace around the patient’s neck. Employee D pushed aside a curtain covering a closet to grab 2nd washcloth, turned the water on, wetted the washcloth, turned the water off, proceeded using bar soap to wash the patients’ legs and feet. Employee D turned the water on, rinsed the washcloth, turned the water off, rinsed the patients’ legs and feet, then dried the patients’ legs and feet. Put a brief and pants on around ankles and socks on patient #4, retrieved the patient’s shoehorn and then placed the patients’ shoes on. Employee D retrieved the patient’s toothbrush, put toothpaste on the brush, handing it to patient, reached for a cup and put water in it, grabbed another cup for the patient to spit in. Employee D entered the bedroom while the patient was brushing their teeth, pulled the blankets up on the bed, re-entered the bathroom, took the toothbrush and cups from the patient and rinsed them. Employee D, HHA, then doffed (removed) the gloves and washed their hands using pump soap, then dried hands with cloth towel next to sink. Employee D donned new pair of gloves, grabbed a container from under the sink, took an electric razor from the container and shaved the patient after being dressed, brushed the patient’s hair, went into the living room to retrieve the patient’s gait belt, put the gait belt on the patient, the patient then stood, while the aide used a wash cloth with soap washing peri area, turned the water on, rinsed the cloth, turned the water off, then rinsed the patient with the same cloth. Employee D pulled the patient’s brief and pants up, threw the towel in the clothes hamper, doffed the gloves. Assisted the patient into the living room, then returned to the bathroom to wash hands, using pump soap, and the same towel at the sink, using bare hands to turn water on/off. The patient was then escorted to the dining room. Employee D exited the building at 9:05 AM. The HHA failed to remove gloves, complete hand hygiene, and apply new gloves at appropriate intervals throughout personal care when moving to clean to dirty areas and back. 3. A review of the clinical record of patient #6, revealed a “Home Health Care Certification and Plan of Care,” dated 1/11/22, for the certification period of 1/9/22 to 3/9/22, which evidenced diagnoses, but not limited to, Type 2 Diabetes Mellitus ( the body either doesn't produce enough insulin, or it resists insulin) with foot ulcer (an open sore or wound that may occur with diabetes, and is commonly located on the bottom of the foot), Malignant neoplasm of the colon (cancer colon), and Colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen). The patient was to receive SN (skilled nursing) 3 times a week for 8 weeks, then 2 times a week for 1 week for wound care. Wound Care orders: Cleanse RLE (right lower extremity) with saline or wound cleanser. Pat dry with gauze. Apply Ammonium Lactate 12% lotion. Apply knee-hi compression socks, then Circaid wrap. Don surgical shoe. Cleanse LLE (left lower extremity) with saline or wound cleanser. Pat dry with gauze. Apply Ammonium Lactate 12% lotion. Apply Blast X gel to wound bed. Cover with silver foam pad. Secure with tape. Apply compression stocking, then Circaid wrap, don surgical shoe. During a home visit on 2/21/22 at 10 AM, Employee C, RN (registered nurse) initiated the visit by creating barriers to place bag on chair, and a barrier on the table. No hand hygiene had been performed at this point. Employee C reached into bag for blood pressure cuff, stethoscope, took patient’s blood pressure, reached into the bag while holding cuff for wipes, cleaned cuff, and placed it on the barrier on the table. Used hand hygiene, reached into patient’s supply tote (on the floor), looking for trash bags. There were none, so the patient ambulated into the kitchen for 2 trash bags, handed them to employee C. Employee C put 1 bag into the other (setting up double bag) and placed on the floor. Patient #6 then handed Kerlix wrap, and employee C put in tote. Employee C cleaned off the chair, placed the stool off the chair on the floor, then sat on the chair. Hand hygiene was performed. Employee C reached into the tote and grabbed 2 sheets of paper towel to create a barrier on the stool for the patient to place foot. Employee C donned gloves, proceeded to remove the patient’s compression stocking, sock, and dressing on LLE. Employee C doffed gloves and used hand hygiene, donned new pair of gloves, reached into the tote to retrieve wound cleanser, proceeded to put cleanser on 4 x4 gauze pads, and began cleansing left lower extremity, from the knee down to the foot. When finished, employee C doffed gloves and performed hand hygiene, and donned new pair of gloves. Reached into the tote to retrieve betadine, Blast X and cotton swab, and placed the betadine on the stool. Employee C placed a small amount of Blast X on the swab to put in the wound on left planter, and in doing so, a small amount of Blast X slid down Patient #6's foot, Employee C used the same swab and scraped up, and reapplied it to the wound. Employee C threw the swab into the trash bag, reached into the tote and picked up a small yellow bag, stating this was Prisma to put into the wound, under the edge of skin around the undermining area of the wound. Once completed, employee C put the Prisma in a yellow bag and reached for the silver alginate out of the yellow bag, and covered the wound, then placed the silver alginate back into the yellow bag, put back into the tote, and grabbed a 2 x2 gauze pad and skin prep from the tote. Skin prep was applied around the wound. Employee C, doffed gloves, hand hygiene was performed, reached into the nursing bag for scissors, donned new gloves, and cut an ABD pad in half. Applied the 2x2 and ABD pad to the wound, secured with tape, then wrapped the LLE with Kerlix, put on a compression stocking, the Circaid wrap, then the surgical shoe was put on. Wound care to RLE was then completed. The RN failed to perform wound care using Contact Precautions to prevent the transmission of microorganisms to the wound, and failed to remove gloves, complete hand hygiene, and apply new gloves at appropriate intervals throughout wound care. On 2/17/22 at 1:30 PM during an interview with the administrator and clinical director, when informed of the home visit conducted at 9 AM with patient #4, and the breached infection prevention/control principles of nursing care, neither commented. On 2/21/22 at 3:35 PM, during an interview with the administrator and clinical director, when informed of the home visit conducted at 10 AM with patient #6, when talking about the breach in infection control, neither commented.

G0686

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 record review, observation, and interview, the agency failed to ensure an effective infection control training/education program was provided, and failed to ensure agency staff demonstrated proper infection control practices when providing wound care and/or personal/hygiene care to patients, in 3 (Patient 4, 5 and 11) of 5 home visits observed. 1. A review of an Agency’s policy titled, “ OSHA Infection Control/Exposure Plan I-213,” revealed POLICY Alliance Home Health Services shall maintain policies and procedures for the care of clients …. and for infection control practices by employees … SPECIAL INSTRUCTION … a. Adhering to standard precautions as outlined by the CDC. b. Wearing and changing gloves as necessary during the delivery of client care. c. Appropriate wound and skin care … g. Frequent hand washing or use of hand sanitizer by home health care employees before and after the provision of direct care … After handling soiled or contaminated materials … Before dawning gloves, After removing gloves.” A review of an Agency’s policy titled, “Infection Prevention/Control I-214,” revealed POLICY Alliance Home Health will observe the recommended precautions for home care as identified by the Centers for Disease Control and Prevention … PURPOSE To ensure employee and client safety. To reduce the risk of transmission of microbes … STANDARD PRECAUTIONS – TIER ONE 1. Standard precautions apply to blood, all body fluids…All are to be treated as a potential source of infection … 2. Hands are washed before donning gloves and immediately after gloves are removed, between client contacts … 3. Gloves are worn when touching blood, body fluids, secretions…contaminated items…DISEASE-SPECIFIC STANDARD PRECAUTIONS – TIER TWO This approach provides … 3. Contact Precautions: Use gowns, gloves … SPECIAL INSTRUCTIONS Alliance Home Health has a process in place to identify the need for infection prevention control activities … Types of care that may place clients at risk for infection …Wound care…” Review of a Centers for Disease Control document, "Standard Precautions, …IV. A. Hand Hygiene. IV. A. 1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces ... Perform hand hygiene: IV. A. 3. a. Before having direct contact with blood, body fluids or excretions, mucus membranes, non-intact skin, or wound dressings. IV. A. 3. b. After contact with blood, body fluids or excretions, mucus membranes, non-intact skin, or wound dressings ... IV. A. 3. d. If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV. A. 3. e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. IV. A. 3. f. After removing gloves … IV. B. Personal Protective equipment (PPE) … IV. B. 2. Gloves. IV. B. 2. a. Wear gloves when it can be reasonably anticipated that contact with blood or potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin … could occur." Review of a photocopied agency training document titled 'Infection Control in Home Healthcare: Winning the War' dated 1998, page 6 stated, "Wash Your Hands: Handwashing is the single most important precaution against the spread of infection ... If no handwashing facilities are available ... come prepared with a waterless handwashing agent. If not visible soiled, decontaminate hands using an alcohol-based hand rub for routine clinical situations. That includes between patients and after removing gloves. Apply the recommended amount of product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry." Page 7 stated, "Always wash hands: On arrival, before going into your nursing bag. After bathing your patient or performing other patient care. After touching blood, body fluids, secretions or excretions such as feces, vomit, wound drainage or saliva and contaminated surfaces - whether gloves are worn or not. Every time you remove gloves. Just before you leave a patient's home." Page 8 stated, "Personal Protective Equipment (PPE): ... Gloves are the PPE you will use most often... before putting them on, wash hands thoroughly ... when removing contaminated gloves be careful not to touch the outside. Always wash your hands after removing them." Page 10 stated, a section titled, 'Home Health Clean Up' stated, "Wear gloves when handling or cleaning soiled items." This photocopied handbook ended with a 20 question test, composed of True/False questions, and included additional space for signature documentation that stated "Acknowledgement of Training ... I have read and understand this Infection Control in Home Healthcare: Winning the Battle handbook. I have also completed the comprehensive quiz at the conclusion of this handbook." There were spaces for the signature of 'attendee' and date, and spaces for the 'trainer' to sign and date as well. Review of an additional photocopied agency training document titled 'Bloodborne Pathogens' dated 2001, page 6 titled, "Work Practice Controls" stated, "Wash you hands every time you remove your gloves ... between patients ... Where handwashing facilities are not available ... use an antiseptic hand cleanser. Wash your hands with soap and running water as soon as you can...When your hands are not visible soiled , CDC approves cleaning your hands with an alcohol-based antiseptic ... Use a decontaminant with a concentration of 60 percent to 90 percent ethanol or isopropanol alcohol. Apply the recommended amount to one of your palms. Vigorously rub your hands together, spreading the solution thoroughly over both ..." A section on page 10 titled, "Gloves" stated, " Gloves are the most widely used form of personal protective equipment. They act as a primary barrier between your hands and bloodborne pathogens. Here's how to use them: ... Replace single-use gloves...as soon as possible if contaminated, torn or punctured in any way. " A section on page 11, titled "Glove Removal" stated, "...Remove gloves when they become contaminated or damaged or before you leave the work area. Wash hands thoroughly." This photocopied handbook also ended with a 20 question test, composed of True/False questions, and included additional space for signature documentation that stated "Acknowledgement of Training...I have read and understand this Infection Control in Home Healthcare: Winning the Battle handbook. I have also completed the comprehensive quiz at the conclusion of this handbook." There were spaces for the signature of 'attendee' and date, and spaces for the 'trainer' to sign and date as well. Review of an untitled agency document on 2/22/22, contained the following dates: 5/20/21, 5/22/21, 6/9/21, and 6/11/22, and was reported to be a record of attendance, by the administrator, for the infection control education trainings (the 'Infection Control in Home Healthcare; Wining the War' and 'Bloodborne Pathogens' handbooks) provided to home health aides, which occurred on the aforementioned dates. This attendance list contained the names of both HHA D and HHA G (who had each subsequently demonstrated a breach in infection control during home visit observations), as having been in attendance for the trainings on 5/22/21 and 5/20/21, respectively. 2. A home visit for Patient #4, conducted on 2/17/22 at 8:28 AM to 9:05 AM, employee D, HHA, entered the patient's apartment at 8:28 AM, immediately donned gloves, assisted the patient out of their bed and into the bathroom using a walker, removed patient’s brief prior to sitting on the toilet (with raised toilet seat). The aide removed the patient’s t-shirt, then left the bathroom to the bedroom to retrieve the clean t-shirt and necklace alarm, placing them on top of the clothes hamper. Employee D turned the water on, wetted the washcloth, using bar soap, turned the water off, gave the washcloth to Patient #4 for the patient to wash their face, moved a curtain to retrieve a clean towel, and placed it on the patient’s wheelchair. Turned the water on, rinsed the washcloth, turned the water off, used bar soap to wash back and arms, turned the water on, then rinsed washcloth, turned the water off, rinsed off back and arms, placing washcloth on the sink, then drying patient’s back and arms. Retrieved the t-shirt and a sweatshirt off clothes hamper and dressed patient’s upper body. Employee D placed the alarm necklace around the patient’s neck. Employee D pushed aside a curtain covering a closet to grab 2nd washcloth, turned the water on, wetted the washcloth, turned the water off, proceeded using bar soap to wash the patients’ legs and feet. Turned the water on, rinsed the washcloth, turned the water off, rinsed the patients’ legs and feet, then dried the patients’ legs and feet. Put an adult incontinent product and pants on around ankles and socks on Patient #4. Retrieved the patient’s shoehorn and proceeded to place the patients’ shoes on. Employee D, retrieved the patient’s toothbrush, put toothpaste on the brush, handed to the patient, reached for a cup and put water in it, grabbed another cup for the patient to spit in. Employee D entered the bedroom while the patient was brushing their teeth, pulled the blankets up on the bed, re-entered the bathroom, took the toothbrush and cups from the patient and rinsed, doffed the gloves and washed their hands using pump soap, then drying hands with cloth towel next to sink. Employee D donned new pair of gloves, grabbed a container from under the sink, took an electric razor from the container and shaved the patient after being dressed, brushed the patient’s hair, went into the living room to retrieve the patient’s gait belt, put the gait belt on the patient, the patient then stood, while the aide using washcloth with soap washing peri area, turned the water on, rinsed the cloth, turned the water off, then rinsed the patient. Employee D pulled the patient’s adult incontinent product and pants up, threw the towel in the clothes hamper, doffed the gloves. Assisted the patient into the living room, then returned to the bathroom to wash hands, using pump soap, and the same towel at the sink, using bare hands to turn the water on/off. Patient was then escorted to the dining room. Employee D exited the building at 9:05 AM. The HHA failed to remove gloves, complete hand hygiene, and apply new gloves at appropriate intervals throughout personal/hygiene care when going from to clean to dirty and back. 3. During a home visit for patient # 6, on 2/21/22 at 10 AM, Employee C, RN (registered nurse) initiated the visit by creating barriers to place the bag on the chair, and the barrier on the table. No hand hygiene had been performed at this point. Employee C reached into the bag for blood pressure cuff, stethoscope, took the patient’s blood pressure, reached into the bag while holding the cuff for wipes, cleaned the cuff, and placed it on the barrier on the table. Used hand hygiene, reached into patient’s supply tote (on the floor), looking for trash bags. There were none, so the patient ambulated into the kitchen for 2 trash bags, handed them to employee C. Employee C put 1 bag into the other (setting up double bag), and placed on the floor. The patient then handed Kerlix wrap, and employee C put in a tote. Employee C cleaned off the chair, placed the stool off the chair on the floor, then sat on the chair. Hand hygiene was performed. Employee C reached into the tote and grabbed 2 sheets of paper towel to create a barrier on the stool for the patient to place foot. Employee C donned gloves, proceeded to remove the patient’s compression stocking, sock, and dressing on LLE. Employee C doffed gloves and used hand hygiene, donned new pair of gloves, reached into the tote to retrieve wound cleanser, proceeded to put cleanser on 4 x4 gauze pads, and began cleansing left lower extremity, from the knee down to the foot. When finished, employee C doffed gloves and performed hand hygiene, donned new pair of gloves. Reached into the tote to retrieve betadine, Blast X, and cotton swab and placed the betadine on the stool. Employee C placed a small amount of Blast X on the swab to put in the wound on the left planter, and in doing so, a small amount of Blast X slid down the foot, Employee C used the same swab and scraped up, and reapplied it to the wound. Employee C threw the swab into the trash bag, reached into the tote, and picked up a small yellow bag, stating this was Prisma to put into the wound, under the edge of skin around the undermining area of the wound. Once completed, employee C put the Prisma in a yellow bag and reached for the silver alginate out of the yellow bag, and covered the wound, then placed the silver alginate back into the yellow bag, put it back into the tote, and grabbed a 2 x2 gauze pad and skin prep from the tote. Skin prep was applied around the wound. Employee C, doffed gloves, hand hygiene performed, reached into the nursing bag for scissors, donned new gloves, and cut ABD pad in half. Applied the 2x2 and ABD pad to wound, securing with tape, then wrapping LLE with Kerlix, putting compression stocking on, the Circaid wrap, then surgical shoe was put on. Skincare to RLE began by employee C removing stocking, doffed gloves, hand hygiene, applied clean gloves, reached into a tote for another 4 x 4 gauze pad, used a wound cleanser to cleanse the entire right lower extremity, knee to foot. Employee painted all toes with Betadine, doffed gloves, used hand hygiene, donned new gloves, put compression stocking on, and placed the Circaid wrap on right lower extremity, then put the diabetic shoe on. Employee C gathered up all trash, placed it in the trash bag, doffed gloves, and threw it in the trash bag. Employee C then reached in the nursing bag to get gloves and wipe to clean scissors and stethoscope, then placed both items on the clean barrier. Removed gloves, hand hygiene, reached into the nursing bag for the oximeter to obtain a reading of 96 with a heart rate of 61, and reached into the bag for thermometer, the temperature was 98 degrees, reached into the bag for pair of gloves, donned gloves, then used a wipe to clean pulse oximeter and thermometer. Retook blood pressure, 138/66, wiped blood pressure cuff, placed back onto the clean barrier, using the stethoscope, listen to lung sounds all fields, bowel sounds all fields, cleaned stethoscope, removed gloves, and placed all items back into the nursing bag. Then put all extra supplies back into the tote. Employee C reached into the nursing bag for tablet began filling out information for the visit, then had the patient sign for visit. The patient indicated that they received a new antibiotic the past week from their last appointment at the wound clinic, employee C stated, we will wait to hear from them, then reached into the nursing bag for a wipe, to cleanse the computer tablet and put in the nursing bag. Employee C, hand bare, picked up the trash bag, and carried it outside to put in the garbage can. The RN failed to perform wound care using Contact Precautions to prevent the transmission of microorganisms to the wound, and failed to remove gloves, complete hand hygiene, and apply new gloves at appropriate intervals throughout wound care. 4. On a home visit conducted on 2/21/22 at 10:05 AM, HHA (Home Health Aide) G attended to Patient #11 in their wheelchair and assisted the patient down the hallway to a newly refurbished bathroom. HHA G positioned patient 11 near the handicapped accessible sink and proceeded to perform hand hygiene at the sink with soap and water, scrubbing all surfaces of hands for at least 20 seconds, then shut off the faucet bare-handed and reached for a cloth towel to dry hands and explained to the surveyor that the family kept a fresh stack of towels for her use today, but that normally the front bathroom is where the bathing activities are performed and that paper towels are available to him\/her there and in the kitchen as well. The aide then needed to step out of the bathroom to obtain gloves from a box of gloves located on a dresser in the adjacent bedroom, then donned gloves. Then assisted the patient in undressing to prepare for bathing. Hand hygiene was not performed after turning off the faucet barehanded and was not performed before returning to the patient to provide personal/hygiene care. The HHA failed to ensure hand hygiene was maintained by failing to ensure the faucet was turned off utilizing a disposable barrier (such as a paper towel), thereby failing to reduce exposure to microorganisms in any subsequent contact made with the patient. 5. In an interview on 2/22/22 at 11:00 AM with the clinical manager and administrator, infection control training information was provided and discussed. The administrator indicated that this particular infection control training had been provided to the home health aides only ( a different, separate training was given to clinicians). When queried as to whether there had been follow-up testing done and whether results of the testing were measured, the administrator indicated that this test was done, "as a group" and there were no individual test results collected. The administrator indicated that attendance had been taken at this training and offered the list for review. Agency failed to ensure staff demonstrated understanding of infection control education provided, failed to show written proof of competency, and failed to ensure home health aides were able to demonstrate competency of infection control practices when providing direct care to patients.

G0710

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, observation, and interview, the clinicians failed to follow the plan of care for 1 of 2 home visits receiving skilled services (Patient #6), and the HHA (home health aide) failed to follow the Aide Care Plan in 1 of 2 home visits. (Patient #4) Findings include: 1. A review of an Agency's policy dated 1/19/17, titled, "Home Health Aide Care Plan", revealed, "POLICY CDT 7.I.M.7 A complete and appropriate Care Plan, identifying duties to be performed....All home health aide staff will follow the identified plan. PURPOSE To provide a means of assigning duties to the Home Health Aide that are clear to the Nurse, Home Health Aide...To provide documentation that the client's care is individualized..." A review of an Agency's policy dated 8/22/17, titled, "Home Health Aide: Assignment", revealed, "POLICY...When the services are ordered by the physician, the designated Registered Nurse/Therapist will assign and orient the aide to the care plan. PURPOSE To meet the client needs...To orient the aide to the client and to the care plan. To provide direction and supervision of care...To assure the quality of services provided by the Home Health Aide. To provide education and resource...SPECIAL INSTRUCTIONS 1...The assignment of tasks will be identified in the home health aide care plan/Assignment Sheet..." A review of an Agency's policy dated 8/24/17, titled, "Care Plans", revealed, "POLICY Each client will have a care plan on file that addresses their identified needs and the agency's plan to respond to those needs...PURPOSE To assure continuity and consistency...To focus the interventions and frequency and duration based on the effectiveness of interventions and progress toward goals. To provide an updated, coordinated document that reflects the current home care services. SPECIAL INSTRUCTION 1. Following the initial assessment, a Care Plan shall be developed with the client...2. The Care Plan shall be reviewed, evaluated, revised (minimally every sixty (60) days and as needed) based upon the client's health status...3. The Care Plan shall include...c. A list of specific interventions with plans for implementation..." A review of an Agency's undated policy, titled, "Plan of Care", revealed, "POLICY...Planning for care is a dynamic process that addresses the care, treatment and services to be provided...PURPOSE To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs...SPECIAL INSTRUCTIONS 1. An individualized Plan of Care signed by a physician shall be required for each client...2. The Plan of Care shall be completed in full to include...c Type, frequency, and duration of all visits/services d. Specific procedures and modalities for therapy services...l Medications, treatments, and procedures..." 2. A review of the clinical record of patient #4, revealed a “Home Health Care Certification and Plan of Care”, dated 1/19/22 for the certification period of 1/19/22 to 3/19/22 which evidenced diagnoses but not limited to Osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time), Scoliosis (a sideways curvature of the spine), and Intervertebral Disc Disorders with radiculopathy (a condition characterized by the breakdown of one or more of the discs that separate the bones of the spine, that can cause pain, numbness, and/or leg weakness) with SN (skilled nursing) 1 x month for 2 months, and HHA (home health aide) services 7 x week for 1st week, then 12 times a week for 8 weeks. A review of an undated document titled,” Aide Care Plan”, revealed the HHA was to 1. Ambulate only with assistance 2. Ambulate patient using assistive device…3. Assist with transfer 4. Up in chair 5. Assist to BSC (bedside commode)/toilet 6. Assist patient with dressing 7. Bath-Shower 8. Shampoo 9. Shave 10. Remind patient to take medications 11. Fall precautions 12. Standard precautions 13. Universal precautions A home visit conducted for Patient #4, on 2/17/22 at 8:28 AM to 9:05 AM, employee D, HHA, entered the apartment at 8:28 am, immediately donned gloves, assisted the patient out of their bed and into the bathroom using a walker, removed patient’s brief prior to sitting on the toilet (with raised toilet seat). The aide removed the patient’s t-shirt, then left the bathroom to bedroom to retrieve the clean t-shirt and necklace alarm, placing them on top of the clothes hamper. Employee D turned the water on, wetted the washcloth, using bar soap, turned the water off, gave the washcloth to the patient for the patient to wash their face, moved a curtain to retrieve a clean towel, and placed it on the patient’s wheelchair. Turned the water on, rinsed the washcloth, turned the water off, used bar soap to wash back and arms, turned the water on, then rinsed washcloth, turned the water off, rinsed off back and arms, placing washcloth on the sink, then drying patient’s back and arms. Retrieved the t-shirt and a sweatshirt off clothes hamper and dressed patient’s upper body. Employee D placed the alarm necklace around the patient’s neck. Employee D pushed aside a curtain covering a closet to grab 2nd washcloth, turned the water on, wetted the washcloth, turned the water off, proceeded using bar soap to wash the patients’ legs and feet. Turned the water on, rinsed the washcloth, turned the water off, rinsed the patients’ legs and feet, then dried the patients’ legs and feet. Put an adult incontinent product and pants on around ankles and socks on the patient, retrieved the patient’s shoehorn, and proceeded to place the patients’ shoes on. Employee D, retrieved the patient’s toothbrush, put toothpaste on the brush, handing to the patient, reached for a cup and put water in it, grabbed another cup for the patient to spit in. Employee D entered the bedroom while the patient was brushing their teeth, pulled the blankets up on the bed, re-entered the bathroom, took the toothbrush and cups from the patient and rinsed, doffed the gloves and washed their hands using pump soap, then drying hands with cloth towel next to sink. Employee D donned new pair of gloves, grabbed a container from under the sink, took an electric razor from the container and shaved the patient after being dressed, brushed the patient’s hair, went into the living room to retrieve the patient’s gait belt, put the gait belt on the patient, the patient then stood, while the aide using a washcloth with soap washing peri area, turned the water on, rinsed the cloth, turned the water off, then rinsed the patient. Employee D pulled the patient’s adult incontinent product and pants up, threw the towel in the clothes hamper, doffed the gloves. Assisted the patient into the living room, then returned to the bathroom to wash hands, using pump soap, and the same towel at the sink, using bare hands to turn the water on/off. The patient was then escorted to the dining room During the home visit, employee D failed to remind the patient to take their medications, did not wash their hair, and failed to practice standard/universal precautions by not using hand hygiene and changing gloves when appropriate. 3. A review of the clinical record of patient #6, revealed a “Home Health Care Certification and Plan of Care”, dated 1/11/22, for the certification period of 1/9/22 to 3/9/22, which evidenced diagnoses but not limited Type 2 Diabetes Mellitus ( the body either doesn't produce enough insulin, or it resists insulin) with foot ulcer (an open sore or wound that may occur with diabetes, and is commonly located on the bottom of the foot), Malignant neoplasm of colon (cancer colon), and Colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen). The patient was to receive SN (skilled nursing) 3 times a week for 8 weeks, then 2 times a week for 1 week for wound care. Wound Care orders: Cleanse RLE (right lower extremity) with saline or wound cleanser. Pat dry with gauze. Apply Ammonium Lactate 12% lotion. Apply knee hi compression socks, then Circaid wrap. Don surgical shoe. Cleanse LLE (left lower extremity) with saline or wound cleanser. Pat dry with gauze. Apply Ammonium Lactate 12% lotion. Apply Blast X gel to wound bed. Cover with silver foam pad. Secure with tape. Apply compression stocking, then Circaid wrap, don surgical shoe. During a home visit on 2/21/22 at 10 AM, Employee C, RN (registered nurse) initiated visit by creating barriers to place bag on chair, and barrier on table. No hand hygiene at this point. Employee C reached into bag for blood pressure cuff, stethoscope, took patient’s blood pressure, reached into bag while holding cuff for wipes, cleaned cuff, and placed on the barrier on table. used hand hygiene, reached into patient’s supply tote (on floor), looking for trash bags. There were none, so patient ambulated into kitchen for 2 trash bags, handed them to employee C. Employee C put 1 bag into the other (setting up double bag) and placed on floor. Patient then handed Kerlix wrap, and employee C put in tote. Employee C cleaned off chair, placing the stool off the chair on the floor, then sat on chair. Hand hygiene performed. Employee C reached into tote and grabbed 2 sheets of paper towel to create barrier on stool for patient to place foot. Employee C donned gloves, proceeded to remove patient’s compression stocking, sock, and dressing on LLE. Employee C doffed gloves and used hand hygiene, donned new pair of gloves, reached into tote to retrieve wound cleanser, and proceeded to put cleanser on 4 x4 gauze pads, and began cleansing left lower extremity, from the knee down to foot. When finished, employee C doffed gloves and performed hand hygiene, donned new pair of gloves. Reached into tote to retrieve betadine, Blast X and cotton swab and placed the betadine on the stool. Employee C placed a small amount of Blast X on swab to put in wound on left planter, and in doing so, a small amount of Blast X slid down foot, Employee C used same swab and scraped up, and reapplied it to the wound. Employee C threw swab into trash bag, reached into the tote and picked up a small yellow bag, stating this was Prisma to put into wound, under the edge of skin around the undermining area of wound. Once completed, employee C put the Prisma in yellow bag and reached for the silver alginate out of yellow bag, and covered the wound, then placed the silver alginate back into yellow bag, put back into tote, and grabbed a 2 x2 gauze pad and skin prep from tote. Skin prep applied around wound. Employee C, doffed gloves, hand hygiene performed, reached into nursing bag for scissors, donned new gloves, and cut Abd pad in half. Applied the 2x2 and Abd pad to wound, securing with tape, then wrapping LLE with Kerlix, putting compression stocking on, the Circaid wrap, then surgical shoe was put on. Skincare to RLE began by employee C removing stocking, doffed gloves, hand hygiene, donned clean gloves, reached into a tote for another 4 x 4 gauze pad, used wound cleanser to cleanse entire right lower extremity, knee to foot. Employee painted all toes with Betadine, doffed gloves, used hand hygiene, donned new gloves, put compression stocking on, and placed the Circaid wrap on right lower extremity, then put the diabetic shoe on. Employee C gathered up all trash, placed in the trash bag, doffed gloves, and threw it in a trash bag. Employee C then reached in the nursing bag to get gloves and wipe to clean scissors and stethoscope, then placed both items on the clean barrier. Removed gloves, hand hygiene, reached into nursing bag for the oximeter to obtain a reading of 96 with a heart rate of 61 and reached into the bag for thermometer, the temperature was 98 degrees, reached into the bag for pair of gloves, donned gloves, then used wipe to clean pulse oximeter and thermometer. Retook blood pressure, 138/66, wiped blood pressure cuff, placed back onto the clean barrier, using the stethoscope, listen to lung sounds all fields, bowel sounds all fields, cleaned stethoscope, removed gloves, and placed all items back into the nursing bag. Then put all extra supplies back into the tote. Employee C reached into the nursing bag for tablet began filling out information for the visit, then had the patient sign for visit. The patient indicated that they received a new antibiotic the past week from the last appointment at the wound clinic, employee C stated, we will wait to hear from them, then reached into nursing bag for a wipe, to cleanse computer tablet and put in the nursing bag. Employee C, hand bare, picked up the trash bag, and carried it outside to put it in the garbage can. The RN failed to apply Ammonium Lactate 12% lotion to both lower extremities, failed to perform wound care using Contact Precautions to prevent the transmission of microorganisms to the wound, and failed to remove gloves, complete hand hygiene, and apply new gloves at appropriate intervals throughout wound care. 410 IAC 17-14-1(a)(1)(H)

G0800

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, observation,and interview, the agency failed to ensure home health aides (HHA) provided services per the plan of care in 1 home visit of 2. (Patient #4) 1. A review of an Agency’s policy “Home Health Aide Care Plan C-751”, dated 1/19/17, revealed, “ POLICY CDT 7.1.M.7 A complete and appropriate Care Plan, identifying duties to be performed by the Home Health Aide, shall be … All home health aide staff will follow the identified plan…PURPOSE To provide a means of assigning duties to the Home Health Aide that are clear to the Nurse Home Health Aide… " 2. A review of an undated document titled,” Aide Care Plan,” revealed the HHA was to 1. Ambulate only with assistance 2. Ambulate patient using assistive device…3. Assist with transfer 4. Up in chair 5. Assist to BSC (bedside commode)/toilet 6. Assist patient with dressing 7. Bath-Shower 8. Shampoo 9. Shave 10. Remind patient to take medications 11. Fall precautions 12. Standard precautions 13. Universal precautions. During a home visit on 2/17/22 at 8:28 AM to 9:05 AM, employee D, HHA, entered the apartment, immediately donned gloves, assisted the patient out of their bed and into the bathroom using a walker, removed the patient’s brief prior to sitting on the toilet (with raised toilet seat). The aide removed the patient’s t-shirt, then left the bathroom to the bedroom to retrieve the clean t-shirt and necklace alarm, placing them on top of the clothes hamper. Employee D turned the water on, wetted the washcloth, using bar soap, turned the water off, gave the washcloth to the patient for the patient to wash their face, moved a curtain to retrieve a clean towel, and placed it on the patient’s wheelchair. Turned the water on, rinsed the washcloth, turned the water off, used bar soap to wash back and arms, turned the water on, then rinsed washcloth, turned the water off, rinsed off back and arms, placing washcloth on the sink, then drying patient’s back and arms. Retrieved the t-shirt and a sweatshirt off clothes hamper and dressed patient’s upper body. Employee D placed the alarm necklace around the patient’s neck. Employee D pushed aside a curtain covering a closet to grab 2nd washcloth, turned the water on, wetted the washcloth, turned the water off, proceeded using bar soap to wash the patients’ legs and feet. Turned the water on, rinsed the washcloth, turned the water off, rinsed the patients’ legs and feet, then dried the patients’ legs and feet. Put an adult incontinent product and pants on around ankles and socks on the patient. Retrieved the patient’s shoehorn and proceeded to place the patients’ shoes on. Employee D retrieved the patient’s toothbrush, put toothpaste on the brush, handed it to the patient, reached for a cup and put water in it, grabbed another cup for the patient to spit in. Employee D entered the bedroom while the patient was brushing their teeth, pulled the blankets up on the bed, re-entered the bathroom, took the toothbrush and cups from the patient and rinsed, doffed the gloves and washed their hands using pump soap, then drying hands with cloth towel next to sink. Employee D donned new pair of gloves, grabbed a container from under the sink, took an electric razor from the container and shaved the patient after being dressed, brushed the patient’s hair, went into the living room to retrieve the patient’s gait belt, put the gait belt on the patient, the patient then stood, while the aide using a washcloth with soap washing peri area, turned the water on, rinsed the cloth, turned the water off, then rinsed the patient. Employee D pulled the patient’s brief and pants up, threw the towel in the clothes hamper, doffed the gloves. Assisted the patient into the living room, then returned to the bathroom to wash hands, using pump soap, and the same towel at the sink, using bare hands to turn the water on/off. The patient was then escorted to the dining room. Employee D failed to remind the patient to take medications, failed to shampoo the patient, and failed to use standard and universal precautions.

G0948

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to be responsible for the day to day operation of the home health agency, ensuring patient care plans were collaborated by the staff with the physician every 60 days, failed to obtain verbal orders before furnishing services, failed to ensure services being provided met the patient's needs, failed to ensure all entries were authenticated, and failed to review the record for compliance with the EVV documentation for 1 of 1 home health agency administrator. 1. In regard to lack of individualized care planning, coordination of services, and quality of care The agency failed to ensure the individualized plan of care included all accurate treatments, failed to ensure the plan of care was created in conjunction with the primary care physician after an assessment, failed to obtain verbal orders for start of care and recertification orders from the physician, with the date and time when verbal orders were received; failed to ensure the documentation with dates and times; clinicians communicated with the prescribing physician, failed to ensure they adhered to patient rights and provide all services as outlined on the patient's plan of care and failed to ensure they coordinated and documented care delivery in the clinical record to meet the patient's needs, and failed to ensure all entries were authenticated and failed to review the record for compliance with the EVV documentation. (See G 436, G 570, G 572, G 580. G 584, G 588 G 710, G 800, and G 1008) 2. In regard to lack of Infection Control Education and Infection Prevention The agency failed to ensure all staff followed infection control policies and failed to ensure an effective infection control training/education program was provided, and failed to ensure agency staff demonstrated proper infection control practices when providing wound care and/or personal/hygiene care to patients. (See G 682 and G 686) 3. During an interview on 2/22/22 at 2:15, the clinical director stated they was responsible for overseeing processes and policies, overseeing Home Health aides, Clinicians, and Therapists, schedules for staff, and obtaining physician orders. During an interview on 2/22/22 at 2:18, the administrator stated they were responsible for overseeing operations, strategic planning, financials, compliance issues, regulatory compliance, and overseeing the day-to-day activities of the home health agency. 410 IAC 17-12-1(b) 410 IAC 17-12-1(e)

G1008

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure all clinical record entries were accurate and failed to review the record for compliance with the EVV documentation policy for 1 of 9 (Patients #4) active records reviewed. Findings include: 1. A review of an undated agency's policy, titled, "Electronic Visit Verification Submission E-101," revealed; POLICY Alliance Home Health Care has established systems and procedures to assure compliance with State and Federal regulations in regard to EVV (electronic visit verification), and accepted standards of practice.” “All Services requiring an in-home visit that are included in claims under the home health category or personal care services … are subject to the EVV requirement … PURPOSE To define the responsibilities of the Direct Care Staff in the Electronic Visit Verification Process … SPECIAL INSTRUCTIONS: 1. EV requirement under section 1903(I)(5)(A) provides that the system must be able to electronically verify … a. the type of service performed; which must match the care plan or explain why it did not b. the individual receiving the service; verified by signature … 6. All services are provided under a physician plan of care and only services ordered by the physician may be submitted in the EVV documentation. If any services are not provided, it must be documented as to exactly why they were not provided. 7. Upon the completion of a scheduled shift … It is required to have the client sign the EVV documentation to ensure validity of visit before transmission of completed shift is accepted by the state or federal government … 9. A designated clinician reviews the clinical record for compliance with EVV documentation requirements and the appropriateness of submission …” 2. A review of an Agency’s policy “Home Health Aide Care Plan C-751,” dated 1/19/17, revealed, “ POLICY CDT 7.1.M.7 A complete and appropriate Care Plan, identifying duties to be performed by the Home Health Aide, shall be … All home health aide staff will follow the identified plan … PURPOSE To provide a means of assigning duties to the Home Health Aide that are clear to the Nurse Home Health Aide… " 3. A review in the clinical record of Patient #4 of an undated document titled,” Aide Care Plan,” revealed the HHA was to 1. Ambulate only with assistance 2. Ambulate patient using assistive device…3. Assist with transfer 4. Up in chair 5. Assist to BSC (bedside commode)/toilet 6. Assist patient with dressing 7. Bath-Shower 8. Shampoo 9. Shave 10. Remind patient to take medications 11. Fall precautions 12. Standard precautions 13. Universal precautions A home visit conducted on 2/17/22 at 8:28 AM to 9:05 AM, employee D, HHA, entered the apartment of patient 4, at 8:28 am (visit had been scheduled for 8:00 AM), immediately donned gloves, assisted the patient out of their bed, and into the bathroom using a walker to perform personal care. The patient was then escorted to the dining room. Employee D and this writer said our goodbyes, and both left the building at 9:05 AM. This writer observed, the aide did not have a device or paperwork on their person to document the visit nor had the patient or family member signed for the visit. The aide failed to obtain the patient's signature at the completion of the visit, in the presence of the surveyor. 4. A review of the clinical record on 2/17/22, after the home visit with patient #4, evidenced in the clinical record the patient had signed for the visit above. A review of 4 different HHA visits, evidenced conflicting patient signatures on the aide visit notes on 6/20/21, 7/8/21, 2/11/22, and 2/17/22. 5. A review of employee records on 2/23/22, revealed employee D signed for the receipt and education related to the “Electronic Visit Verification Submission E-101,” policy on 8/15/19. 6. In an interview on 2/17/22 at 2:02 PM, with the administrator and clinical manager, when queried as to how HHA’s documented care visits, they stated the patient signs the aide’s device. When notified of the HHA visit earlier in the day, where the aide did not have a device on them and did not obtain the patient's signature at the conclusion of the visit, they stated they would follow up with the aide. A document request was made for the document with the patient’s signature. The administrator and clinical manager failed to produce a document with the patient's signature. In an interview on 2/22/22 at 3:35 PM, the administrator stated they didn’t know what to say about the different signatures, stated they check for missed signatures daily, and if a pattern is observed of missed signatures, the employee will get reprimanded. The administrator stated the agency followed up with the aide, stating the aide had re-entered the facility and asked the patient to sign for the visit, then further stated the agency called and spoke with the spouse of the patient, with the spouse confirming the aide did return for the signature. In an interview on 2/23/22 at 9:30 AM, during a subsequent home visit with patient 4, after having shown Patient #4 and spouse the 4 HHA visits with the conflicting signatures, the patient stated, “Those are not my signatures.” The spouse sitting next to the patient stated, "No, those are not the patient’s signatures." When queried if after the home visit conducted on 2/17/22, the aide had returned to the patient's home to have the patient sign for the visit, they both stated "No." When asked if either one of them had received a phone call from the agency, they both stated, "No." The spouse and the husband stated neither one had signed anything from any of the agency's aides, and never have. The spouse stated the only time anything is signed, was when the nurse came in and went over paperwork with them. The spouse stated that he/she was usually the one who signs anything. In an interview on 2/24/22 at 12:24 PM, with the administrator and clinical director, when queried about the discrepancies and if either one could explain, the administrator stated, “I can’t really explain the discrepancies.” 410 IAC 17-15-1(a)(7)

← Back to the Alliance Home Health Services LLC record

Federal survey findings only. State licensure findings for home health agencies are not shown.

Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction