Every finding on record at Alternative Care Solutions PA LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 05/01/2025-05/02/2025 & 05/05/2025-05/07/2025 Active Census: 7 At this Emergency Preparedness survey, Alternative Care Solutions PA, LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers 42 CFR 484.102.

This visit was for an Initial Federal Certification and State Licensure survey of a Home Health Provider Survey Dates: 05/01/2025-05/02/2025 & 05/05/2025-05/07/2025 Unduplicated 12-month skilled admissions: 11 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse MD Medical Doctor SN Skilled Nurse NP Nurse Practitioner LPN Licensed Practice Nurse SOC Start of Care CNA Certified Nurse Aide POC Plan of Care HHA Home Health Aide EMR Electronic Medical Record CM Clinical Manager

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN initial assessment visit was completed within 48 hours of referral for 1 of 4 home visit patients' records reviewed (Patient #3). Findings include: Review of a policy titled "Start of Care Policy," indicated but was not limited to: "Ensure that a visit is scheduled with 24-48 hours of start of care, if unable to do start of care in this set time, physician shall be notified on start of care date." The clinical record for Patient #3, evidenced a referral date of 11/22/2024 and a SOC date of 11/26/2024. The record failed to evidence documentation of a RN initial assessment within 48 hours of the referral date. During an interview on 05/06/2025 at 1:37 PM, the Administrator indicated she was unsure why there was a gap between the referral order and the SOC. She indicated there was no documentation in the clinical record as to why the 48-hour requirement was not met. During an interview on 05/06/2025 at 2:19 PM, the Alternate Administrator indicated the agency received the signed referral order on 11/22/2024 which was on a Friday. She indicated the initial assessment was not completed until 11/26/2024 because the referral was received the day before the weekend and then Monday was the Thanksgiving holiday. 410 IAC 17-14-1(a)(1)(A)

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 HHA services were received by patients as ordered on the POC for 2 of 5 active patients with HHA records reviewed (Patient #1, #2). Findings include: 1. Review of a policy titled "Physician Order Policy," indicated but was not limited to: "Alternative Care Solutions PA LLC will follow doctor's orders…upon assignment of nursing visits a thorough review of care and treatment prior to visit…" 2. The clinical record for Patient #1, benefit period 01/25/2025 - 03/25/2025, evidenced a physician's order for HHA two (2) times a week for nine (9) weeks. The record failed to evidence HHA visits were performed during the benefit period. It also failed to include documentation as to why frequency and duration were not met or documentation of communication with physician related to why HHA frequency and duration were not met. 3. The clinical record for Patient #2, benefit period 02/25/2025 - 04/25/2025, evidenced a POC with order for HHA four (4) times a week for nine (9) weeks. It also evidenced HHA visits were completed on 03/03/2025, 03/04/2025, 03/05/2025, and 03/06/2025. The record failed to evidence documentation related to why no other HHA visits were completed during the benefit period or documentation of communication with physician related to why HHA frequency and duration were not met. 4. During an interview on 05/06/2025 at 9:02 AM, the Administrator indicated she did not realize documentation was needed for not meeting HHA frequency and duration. She indicated the agency had trouble finding aides that would be a good fit for Patient #3. She indicated the physician would be notified and a new order obtained for documentation purposes. 5. During an interview on 05/06/2025 at 10:47 AM, the Administrator indicated the patient decided not to continue with home health aide services and only receive attendant care services after the agency provided them with information related to the Structured Family Caregiving rules of not receiving both care types by the same staff member. The Administrator indicated she did not obtain an order from the physician to discontinue HHA services. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure POCs included personalized patient and caregiver training or education to promote an efficient discharge or referral, patient/caregiver stated goals, and individualized patient interventions or education for 7 of 7 active patients' records reviewed (Patient #1, #2, #3, #4, #5, #6, #7). Findings include: Review of a policy titled "Development and Management of Medical Plan of Care," indicated but was not limited to: "Collaborate with the patient's physician, dentist, chiropractor, optometrist, or podiatrist to develop a medical plan of care that includes: pertinent diagnoses, mental status, services and equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures, discharge or referral instructions, and any other relevant items…" 2. The clinical record for Patient #1, benefit period 01/25/2025 - 03/25/2025, evidenced the POC failed to include education and training for the patient or caregiver to support timely discharge or referral. It also failed to include patient or caregiver stated goals, as well as individualized interventions and education related to measurable goals and outcomes. 3. The clinical record for Patient #2, benefit period 02/25/2025 - 04/25/2025, evidenced the POC failed to include education and training for the patient or caregiver to support timely discharge or referral. It also failed to include patient or caregiver stated goals, as well as individualized interventions and education related to measurable goals and outcomes. 4. The clinical record for Patient #3, benefit period 03/25/2025 - 05/25/2025, evidenced the POC failed to include education and training for the patient or caregiver to support timely discharge or referral. It also failed to include patient or caregiver stated goals, as well as individualized interventions and education related to measurable goals and outcomes. 5. The clinical record for Patient #4, benefit period 04/03/2025 - 06/01/2025, evidenced the POC failed to include education and training for the patient or caregiver to support timely discharge or referral. It also failed to include patient or caregiver stated goals, as well as individualized interventions and education related to measurable goals and outcomes. 6. The clinical record for Patient #5, benefit period 04/17/2025 - 06/15/2025, evidenced the POC failed to include education and training for the patient or caregiver to support timely discharge or referral. It also failed to include patient or caregiver stated goals, as well as individualized interventions and education related to measurable goals and outcomes. 7. The clinical record for Patient #6, benefit period 04/20/2025 - 06/18/2025, evidenced the POC failed to include education and training for the patient or caregiver to support timely discharge or referral. It also failed to include patient or caregiver stated goals, as well as individualized interventions and education related to measurable goals and outcomes. 8. The clinical record for Patient #7, benefit period 03/04/2025 - 05/02/2025, evidenced the POC failed to include education and training for the patient or caregiver to support timely discharge or referral. It also failed to include patient or caregiver stated goals, as well as individualized interventions and education related to measurable goals and outcomes. 9. During an interview on 05/06/2025 at 12:30 AM, the Administrator acknowledged the POCs for agency patients do not contain personalized patient and caregiver training or education to promote an efficient discharge or referral, patient/caregiver stated goals, and individualized patient interventions or education. She indicated the plan is to reach out to the EMR vendor for assistance. 410 IAC 17-13-1(a)(1)(D)(xi) 410 IAC 17-13-1(a)(1)(D)(xiii)

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 staff followed standard precautions for appropriate disinfection of equipment to prevent cross-contamination and ensure safety of staff and patients for 4 of 4 home visits (Patient #3, #4, #5, #6). Findings include: 1. An undated policy titled "Equipment cleaning policy" indicated but was not limited to, "Cleaning and disinfection: Cleanse using 99.9% disinfection wipe and allow it to air dry on a clean surface." 2. An undated policy titled "Nursing Bag" indicated, but was not limited to, "When in client's home, place a waterproof disposable barrier on a clean and dry surface then place the bag down on the barrier." 3. A review of the manufacturer's guidelines and directions for use listed on the container was provided by the Administrator on 05/07/2025 at 12:24 PM. The manufacturer's instructions for use indicated Purell Hand Sanitizing Wipes should be used as "hand sanitizer to help reduce bacteria on the skin." 4. During a home visit on 05/05/2025 at 1:10 PM with Patient #4, the Administrator placed the nursing bag on patient's couch with no barrier underneath. The Administrator cleaned vital sign equipment (blood pressure cuff, stethoscope, oxygen saturation device, thermometer) after use with Purell Hand Sanitizing Wipes. 5. During a home visit on 05/05/2025 at 2:18 PM with Patient #6, the Administrator placed the nursing bag on patient's couch with no barrier underneath. The Administrator cleaned vital sign equipment (blood pressure cuff, stethoscope, oxygen saturation device, thermometer) after use with Purell Hand Sanitizing Wipes. 6. During a home visit on 05/06/2025 at 9:10 AM with Patient #3, the Alternate Administrator cleaned vital sign equipment (blood pressure cuff, stethoscope, oxygen saturation device, thermometer) after use with Purell Hand Sanitizing Wipes. 7. During a home visit on 05/06/2025 at 10:48 AM with Patient #5, the Alternate Administrator placed the nursing bag on patient's couch with no barrier underneath. The Alternate Administrator cleaned vital sign equipment (blood pressure cuff, stethoscope, oxygen saturation device, thermometer) and retractable tape measure after use with Purell Hand Sanitizing Wipes. 8. Interview with Administrator on 05/07/2025 at 1:46 PM indicated needing to use a barrier under nursing bag in patient's home and disinfectant wipes for equipment following use. 9. Interview with Alternate Administrator on 05/07/2025 at 1:55 PM indicated needing to use a barrier under nursing bag in patient's home and Lysol or Sani Wipes (disinfectant) for equipment following use. 410 IAC 17-12-1(m)

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician's orders were obtained for HHA visits performed for 1 of 4 home visit patients' records reviewed (Patient #6). Findings include: Review of a policy titled "Review of a policy titled "Physician Order Policy," indicated but was not limited to: "Alternative Care Solutions PA LLC will follow doctor's orders…upon assignment of nursing visits a thorough review of care and treatment prior to visit…" The clinical record for Patient #6, benefit period 02/19/2025 - 04/19/2025, evidenced a POC without HHA orders or a separate physician's orders for HHA services. The record evidenced HHA visits were completed on 04/14/2025 and 04/18/2025. During an interview on 05/07/2025 at 9:10 AM, the Administrator indicated she was unsure why aide visits were completed on those days without an order and indicated no order for those dates was in the record. She indicated the physician would be notified and a new order obtained for documentation purposes. 410 IAC 17-15-1(a)(3)