Every finding on record at Bethany Holding LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Date: 6/1/2023-6/7/2023 Facility Number: IN005318 Unduplicated skilled census: 464 At this Emergency Preparedness survey, King's Daughter's Health was found in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: June 1st, 2nd, 5th, 6th, and 7th of 2023. 12-Month Unduplicated Skilled Admissions: 464 Partially Extended Survey Announced June 5th of 2023 at 2:25 p.m. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. QR Completed on 06/12/2023 by A4.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the psychosocial assessment was implemented in the plan of care for 10 of 10 patient records reviewed (Clinical record #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10). Findings include: 1. A policy titled, "Care Planning", revised 02/2021 was provided by the alternate administrator on 6/05/2023 at 4:07 p.m. The policy indicated but was not limited to, "The medical plan of care is developed in consultation with the agency staff and includes the following: … 2. Mental status, psychosocial and cognitive status." 2. Patient #1, SOC (start of care) 02/07/23, POC (plan of care) was reviewed for the certification period 04/08/2023-06/06/2023. The POC failed to include the psychosocial status. 3. Patient #2, SOC 09/15/2021, POC was reviewed for the certification period 05/08/2023-07/06/2023. The POC failed to include the psychosocial status. 4. Patient #3, SOC 05/31/2023, POC was reviewed for the certification period 05/31/2023-07/29/2023. The POC failed to include the psychosocial status. 5. Patient #4, SOC 05/22/2023, POC was reviewed for the certification period 05/22/2023-07/20/2023. The POC failed to include the psychosocial status. 6. Patient #5, SOC 03/10/2023, POC was reviewed for the certification period 05/09/2023-07/07/2023. The POC failed to include the psychosocial status. 7. Patient #6, SOC 11/17/2022, POC was reviewed for the certification period 05/16/2023-07/14/2023. The POC failed to include the psychosocial status. 8. Patient #7, SOC 05/19/2023, POC was reviewed for the certification period 05/19/2023-07/17/2023. The POC failed to include the psychosocial status. 9. Patient #8, SOC 04/26/2023, POC was reviewed for the certification period 04/26/2023-06/24/2023. The POC failed to include the psychosocial status. 10. Patient #9, SOC 04/19/2023, POC was reviewed for the certification period 04/19/2023-06/17/2023. The POC failed to include the psychosocial status. 11. Patient #10, SOC 02/11/2023, POC was reviewed for the certification period 02/11/2023-04/11/2023. The POC failed to include the psychosocial status. 12. During an interview on 06/05/2023 at 2:25 p.m. the Alternate Administrator agreed that the psychosocial status was not included on any POCs and indicated the inability of the current EMR (electronic medical record) system to generate psychosocial status on the POC report.