Every finding on record at Carefirst Rehab LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 12/3/24-12/5/24 and 12/9/24-12/10/24 Active Census: 136 At this Emergency Preparedness survey, Carefirst Rehab, LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QA Area 4 12/16/2024

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 12/3/24-12/5/24 and 12/9/24-12/10/24 12-Month Unduplicated Skilled Admissions: 721 Survey was Partially Extended on 12/05/2024 at 4:31 PM If additional state deficiencies are cited for HHA: This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure patients were advised in writing of the charges for services the individual may have to pay before care is initiated for 8 of 17 patient records reviewed (Patient #1, #4, #5, #6, #7, #13, #15, #17). Findings include: 1. Review of a policy titled "Charge Determination" indicated but was not limited to: "The patient's authorization to bill for services shall be initiated and presented to the responsible party for signature at the time of the initial visit. The agreement shall specify: Patient name, Service address, Responsible party, Charges for services (may be on separate form), Assignment of benefits, Responsibility and terms for payment … Patients with financial liability shall be notified in writing at the time of admission and before the onset of services of the Agency's charges…" 2. The Clinical Record for Patient #1, SOC 08/26/2022, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement," which details the cost of services provided and the expected amount due by the patient after insurance payment. 3. The Clinical Record for Patient #4, SOC 12/23/2023, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement," which details the cost of services to be provided and expected patient responsibility after insurance payment. 4. The Clinical Record for Patient #5, SOC 08/12/2024, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement," which details the cost of services to be provided and expected patient responsibility after insurance payment. 5. The Clinical Record for Patient #6, SOC 11/21/2024, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement" which details the cost of services to be provided and expected patient responsibility after insurance payment. 6. The Clinical Record for Patient #7, SOC 10/29/2024, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement" for the cost of services to be provided and expected patient responsibility after insurance payment. 7. The Clinical Record for Patient #13, SOC 08/23/2024, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement" which details the cost of services to be provided and expected patient responsibility after insurance payment. 8. The Clinical Record for Patient #15, SOC 08/28/2024, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement" which details the cost of services to be provided and expected patient responsibility after insurance payment. 9. The Clinical Record for Patient #16, SOC 11/07/2024, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement" which details the cost of services to be provided and expected patient responsibility after insurance payment. 10. The Clinical Record for Patient #17, SOC 09/13/2024, failed to evidence a completed document titled "Consent for Treatment and Financial Agreement" which details the cost of services to be provided and expected patient responsibility after insurance payment. 11. During an interview on 12/10/2024 at 1:22 PM, the Alternate Clinical Supervisor and Administrator indicated at the initial/SOC visit, agency staff is expected to fill out costs or indicate 'not applicable' as appropriate and completely fill out the consent for treatment and financial agreement form provided for patient/power of attorney signature.

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 initial assessment visit was completed within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician ordered start of care date for 8 of 11 skilled nursing records reviewed (Patients #3, #5, #7, #8, #13, #14, #15, and #17). Findings include: 1. Review of a policy titled "Referral and acceptance of Patients/Clients" indicated but was not limited to: "Upon receipt of a referral, an evaluation by a RN and/or appropriate therapist will be made to determine that the care can be adequately and safely performed at home, to assess the patient/client care needs, and to ensure that the patient/client meets the admission criteria. Patients/clients will be evaluated by a nurse or appropriate staff member within 48 hours of referral or discharge from a facility whenever possible." 2. The clinical record for Patient #3 included a referral received on 07/17/2023 with an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 07/21/2023 for the POC certification period of 07/21/2023 to 09/18/2023. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 3. The clinical record for Patient #5 included a referral received on 07/23/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 08/12/2024 for the POC certification period of 08/12/2024 to 10/10/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and admission into the agency with the initial nursing assessment. 4. The clinical record for Patient #7 included a referral received on 10/17/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 10/29/2024 for the POC certification period of 10/29/2024 to 12/27/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and admission into the agency with the initial nursing assessment. 5. The clinical record for Patient #8 included a referral received on 09/17/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 09/24/2024 for the POC certification period of 09/24/24 to 11/22/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 6. The clinical record for Patient #13 included a referral received on 08/07/2024 with an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 08/23/2024 for the POC certification period of 08/23/2024 to 10/21/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 7. The clinical record for Patient #14 included a referral received on 9/22/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 9/25/2024 for the POC certification period of 9/25/2024 to 11/3/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 8. The clinical record for Patient #15 included a referral received on 08/23/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 08/25/2024 for the POC certification period of 08/28/2024 to 10/26/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 9. The clinical record for Patient #17 included a referral received on 08/07/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 09/13/2024 for the POC certification period of 09/13/2024 to 11/11/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 10. During an interview on 12/05/2024 at 1:30 PM, the Administrator, Alternate Administrator, and Alternate Director of Nursing (Alternate Clinical Supervisor) indicated that Medicare patients most often meet the 48-hour window required for compliance between receipt of referral and completion of the initial assessment/SOC OASIS comprehensive assessment for admission. However, Medicaid and private insurance approval for requested services has not been received in a timely manner, requiring the agency to write a new order for SOC once received and sent to the ordering physician for signature. The provider then completed admission OASIS/initial assessments within 48 hours of receipt of the new order. 410 IAC 17-14-1(a)(1)(A)

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the initial assessment visit was completed within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician ordered start of care date for 2 of 6 therapy only records reviewed (Patients #4 and #9). Findings include: 1. Review of a policy titled "Referral and acceptance of Patients/Clients" indicated but was not limited to: "Upon receipt of a referral, an evaluation by a RN and/or appropriate therapist will be made to determine that the care can be adequately and safely performed at home, to assess the patient/client care needs, and to ensure that the patient/client meets the admission criteria. Patients/clients will be evaluated by a nurse or appropriate staff member within 48 hours of referral or discharge from a facility whenever possible." 2. The clinical record for Patient #4 included a referral received on 11/16/2023, which included an initial therapy assessment and SOC OASIS Comprehensive Assessment admission completed on 12/8/2023 for the POC certification period of 4/6/2024 to 6/4/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record that indicated a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 3. The clinical record for Patient #9 included a referral received on 10/23/2024 that had an initial therapy assessment and SOC OASIS Comprehensive Assessment admission completed on 11/5/2024 for the POC certification period of 11/5/2024 to 1/3/2025. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 4. During an interview on 12/5/2024 at 1:30 PM, the Administrator, Alternate Administrator, and Alternate Director of Nursing (Alternate Clinical Supervisor) indicated that Medicare patients most often meet the 48-hour window required for compliance between receipt of referral and completion of the initial assessment/SOC OASIS comprehensive assessment for admission. However, Medicaid and private insurance approval for requested services has not been received promptly, requiring the agency to write a new order for SOC once received and sent to the ordering physician for signature. The provider then completed admission OASIS/initial assessments within 48 hours of receipt of the new order. 410 IAC 17-14-1(b)(3)(C)

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure an update of the comprehensive assessment was completed within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician ordered resumption date for 1 of 5 discharged patient records reviewed (Patient #5). Findings include: A review of a policy titled "Referral and acceptance of Patients/Clients" indicated but was not limited to: "Upon receipt of a referral, an evaluation by a RN and/or appropriate therapist will be made to determine that the care can be adequately and safely performed at home, to assess the patient/client care needs, and to ensure that the patient/client meets the admission criteria. Patients/clients will be evaluated by a nurse or appropriate staff member within 48 hours of referral or discharge from a facility whenever possible." The Clinical Record for Patient #5, Certification Period 08/12/2024 - 10/10/2024, evidenced the patient was discharged from an inpatient hospital stay on 08/21/2024 and failed to evidence an update of the comprehensive assessment/ROC until 08/24/2024. During an interview on 12/05/2024 at 3:44 PM, the Alternate Clinical Supervisor stated that the staff did not complete the ROC for Patient 5 within 48 hours of their discharge from the hospital. She stated the agency's goal was to meet that timeframe, but she was unsure why the staff did not complete it.

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 had written patient care instructions prepared by a registered nurse or other appropriate skilled professional for 1 of 3 patients with home health aides, records reviewed (Patient #13). Findings include: 1. A review of a policy titled "Home Health Aide Care Plan" indicated but was not limited to: "Each patient receiving service from a Home Health Aide is to have a care plan developed by the coordinating nurse at the onset of service. It is to be updated as needed and at least every 60 days for patients receiving skilled services and at least every 6 months for patients receiving only unskilled services…" 2. The Clinical Record for Patient #13 failed to evidence an updated Home Health Aide Care Plan for the Certification Period 10/22/2024-12/20/2024. 3. During an interview on 12/09/2024 at 1:55 PM, the Alternate Clinical Supervisor indicated the clinical record for Patient #13 did not include a Home Health Aide Care Plan for the current certification period. She indicated she would update and initiate the Care Plan immediately and was unsure why staff had not created a Care Plan for the current certification period. 410 IAC 17-13-2(a)

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 a registered nurse completed a supervisory assessment of the aide services being provided no less frequently than every 14 days for 1 of 3 patients with home health aides, records reviewed (Patient #15). Findings include: 1. Review of a policy titled "Carefirst Rehab Home Health Aide Supervisory Visit Policy" indicated but was not limited to: "Supervisory visits will occur at least every 14 days for each HHA, or more frequently if required by the patient's condition…Supervisory visit notes will be documented in the patient's medical record at time of visit…" 2. The Clinical Record for Patient #15, Certification Period 10/27/2024 - 12/25/2024, was reviewed on 12/9/2024 and evidenced a supervisory visit performed by RN 2 on 11/18/2024. The record failed to evidence any further supervisory visits after 11/18/2024. 3. During an interview on 12/09/2024 at 4:31 PM, the Alternate Clinical Supervisor indicated the clinical record for Patient #15 did not include documentation of an aide supervisory visit completed past 11/18/2024. She indicated that after speaking with RN 2, she discovered that the staff completed the supervisory visit on 12/2/2024, but the staff did not complete the documentation at the time of the visit. The Alternate Clinical Supervisor indicated that agency policy required staff to complete documentation of supervisory visits at the time of the visit.

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for a Home Health Provider. Survey Dates: 4/18/22-4/21/2022 Census: 598 unduplicated At this Emergency Preparedness survey, Carefirst Rehab LLC was found to be found to be in compliance with Conditions of Participation 42 CFR 484.102 Emergency Preparedness requirements for Medicare Participating Providers. QR Completed 5/5/2022 A4

This visit was for a Federal Recertification and State Re-licensure Survey of a Home Health provider. Survey Dates: 4/18/22, 4/19/22, 4/20/22, and 4/21/22 Census: 598 unduplicated Extended Survey Announced 4/20/22 at 3:00 pm These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were provided written notice of transfer and discharge policies for 14 of 14 records reviewed with the potential to affect all 141 active patients. (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) Findings include: 1. The complete clinical record for patient #1 was reviewed on 4-18-2022. The record failed to evidence written notification of transfer and discharge policies. 2. The complete clinical record for patient #2 was reviewed on 4-18-2022. The record failed to evidence written notification of transfer and discharge policies. 3. The complete clinical record for patient #3 was reviewed on 4-20-2022. The record failed to evidence written notification of transfer and discharge policies. 4. The complete clinical record for patient #4 was reviewed on 4-18-2022. The record failed to evidence written notification of transfer and discharge policies. 5. The complete clinical record for patient #5 was reviewed on 4-20-2022. The record failed to evidence written notification of transfer and discharge policies. 6. The complete clinical record for patient #6 was reviewed on 4-20-2022. The record failed to evidence written notification of transfer and discharge policies. 7. The complete clinical record for patient #7 was reviewed on 4-19-2022. The record failed to evidence written notification of transfer and discharge policies. 8. The complete clinical record for patient #8 was reviewed on 4-20-2022. The record failed to evidence written notification of transfer and discharge policies. 9. The complete clinical record for patient #9 was reviewed on 4-19-2022. The record failed to evidence written notification of transfer and discharge policies. 10. The complete clinical record for patient #10 was reviewed on 4-21-2022. The record failed to evidence written notification of transfer and discharge policies. 11. The complete clinical record for patient #11 was reviewed on 4-18-2022. The record failed to evidence written notification of transfer and discharge policies. 12. The complete clinical record for patient #12 was reviewed on 4-20-2022. The record failed to evidence written notification of transfer and discharge policies. 13. The complete clinical record for patient #13 was reviewed on 4-20-2022. The record failed to evidence written notification of transfer and discharge policies. 14. The complete clinical record for patient #14 was reviewed on 4-21-2022. The record failed to evidence written notification of transfer and discharge policies. 15. During interview with Clinical Manager C and Business Office Manager L on 4/21/2022 at 1220 they stated there is the Advanced Beneficiary Notice (ABN) explanation in the patient admission book and thought this covered the discharge notice requirement.

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 record review, observation, and interview the agency failed to review and update all patient medications every 60 days and failed to have documentation in the clinical record addressing any potential adverse reactions for 14 of 14 clinical records reviewed. (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). Findings include: 17. Observation during the home visit with patient #7 on 4/19/2022 revealed the current medication profile was inconsistent with the medications in the home. The medication profile indicated patient #7 took docusate sodium (medication used to treat constipation) Oral (by mouth) tablet 50 mg (milligrams)-8.6 mg daily, Levemir FlexPen subcutaneous solution (medication used to treat diabetes) subcutaneous (under the skin) SQ injection 100 units/ml- 25 units SQ at bedtime, Novolog FlexPen subcutaneous solution (medication used to treat diabetes) subcutaneous (under the skin) SQ injection 100 units/ml- 10 units SQ before meals, nyamyc external powder (medication used to treat fungal skin infection) Topical (on the skin) powder 100000 units/gram – apply to affected site twice a day, Nystatin external (medication used to treat fungal skin infection) Topical (on the skin) cream 100000 units/gram – apply to affected site twice a day, Oxycodone HCL ER oral tablet 12 hour (used to treat pain) 10 mg – take 1 tab as needed twice a day as needed, flomax (used to treat urinary retention) 0.4 mg cap oral – take twice daily, and triamterene HCTZ (used to treat high blood pressure) oral (by mouth) capsule 25mg-37.5 mg – take once daily. Patient #7 stated they do not take any of the medications listed on the medication profile other than the insulin and the one for “my blood pressure”. During interview RN E stated she asks the patient #7 every visit if they have any medication changes and what those changes are. She stated patient #7 has denied changes to medication up to this point. 18. Observation during the home visit with patient #8 on 4/19/2022 revealed the current medication profile was inconsistent with the medications in the home. The medication profile indicated patient #7 took duloxetine (medication used to treat depression) Oral (by mouth) capsule 40 mg (milligrams) twice daily. Medication in the home reveals duloxetine 60 mg capsules. Patient #8 had the following medications in the home and were not listed on the medication profile Dulcolax (used to treat constipation) 5 mg daily as needed, Iron with Vitamin C (used to treat a vitamin or mineral deficiency) 65 mg daily, and hydrocodone-APAP (used to treat pain) 5mg-325 mg every eight hours as needed. Patient stated they take the medications that are in the home at this time. Patient stated ondansetron (used to treat nausea) 4 mg tab daily has been discontinued. During interview PT F they stated the patient is asked at every visit if they have any medication changes and medication bottles are reviewed at recertification visits. 410 IAC 17-14-1(a)(1)(B) 1. An undated policy titled "Medication Administration" and "Medication Profile" was provided by the Clinical Manager on 4/20/2022 at 12:30 p.m. The policy indicated but was not limited to; "The nurse performs ongoing medication monitoring to determine their action, indication, special precautions, patient's response to therapy, side effects, allergies, and other contraindications, and to ensure appropriateness and continuity of care and include the following information necessary for creating an accurate medication history and a complete medication profile and to identify potential complications from the therapy being provided … The medication list is collectively maintained in the clinical record. The plan of care will demonstrate the patient/client's current medication regimen, and additions and/or modifications will be identified in clinical notes, progress notes, summary reports, or communication notes … medication profiles must be updated at least every 60 days and whenever there is a change in the medication regime." 2. The complete clinical record for patient #1 for the certification period of 3/17/2022 through 5/15/2022 was reviewed on 4-18-2022. The record failed to evidence a signed and updated medication profile. 3. The complete clinical record for patient #2 for the certification period of 3/10/22 through 05/08/2022 was reviewed on 4-18-2022. The record failed to evidence a signed and updated medication profile. 4. The complete clinical record for patient #3 for the certification period of 2/14/2022 through 4/14/2022 was reviewed on 4-20-2022. The record failed to evidence a signed and updated medication profile. 5. The complete clinical record for patient #4 for the certification period of 2/04/2022 through 4/04/2022 was reviewed on 4-18-2022. The record failed to evidence a signed and updated medication profile. 6. The complete clinical record for patient #6 for the certification period of 1/28/2022 through 3/28/2022 was reviewed on 4-20-2022. The record failed to evidence a signed and updated medication profile. The record revealed a document titled "Physician's Order Report" received from patient #6 included an order for Mary's Magic Butt Cream to be applied twice daily to the peri area. The medication profile in the clinical record indicated an order for Mary's Magic Butt Cream to be taken orally twice a day. Observation during the 4/20/2022 home visit revealed patient #6's current medication profile was inconsistent with the medications in the home. The medication profile indicated patient #6 took Omeprazole (medication used to treat heartburn) Oral (by mouth) Capsule Delayed-Release 20mg (milligrams) daily. Patient #6 stated they do not take Omeprazole for heartburn. The patient stated they take Papaya Enzymes and Chlorella Micro-Algae for heartburn, neither of the two medications are listed on the medication profile. The patient's medication profile included Cough DM Children's Oral Liquid Extended-Release 30mg/5mL as an ongoing medication. The patient stated they only took the medication for a short period when sick. The medication profile in the home included an order for Alendronate Sodium Oral Tablet 70mg taken once a week, the patient stated they are not on that medication. The patient medication profile included an order for Magnesium Oxide 400 mg taken daily but the patient did not have the medication at the home. The patient stated they are also taking Bilberry and Blackseed oil as needed neither of which are included on the medication profile. 7. The complete clinical record for patient #5 for the certification period of 4/13/2022 through 6/11/2022 was reviewed on 4-20-2022. The record failed to evidence a signed and updated medication profile. Observation during the 4/19/2022 at 12:00 p.m. home visit revealed Patient #5's current medication profile for the certification period 3/29/2022 to 5/27/2022 was inconsistent with the medications in the home. The medication profile indicated the following: Amlodipine Besylate (a medication to treat high blood pressure) 5 mg (milligrams) oral tablet daily. Patient #5 and spouse indicated this medication had been discontinued. Aspirin (a medication to relieve pain, fever, or inflammation) adult low dose delayed release 81 mg daily (1 tablet). Patient #5 and spouse indicated the correct dose to be 2 tablets daily. Carbidopa-Levodopa (a medication to treat Parkinson’s Disease) oral tablet disintegrating 25-100 mg, 1 tablet 4 times per day orally and Carbidopa-Levodopa ER (extended release) oral tablet 50-200 mg, 1 tablet at bedtime orally. Patient #5 and spouse indicated the correct dose to be Carbidopa-Levodopa ER oral tablet 25-200 mg, take 2 tablets (6 a.m., 10 a.m., 2 p.m., 6 p.m., and 10 p.m.) daily. Sennosides-Docusate Sodium (a medication used to treat constipation) oral tablet 8.6-50 mg, 1 tablet twice per day. Patient #5 and spouse indicated this medication is only taken as needed. Medications missing from medication profile per Patient #5 and spouse included: Furosemide (a medication used to treat fluid build-up) 20 mg tablet, 2 tablets daily (breakfast and 2 p.m.), Keflex (an antibiotic) 500 mg twice per day for 10 days then discontinue and start Keflex 250 mg daily routinely, and Vitamin D3 (supplement) 50 mcg (micrograms), one tablet daily. 8. The complete clinical record for patient #7 for the certification period of 4/20/2022 through 6/18/2022 was reviewed on 4-19-2022. The record failed to evidence a signed and updated medication profile. 9. The complete clinical record for patient #8 for the certification period of 1/21/2022 through 3/21/2022 was reviewed on 4-20-2022. The record failed to evidence a signed and updated medication profile. 10. The complete clinical record for patient #9 for the certification period of 2/09/2022 through 4/09/2022 was reviewed on 4-19-2022. The record failed to evidence a signed and updated medication profile. The medication profile for patient #9 revealed an allergy to codeine (opiate used to treat pain) and an ongoing medication order for acetaminophen/codeine (combination medication used to treat pain) oral tablet consisting of 300 mg of acetaminophen and 30 mg of codeine prescribed to be taken once a day. The record failed to include documentation of communication with the physician related to the patient currently taking a medication listed as an allergy or the described reaction of the allergy to the medication. 11. The complete clinical record for patient #10 for the certification period of 2/01/2022 through 4/01/2022 was reviewed on 4-21-2022. The record failed to evidence a signed and updated medication profile. 12. The complete clinical record for patient #11 for the certification period of 3/17/2022 through 5/15/2022 was reviewed on 4-18-2022. The record failed to evidence a signed and updated medication profile. 13. The complete clinical record for patient #12 for the certification period of 3/18/2022 through 5/16/2022 was reviewed on 4-20-2022. The record failed to evidence a signed and updated medication profile. 14. The complete clinical record for patient #13 for the certification period of 2/16/2022 through 4/26/2022 was reviewed on 4-20-2022. The record failed to evidence a signed and updated medication profile. 15. The complete clinical record for patient #14 for the certification period of 2/16/2022 through 4/16/2022 was reviewed on 4-21-2022. The record failed to evidence a signed and updated medication profile.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure all patient care orders were included in the plan of care for 3 of 5 home visits folders reviewed. (#6, #7, and #8) Findings include: 4. Observation during the 4/20/2022 home visit revealed patient #6's current medication profile included in the home record was inconsistent with the medications in the home. Bilberry, Blackseed Oil, Papaya Enzymes, and Chlorella Micro-Algae were all observed in the home during the visit. Patient #6 stated they are currently taking Bilberry and Blackseed Oil daily and Papaya Enzymes and Chlorella Micro Algae as needed for heartburn. The patient stated the agency has written down they take omeprazole for heartburn but that is a medication they no longer take. A document titled "Plan of Care" for the certification period of 4/13/2022 through 6/11/2022 located in the home record for patient #6 failed to evidence orders for Bilberry, Blackseed Oil, Papaya Enzymes, and Chlorella Micro-Algae. A document titled "Medication Profile" for patient #6 located in the home record failed to evidence orders for Bilberry, Blackseed Oil, Papaya Enzymes, and Chlorella Micro-Algae. During an interview on 4/20/2022 at 1:10 p.m., the Speech-Language Pathologist (SLP) stated the patient does take a lot of supplements and nursing is following the patient. The SLP confirmed with the patient all medication changes. 1. An undated policy titled "Physicians Plan of Treatment" was provided by the Clinical Manager on 4/20/2022 at 12:30 pm. The policy indicated but was not limited to "... physician orders are established and documented for the health care services the Agency provides to those patients/clients ... " 2. During the home visit with patient #8 on 4/19/2022 review of the home folder revealed the current medication profile was inconsistent with the medications in the home. The medication profile indicated patient #7 took duloxetine (medication used to treat depression) Oral (by mouth) capsule 40 mg (milligrams) twice daily. Medication in the home reveals duloxetine 60 mg capsules. Patient #8 had the following medications in the home and were not listed on the medication profile Dulcolax (used to treat constipation) 5 mg daily as needed, Iron with Vitamin C (used to treat a vitamin or mineral deficiency) 65 mg daily, and hydrocodone-APAP (used to treat pain) 5mg-325 mg every eight hours as needed. Patient stated they take the medications that are in the home at this time. Patient stated ondansetron (used to treat nausea) 4 mg tab daily has been discontinued. During interview PT F they stated the patient is asked at every visit if they have any medication changes and medication bottles are reviewed at recertification visits. 3. During the home visit with patient #7 on 4/19/2022 view of the home folder revealed the current medication profile was inconsistent with the medications in the home. The medication profile indicated patient #7 took docusate sodium (medication used to treat constipation) Oral (by mouth) tablet 50 mg (milligrams)-8.6 mg daily, Levemir FlexPen subcutaneous solution (medication used to treat diabetes) subcutaneous (under the skin) SQ injection 100 units/ml- 25 units SQ at bedtime, Novolog FlexPen subcutaneous solution (medication used to treat diabetes) subcutaneous (under the skin) SQ injection 100 units/ml- 10 units SQ before meals, nyamyc external powder (medication used to treat fungal skin infection) Topical (on the skin) powder 100000 units/gram – apply to affected site twice a day, Nystatin external (medication used to treat fungal skin infection) Topical (on the skin) cream 100000 units/gram – apply to affected site twice a day, Oxycodone HCL ER oral tablet 12 hour (used to treat pain) 10 mg – take 1 tab as needed twice a day as needed, flomax (used to treat urinary retention) 0.4 mg cap oral – take twice daily, and triamterene HCTZ (used to treat high blood pressure) oral (by mouth) capsule 25mg-37.5 mg – take once daily. Patient #7 stated they the only medication they take is the insulin and the one for “my blood pressure”. During interview RN E stated she asks the patient #7 every visit if they have any medication changes and what those changes are. She stated patient #7 has denied changes to medication up to this point.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to promptly alert the physician of changes in the patient's condition for 2 of 2 clinical records reviewed of patients with histories of UTIs (Urinary Tract Infection). (#4, #9) Findings include: 1. An undated policy titled "Physician's Plan of Treatment" was provided by the Clinical Manager on 04/18/2022 at 3:45 p.m. The policy indicated but was not limited to; "The physician's plan of treatment shall be reviewed by the attending physician in consultation with the Agency's professional personnel at such interval as the severity of the patient/client's illness inquires … more frequently when … there is a significant change in condition." 2. The complete clinical record for patient #4 with a start of care (SOC) of 2/04/2022 was reviewed on 04/18/2022. The record evidenced the following: A SOC OASIS document dated 2/4/2022 indicated, but was not limited to; "Urinary Incontinence or catheter … no incontinence or catheter … renal/genitourinary status … within normal limits." A document titled "Patient Communication Log" dated 2/14/2022 signed by the Clinical Manager stated "SN {skilled nurse] reports no concerns. SN plans to see the patient every other week." A document titled "Skilled Visit Note" dated 2/15/2022 signed by RN B indicated but was not limited to; "Genitourinary … Incontinence … urine color … yellow-green … urine odor … foul odor … checked patient groin area and looks red and irritated." RN LM failed to notify the physician of patient #4's yellow-green foul odor and new-onset incontinence. A document titled "Skilled Visit Note" dated 3/04/2022 signed by RN B indicated patient #4 had a pain level of 5 in the groin area and penis described as a burning sensation. The patient exhibited incontinence, yellow-green urine with a foul odor, and a Foley catheter (a flexible tube that a clinician passes through the urethra and into the bladder to drain urine) now present. RN LM documented "the patient has redness on the going [sic] area, testis [sic] are swollen and irritated … positive for difficulty urinating, dysuria (painful urination), and testicular pain, fatigue, and low-grade temperature. At PE (physical exam) the patient has mild suprapubic discomfort with palpation … urology was contacted and recommended sending the patient to ER (emergency room) … the patient was seen in the ER, prescribed ceftriaxone 2g IV (intravenously). Discharged with a prescription for cefdinir 300 twice daily." Eighteen (18) days elapsed from RN B identifying abnormal genitourinary findings to reporting the abnormal findings to the physician resulting in an adverse outcome, an emergency room admission, for the patient. 3. The complete clinical record for patient #9 with a start of care (SOC) of 2/09/2022 was reviewed on 04/18/2022. The record evidenced the following: A document titled "Home Health Plan of Care & Certification" for the certification period 2/09/2022 through 4/09/2022 was signed by the patient's physician on 1/21/2022 and the Clinical Manager on 2/14/2022. The document indicated patient #9 had an extensive history of urinary tract infections. A document titled "Skilled Nursing Visit Note" for dates 2/12/2022, 2/23/2022, 3/02/2022, 3/09/2022, 3/16/2022, 3/22/2022, and 3/30/2022 signed by RN B all indicated but were not limited to; "Genitourinary … urgency … dysuria … retention … Pt (patient) voiding well …SN (skilled nurse) conts (continues) to educate patient on … s/s (signs/symptoms) of UTI … pt voiced no concerns at this time" A document titled "Skilled Nursing Visit Note" dated 3/30/2022 signed by RN B indicated a goal of "patient will be UTI free within 6wks (6 weeks) … goal status: progressing." A discharge OASIS document dated 4/07/2022 indicated, but was not limited to; "Elimination Status … has this patient been treated for a Urinary Tract Infection in the past 14 days … no" RN B failed to notify patient #9's physician of patient #9's symptoms of a UTI for all 7 visits completed by the RN. 4. During an interview on 4/20/2022 at 10:15 a.m., the Clinical Manager stated they could not find any other notes as to why the MD (medical doctor) was not notified of patient #4's dark foul urine and stated patient #9's notes were clearly copied and pasted but they did find a few notable differences unrelated to urinary status and patient #9 was on antibiotics prophylactically for urinary tract infections. IAC 410 17-13-1(a)(2)

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide medication instructions in plain language for 5 of 5 home visit clinical records reviewed. (#4, #5, #6, #7, and #8) Findings include: 4. The home care folder for Patient #6 was reviewed during the home visit on 4-19-2022 and revealed a document titled "Medication Profile (Patient Version)" for the certification period 04/013/2022 through 06/11/2022. The medication instructions included the following terminology "OD [Every Day] … BID [Twice a Day], PRN [As Needed], and PO [By Mouth]. The Medication Profile failed to use plain language. 5. The home care folder for Patient #5 was reviewed during the home visit on 4-20-2022 and revealed a document titled "Medication Profile (Patient Version)" for the certification period 04/13/2022 through 06/11/2022. The medication instructions included the following terminology "OD [Every Day] … BID [Twice a Day], PRN [As Needed], QHS [every night at bedtime], QID [4 times a day], TID [3 times a day] and PO [By Mouth]. The Medication Profile failed to use plain language. 6. During the exit conference on 4/21/2022 at 12:45 p.m. the administrator, alternate administrator, and clinical manager acknowledged the medication profiles were not in plain language. 1. The home folder for Patient #4 was reviewed during the home visit on 4-19-2022. The folder failed to evidence medication instructions written in plain language. The folder evidenced the following: A document titled "Care Plan (Patient Version)" for the certification period 04/05/2022 through 06/03/2022 revealed medication instructions including "amlodipine besylate ... QD - PO ... Docusate sodium ...BID ... Milk of Magnesia ... Q24H PRN ... ropinirole ... QHS". 2. The home folder for Patient #8 was reviewed during the home visit on 4-19-2022. The folder failed to evidence medication instructions written in plain language. The folder evidenced the following: A document titled "Care Plan (Patient Version)" for the certification period 1/21/2022 through 03/21/2022 revealed medication instructions including "ondansetron ... TID ... Nystatin...QID" 3. The home folder for Patient #7 was reviewed during the home visit on 4-19-2022. The folder failed to evidence medication instructions written in plain language. The folder evidenced the following: A document titled "Care Plan (Patient Version)" for the certification period 02/19/2022 through 04/19/2022 revealed medication instructions including "amlodipine besylate ... QD - PO ... Levemir FlexPen ... SQ"

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: The skilled nurse failed to ensure all clinical notes were accurate and depicted an accurate assessment of the patient for 1 of 5 closed records reviewed. (#9) Findings include: A policy titled "Clinical Record Contents" was provided by the Clinical Manager on 4/18/2022 at 3:45 p.m. The document indicated but was not limited to; "Progress Notes … each caregiver is responsible for recording the care delivered." The complete clinical record for patient #9 with a start of care (SOC) of 2/09/2022 was reviewed on 04/18/2022. The record evidenced the following: A document titled "Skilled Nursing Visit Note" for dates 2/12/2022, 2/23/2022, 3/02/2022, 3/09/2022, 3/16/2022, 3/22/2022, and 3/30/2022 signed by RN B all indicated but were not limited to; "Genitourinary … urgency … dysuria … retention … Pt (patient) voiding well …SN (skilled nurse) conts (continues) to educate patient on … s/s (signs/symptoms) of UTI … pt voiced no concerns at this time." The clinical summary for the certification period of 12/29/2021 through 2/26/2022 indicated but was not limited to; "Admission summary pt (#9) is alert and able to make needs known, pt states she is forgetful at times. Pt complains of pain in her lower back daily. Pt has health hx (history) GERD, HTN (hypertension), Depression, Degenerative Disc, PVD (peripheral vascular disease), Osteroparitis. Pt lives in a 2-story home with her husband who is the primary CG (caregiver) for spouse. Spouse has CG 3xs to assist them with daily needs. VS (vital signs) wnl (within normal limits) per pt baseline. Skin warm and dry to touch. No open areas noted. Abd soft and tender BS+ (bowel sounds positive) x 4 quads. Pt had BM (bowel movement) today. The clinical summary for the certification period of 2/9/2022 through 4/09/2022 indicated but was not limited to; "Admission summary pt (#9) is alert and able to make needs known, pt states she is forgetful at times. Pt complains of pain in her lower back daily. Pt has health hx (history) GERD, HTN (hypertension), Depression, Degenerative Disc, PVD (peripheral vascular disease), Osteroparitis. Pt lives in a 2-story home with her husband who is the primary CG (caregiver) for spouse. Spouse has CG 3xs to assist them with daily needs. VS (vital signs) wnl (within normal limits) per pt baseline. Resp (respirations) even and unlabored no soa (shortness of air) noted. Skin warm and dry to touch. No open areas noted. Abd soft and tender BS+ (bowel sounds positive) x 4 quads. Pt had BM (bowel movement) today. During an interview on 4/20/2022 at 10:15 a.m., the Clinical Manager stated patient #9's notes were clearly copied and pasted but they did find a few small differences. The clinical Manager acknowledged "patient voiding well" and painful urination, urgency, and retention were contradictive statements all listed on every visit note. 410 IAC 17-14-1(a)(1)(E)

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to document all interventions and patient responses to those interventions for 3 of 4 complex patient clinical records reviewed. (#4, #9, #7) Findings include: 4. The complete clinical record for patient #7 with a SOC 12/21/2021 was reviewed on 4/19/2021. The record failed to reveal documentation of wound measurements obtained by the agency throughout the admission. During interview with the Clinical Manager they stated there was a conversation regarding patient #7 and his wound measurements. It was decided not to measure this wound due to its size and irregularity. Documentation was not evidenced in the medical record of the decision to not measure the wound and why. 1. An undated policy titled "Physician's Plan of Treatment" was provided by the Clinical Manager on 04/18/2022 at 3:45 p.m. The policy indicated but was not limited to; "The physician's plan of treatment shall be reviewed by the attending physician in consultation with the Agency's professional personnel at such interval as the severity of the patient/client's illness inquires … more frequently when … there is a significant change in condition." 2. The complete clinical record for patient #4 with a start of care (SOC) of 2/04/2022 was reviewed on 04/18/2022. The record failed to include interventions and/or results of those interventions for abnormal findings for patient #4 on visit date 2/14/2022. The record evidenced the following: A SOC OASIS document dated 2/4/2022 indicated, but was not limited to; "Urinary Incontinence or catheter … no incontinence or catheter … renal/genitourinary status … within normal limits." A document titled "Patient Communication Log" dated 2/14/2022 signed by the Clinical Manager stated "SN {skilled nurse] reports no concerns. SN plans to see the patient every other week." A document titled "Skilled Visit Note" dated 2/15/2022 signed by RN B indicated but was not limited to; "Genitourinary … Incontinence … urine color … yellow-green … urine odor … foul odor … checked patient groin area and looks red and irritated." RN LM failed to notify the physician of patient #4's yellow-green foul odor and new-onset incontinence. During an interview on 4/20/2022 at 10:15 a.m., the Clinical Manager stated they could not find any other notes as to why the MD (medical doctor) was not notified of patient #4's dark foul urine and stated patient #9's notes were clearly copied and pasted but they did find a few notable differences unrelated to urinary status." 3. The complete clinical record for patient #9 with a start of care (SOC) of 2/09/2022 was reviewed on 04/18/2022. The record failed to include interventions and/or results of those interventions for abnormal findings for patient #9 for 7 home visits reviewed. The record evidenced the following: A document titled "Home Health Plan of Care & Certification" for the certification period 2/09/2022 through 4/09/2022 was signed by the patient's physician on 1/21/2022 and the Clinical Manager on 2/14/2022. The document indicated patient #9 had an extensive history of urinary tract infections. A document titled "Skilled Nursing Visit Note" for dates 2/12/2022, 2/23/2022, 3/02/2022, 3/09/2022, 3/16/2022, 3/22/2022, and 3/30/2022 signed by RN B all indicated but were not limited to; "Genitourinary … urgency … dysuria … retention … Pt (patient) voiding well …SN (skilled nurse) conts (continues) to educate patient on … s/s (signs/symptoms) of UTI … pt voiced no concerns at this time" A document titled "Skilled Nursing Visit Note" dated 3/30/2022 signed by RN B indicated a goal of "patient will be UTI free within 6wks (6 weeks) … goal status: progressing." A discharge OASIS document dated 4/07/2022 indicated, but was not limited to; "Elimination Status … has this patient been treated for a Urinary Tract Infection in the past 14 days … no"

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to send a detailed discharge summary to the primary care practitioner including admission and discharge dates, types of services and frequencies, medications patient is on at discharge, outcomes in meeting goals, and post-discharge instructions for 5 of 5 closed records reviewed. (#1, #2, #9, #10, #11) Findings incude: 5. The complete clinical record for patient #2 for the certification period of 12/03/2021 through 1/31/2022 was reviewed on 4-18-2022. The record failed to evidence a complete written discharge summary. The record evidenced the following: A document titled "Discharge Order" dated 12/30/2021 at 10:00 am indicated "To discharge from Carefirst Rehab for home health care services due to therapy goals met … Goals To meet patient's medical needs. Patient Informed: Yes." 6. The complete clinical record for patient #10 for the certification period of 12/31/2021 through 2/28/2022 was reviewed on 4/21/22. The record failed to evidence a complete written discharge summary. The record evidenced the following: Document titled "OASIS Assessment Details" dated 2/24/2022 and contained a discharge summary that stated "Pt has partially met his goals and is being dc'd from HHS to OP services for continuation of therapy...". 7. The complete clinical record for patient #11 for the certification period of 2/01/2021 through 4/01/2022 was reviewed on 4/18/22. The record failed to evidence a complete written discharge summary. During interview on 4/20/2022 Clinical Manager stated there was not a discharge summary for patient 11. 410 IAC 17-15-1(a)(6) 1. An undated policy titled "Discharge/Transfer" policy was provided by the clinical manager on 4/20/2022 at 12:30 p.m. The document indicated but was not limited to; "Prior to discharging the patient/client, the attending physician shall be notified. A written discharge summary, which shall be prepared within 30 days of discharge, will be sent to the physician with a copy maintained in the clinical record. The discharge summary will include: a. The reason for discharge. B. The patient/client's physical and psychosocial status at the time of the discharge c. A summary of the care and services provided d. Patient/client progress toward desired goals e. Instructions and referrals provided to the patient/client." 2. The complete clinical record for patient #1 for the certification period of 3/17/2022 through 5/15/2022 was reviewed on 4-18-2022. The record failed to evidence a complete written discharge summary. The record evidenced the following: A 3/17/2022 dated OASIS assessment signed by RN B that indicated patient # 1 did not have a power of attorney. A document titled "Patient Communication Log" with an entry dated 4/05/2022 signed by RN B that indicated but was not limited to; "Called and spoke with patient son … about seeing patient for resumption of care … PT (patient is no longer living with son … he is living with a different son … states (patient #1) doesn't want additional HH (home health) services." 3. During an interview on 4/20/2022 at 12:30 p.m. the Clinical Manager stated a discharge order was sent due to the patient's son stating he didn't want services but it was just an order to discharge from the agency. 4. The complete clinical record for patient #9 for the certification period of 2/09/2022 through 4/09/2022 was reviewed on 4-19-2022. The record failed to evidence a complete written discharge summary. The record evidenced the following: A document titled "Discharge Order" dated 04/07/2022 indicated "To discharge from Carefirst Rehab for home health care services due to therapy goals met … Goals To meet patient's medical needs. Patient Informed: Yes."