Every finding on record at Centerwell Certified Healthcare Corp

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102. Survey Dates: December 18, 19, and 20, 2023 12-Month Unduplicated Census: 1,004 At this Emergency Preparedness survey, Centerwell Home Health was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal and State complaint survey of a Deemed HHA Provider. Survey Dates: December 18, 19, and 20, 2023 The survey was announced as fully extended on December 20, 2023, at 11:05 AM. Complaint: IN00101390. Federal and State deficiencies were cited. 12-Month unduplicated Census: 1,004 During this Federal Recertification Survey, Centerwell Home Health was found to be out of compliance with Condition of Participation 484.60 Care planning, coordination of services, and quality of care. Based on the Condition-level deficiencies during the December 20, 2023, survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on December 20, 2023. 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 December 20, 2023, and continuing through December 19, 2025. QR completed by A2 on 1/2/2024

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to follow all the required steps for discharge for cause for 1 of 1 patient record reviewed who was discharged for cause (Patient #3). Findings Include: 1. The Discharge or Transfer policy indicated that prior to discharging a patient for cause the agency must including but not limited to advise the patient/caregiver and the patient's providers that discharge for specific cause is being considered; make efforts to solve the problems presented by the patient's behavior or situation; and document any problems, resolution efforts, and contact information for other agencies/providers within the medical record. 2. Patient #3’s clinical record included a plan of care (POC) for certification period 09/10/23 to 11/08/23 with orders for skilled nursing (SN) services 3 times per week to perform wound care and change the patient’s suprapubic catheter. The clinical record failed to evidence Patient #3 or the patient’s ordering physician was notified prior to discharge that the agency was considering discharging the patient for cause. The clinical record failed to evidence the agency made efforts to resolve the alleged problems presented by the patient’s behavior. The clinical record included a SN visit completed by Registered Nurse (RN) 1 on 09/13/2023 which indicated Patient #3 called RN 1 a derogatory name and then apologized about 30 seconds later. The clinical record failed to evidence an incident report related to this alleged incident. 3. On 12/18/2023 at 11:40 AM, Patient #3 relayed he/she received a phone call from the Clinical Manager on the Monday following the 09/13/2023 SN visit. Patient #3 relayed the Clinical Manager stated a staff member had reported the patient calling them a derogatory name to his/her face and that the behavior would not be tolerated and the patient was being discharged effective immediately. Patient #3 indicated the Clinical Manager would not let the patient talk and give his/her side of the story and said it didn’t matter. 4. On 12/19/2023 at 11:42 AM, RN 1 relayed that during the last visit he/she had with Patient #3, he/she called RN 1 a derivative of the “B” word and then apologized. RN 1 relayed he/she did not file an incident report for this alleged incident and had informed the Clinical Manager of the alleged incident the following morning. RN 1 relayed he/she had not felt unsafe. 5. On 12/19/2023 at 11:54 AM, the Clinical Manager indicated he/she would expect a staff member to file an incident report if a patient called him/her a derogatory name during a visit and that the Clinical Manager would investigate the alleged incident by speaking with the patient and the staff member. The Clinical Manager relayed his/her procedure for discharging for cause was to discuss the incident with the patient and bring up the Medicare rights and responsibilities that the patient has a responsibility to provide a safe environment. The Clinical Manager indicated then, that if the patient allowed, and the clinician felt safe, they would do a discharge visit and otherwise would do a non-visit discharge and mail instructions, etc. The Clinical Manager relayed they had spoken with Patient #3 by phone on the day after the alleged incident but that it was not documented in the clinical record. The Clinical Manager indicated Patient #3 at first denied the alleged incident and then indicated it was the clinician’s fault. The Clinical Manager relayed Patient #3 was discharged because the agency was down to only 2 nurses the patient would allow in the home and then he/she made the derogatory statement to RN 1 so “we figured [he/she would] be happier with a different company.” The Clinical Manager indicated they did not believe the health, safety, and/or welfare of the agency’s employees would have been at immediate and significant risk if the agency had continued to provide services to Patient #3. The Clinical Manager relayed Patient #3’s clinical record failed to include the patient’s notification of discharge and failed to include a discussion of the potential discharge with the patient's physician.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure a patient’s complaint was documented for 1 of 2 patient records reviewed who voiced a complaint to the agency (Patient #3). Findings Include: 1. The Complaint Management policy indicated all patient complaints either verbally or in writing would be reviewed, evaluated, and forwarded to the appropriate manager for resolution. The policy relayed the actions and resolution would be documented on the Complaint Log and details of all contacts with the complainant would be documented. 2. The Patient Rights policy indicated patients have the right to have grievances investigated by the agency. 3. The agency’s complaint log failed to evidence documentation of a complaint voiced by Patient #3 to the Clinical Manager on 09/18/2023 related to the circumstances of the allegation the patient had called Registered Nurse (RN) 1 a derogatory name as documented in a nurse visit note by RN 1 on 09/13/2023 and related to the patient’s subsequent discharge for cause. 4. Patient #3’s clinical record failed to evidence Patient #3 voiced a complaint on 09/18/2023 regarding the alleged events during the nurse visit on 09/13/2023 and his/her unexpected discharge from the agency. 5. On 12/18/2023 at 11:40 AM, Patient #3 relayed they received a phone call from the Clinical Manager on 09/18/2023 indicating Patient #3 had reportedly called a clinician a derogatory name to his/her face and was being discharged effective immediately. Patient #3 relayed he/she tried to give their side of the story but that the Clinical Manager told him/her it didn’t matter. 6. On 12/19/2023 at 11:42 AM, RN 1 relayed he/she did not file a grievance or an incident report regarding the alleged events during the skilled nursing visit on 09/13/23. 7. On 12/19/2023 at 11:54 AM, the Clinical Manager relayed that when he/she spoke with Patient #3 regarding the alleged events during the nurse visit on 09/13/2023 Patient #3 at first denied the allegations of calling the clinician a derogatory name and then said it was the clinician’s fault. The Clinical Manager indicated there was no documentation of an investigation of the alleged events.

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 home health agency failed to send a transfer summary to the home health or hospice agency receiving the agency patient for 2 of 2 discharged patients reviewed who were transferred to another agency (Patient #3 and #4). Findings Include: 1. The Complaint and Transfer policy indicated a copy of the transfer summary will be sent to the receiving healthcare provider responsible for the ongoing care of the patient. 2. Patient #3’s clinical record failed to evidence a transfer summary was sent to the patient’s receiving home health agency. On 12/18/2023 at 11:40 AM, Patient #3 relayed the agency had assisted the patient in finding a new home health agency. On 12/19/2023 at 12:11 PM, the Administrator relayed the only place it is documented when the agency sends a discharge or transfer summary is in the fax transmittals. The Administrator indicated the fax transmittal report did not show a transfer summary was sent to Patient #3’s new home health agency. 3. Patient #4’s clinical record failed to evidence a transfer summary was sent to the patient’s receiving hospice agency. On 12/20/2023 at 3:11 PM, the Administrator relayed the agency had not sent a transfer summary to Patient #4’s receiving hospice agency.

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 and interview, the home health agency failed to ensure the written plan of care was followed and that the patient’s physician was consulted to approve modifications to the original plan of care (See G572); based on record review and interview, the home health agency failed to ensure the physician was promptly notified of the patient's change in condition (See G590); and based on record review and interview, the home health agency failed to ensure changes in discharge planning were discussed with the patient and the patient’s physician prior to discharge (See G598). Findings Include: The cumulative effect of these systemic problems had the potential to impact all 246 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care.

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 home health agency failed to ensure the written plan of care was followed and that the patient’s physician was consulted to approve modifications to the original plan of care for 1 of 1 patient reviewed who was discharged for cause (Patient #3). Findings Include: 1. The Care Planning policy indicated the agency will notify the physician if changes to the plan of care (POC) are needed and obtain physician orders to change the current POC. 2. Patient #3’s clinical record included a POC for certification period 09/10/2023 to 11/08/2023 with orders for skilled nursing (SN) services 3 times per week for including but not limited to wound care and monthly urostomy catheter changes. The POC included discharge plans of discharge to family/ self care under the supervision of the medical doctor when goals are met. The SN visit note completed by Registered Nurse (RN) 1 for a visit on 09/13/2023 indicated Patient #3’s goals not met. Unmet goals included but not limited to, patient/caregiver understands basic measures to control generalized depression symptoms; patient/caregiver verbalizes/demonstrates pressure ulcer management, definition of pressure ulcer, treatment application technique, and intended effects; patient tolerates pressure ulcer care without complications; and patient/caregiver verbalizes central line implantable device intravenous therapy purpose and intended benefits. The clinical record included a non-visit discharge assessment completed by RN 1 and dated 09/17/2023. The clinical record failed to evidence the patient’s potential discharge for cause was discussed with the physician and failed to evidence a physician order for discharge. 3. On 12/19/2023 at 11:54 AM, the Clinical Manager relayed Patient #3’s clinical record did not include documentation that the patient’s potential discharge for cause was discussed with Patient #3’s physician and did not include a physician’s order for discharge.

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 home health agency failed to ensure the physician was promptly notified of the patient's change in condition for 1 of 1 patient records reviewed who expressed suicidal ideations (Patient #3). Findings Include: 1. The Coordination of Care - Case Conferences policy indicated communication with the patient's physician must occur regarding significant changes in the patient's condition. 2. Patient #3’s clinical record included a skilled nursing (SN) visit note completed by Registered Nurse (RN) 1 for a visit on 09/13/2023 which indicated Patient #3 expressed suicidal ideations to RN 1. The note indicated RN 1 would contact Patient #3’s physician in the morning regarding the suicidal ideations as the patient had not voiced a suicidal plan. The clinical record failed to evidence Patient #3’s physician was contacted regarding the patient’s suicidal ideations. 3. On 12/19/2023 at 11:42 AM, RN 1 relayed his/her usual practice if a patient voiced suicidal ideations was to ask if the patient had a plan and that if the patient had a plan RN 1 would notify the patient’s physician immediately or call the emergency services phone number. RN 1 relayed that if the patient did not have a plan and was with a family member they would still notify the physician but would not call the emergency services phone number unless the patient wanted to go. RN 1 relayed that at his/her last nurse visit with Patient #3, the patient voiced suicidal ideations without a plan. RN 1 indicated physician notification should have been in a visit note or a coordination note and indicated he/she did not complete an incident report regarding the patient voicing suicidal ideations. 4. On 12/19/2023 at 11:54 AM, the Clinical Manager indicated his/her expectation for a clinician if a patient voiced suicidal ideations would be for the clinician to contact emergency services and wait with the patient until emergency services arrived regardless of whether the patient had voiced a plan. The Clinical Manager relayed he/she would also expect the clinician to create an incident report. The Clinical Manager relayed there was no documentation of emergency services or that the patient’s physician were notified of Patient #3’s suicidal ideations.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure changes in discharge planning were discussed with the patient and the patient’s physician prior to discharge for 1 of 1 patient records reviewed who were discharged for cause (Patient #3). Findings Include: 1. The Discharge and Transfer policy indicated the patient/caregiver must participate in discharge planning and will receive prior notice of discharge from services. The policy also indicated the physician will be notified of discharge and that notification will be documented in the patient's medical record. 2. Patient #3’s clinical record failed to evidence the home health agency discussed changes in discharge planning with the patient or the physician. 3. On 12/18/2023 at 11:40 AM, Patient #3 relayed the Clinical Manager informed him/her on 09/18/2023 that the agency was discharging the patient effective immediately and that this came as a surprise to the patient. 4. On 12/19/2023 at 11:54 AM, the Clinical Manager relayed the clinical record did not contain documentation of Patient #3 being informed of the discharge and did not contain documentation that the discharge had been discussed with Patient #3’s physician.

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 418.102. Survey Date: February 22, 23, 24, 25, 28, March 1, 2, 2022 Facility Number: 5347 Provider Number: 15-7180 Census = 255 At this Emergency Preparedness survey, Kindred at Home Muncie, was found in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 418.102. QA: Area supervisor

This was a Federal recertification and State re-licensure survey of a home health agency, completed on 3/2/22. The survey was partially extended on 2/28/22 at 1:21 PM. Dates of Survey: February 22, 23, 24, 25, and 28, March 1 and 2; 2022. Facility ID: 5347 Provider ID: 15-7180 Unduplicated Admissions for Previous 12 Months: 996 Active Census: 255 These deficiencies reflect State findings cited in accordance with 410 IAC 17. QA: Area supervisor

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 home health agency failed to ensure the Plan of Care included all pertinent diagnoses, all medications and treatments, patient-specific discharge planning, and patient-specific and measurable goals for 8 of 12 active records reviewed (Patient #1, 3, 4, 6, 7, 8, 10, and 11). Findings include: 1. An agency policy #03-11 titled “Care Planning,” last revised 01/2022, indicated but was not limited to “Each patient must receive an individualized Plan of Care (POC) including any revisions or additions…The individualized POC is comprised of the Home Health Certification and Plan of Care form and all subsequent orders received during the patient’s 60-day episode of care and must include: All pertinent diagnoses…All medications and treatments…Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient…The patient or caregiver will be provided a copy of the POC and/or other form of written instructions outlining …patient medication schedule/instructions, to include medication name, dosage, frequency, and which medications will be administered by HHA associates ….” 2. An agency policy #03-41 titled “Medication Documentation,” last revised 06/2021, indicated but was not limited to “…If the physician/allowed practitioner orders a patient a self-administered drug during the certification period, the drug will be noted in the patient’s clinical record on the medication profile…The drug will be included on the next Plan of Care submitted for physician/allowed practitioner signature if it is still a current medication for the patient ….” 3. The clinical record of Patient #1 was reviewed on 2/24/22 and 2/25/22 and indicated a start of care date of 6/10/21. The record included a plan of care for the certification period 2/5/22 to 4/5/22 with patient diagnoses including but not limited to post-surgical amputation; diabetes mellitus; chronic kidney disease; heart failure; neoplasm (new and abnormal growth of tissue) of head, face, and neck; chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe); depression; and gastroesophageal reflux disease (GERD – a chronic disease that occurs when stomach acid flows into the esophagus [food pipe] and irritates the lining). which indicated service orders for skilled nursing of 1 visit per week for 1 week, 3 visits per week for 7 weeks, 6 visits per week for 1 week, and 1 visit per week for 1 week for including but not limited to “wound care” and “diabetes management.” The plan of care also indicated service orders for physical therapy effective 2/13/22 1 visit per week for 1 week, 1 visit every 2 weeks for 6 weeks, and 1 visit per week for 1 week for including but not limited to “improve endurance…ambulation,” and orders for occupational therapy effective 2/6/22 for 1 visit per week for 1 week, 1 visit every 2 weeks for 4 weeks, 1 visit per week for 2 weeks, and 1 visit every 2 weeks for 2 weeks for including but not limited to “maximize patient’s tolerance during ADLs [activities of daily living]…provide balance training to reduce fall risk.” A comprehensive assessment was completed on 1/31/2022 by RN #1 and indicated the patient had a diagnosis of atrial fibrillation (an irregular and often rapid heart rate that can cause poor blood flow.) The plan of care “Diagnoses” list failed to include atrial fibrillation. The medication list in the plan of care indicated an order for artificial tears1% drop s, ophthalmic (eye) 1 drops PRN (as needed) for dry eyes. The plan of care failed to specify in which eye(s) to administer. The plan of care medication list also indicated an order for Benadryl allergy 25 mg tablet PRN for “ALLERGY” but failed to indicate the type of allergy or the allergy symptoms which would indicate the need for a PRN dose of the medication. The plan of care medication list also indicated an order for saline nasal mist 0.65% spray aerosol 1 spray PRN for dry mucous membranes but failed to specify in which nostril(s) to administer. The plan of care indicated the patient’s goals included but were not limited to “verbalizes/demonstrates heart failure management as evidenced by improved cardiovascular status...patient/caregiver verbalizes/demonstrates wound management without complications as evidenced by improved wound status...verbalizes/demonstrates understanding of infection control measures...verbalize/demonstrate ability to properly manage diabetic foot care…verbalize/demonstrate ability to properly manage depression...verbalize/demonstrate ability to properly manage pain...patient will adopt and integrate home exercise program into daily routine as evidenced by progression of activities and/or condition specific protocol...” The plan of care failed to evidence patient-specific and measurable goals. The plan of care indicated “…DC [discharge] Plans: DC to self care under supervision of MD when goals are met...” The discharge plan failed to be detailed and patient-specific. 4. The clinical record of Patient #3 was reviewed on 2/23/22 and 3/1/22 and indicated a start of care date of 10/4/21. The record included a plan of care for the certification period 2/1/22 to 4/1/22 with patient diagnoses including but not limited to GERD, dysphagia, hypertension (high blood pressure), localized edema (puffiness due to excess fluid trapped in body tissues), rheumatoid arthritis (a progressive and chronic disease that causes inflammation [condition in which a body part becomes hot, swollen, red, and painful] in the joints and results in immobility and painful deformities most often in the fingers, feet, wrists, and ankles), osteoarthritis (breakdown of joint cartilage and bone causing pain and stiffness), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), and history of falls. The plan of care indicated service orders for skilled nursing of 1 visit per week for 4 weeks, 1 visit every 2 weeks for 4 weeks, and 1 PRN visit for “exacerbation [worsening] of chronic illness” for including but not limited to “assess/evaluate co-morbid conditions including removal of J-tube.” The plan of care also indicated service orders effective 2/6/22 for physical therapy 1 visit per week for 6 weeks and 1 visit every 2 weeks for 2 weeks for including but not limited to “improve functional mobility and transfers.” The plan of care also indicated service orders effective 2/6/22 for occupational therapy 1 visit per week for 6 weeks and 1 visit every 2 weeks for 2 weeks for including but not limited to “ADL training to increase independence.” The plan of care indicated the patient’s goals of including but not limited to “…verbalizes/demonstrates hypertension management as evidenced by improved blood pressure readings…verbalizes/demonstrates gastrointestinal disease management as evidenced by decreased symptoms…verbalize/demonstrate ability to properly manage depression…verbalize/demonstrate ability to properly manage pain…” The plan of care failed to evidence patient-specific and measurable goals. The plan of care indicated “…DC [discharge] Plans: DC to family/self care under supervision of MD when goals are met…” The discharge plan failed to be detailed and patient-specific. 5. The clinical record of Patient #4 was reviewed on 2/24/22 and 3/1/22 and indicated a start of care date of 6/4/21. The record included a plan of care for the certification period 1/30/22 to 3/30/22 with patient diagnoses including but not limited to unspecified open wound of head, seizures, neuroleptic-induced parkinsonism (medication-induced Parkinson’s disease-like symptoms), Type 2 diabetes mellitus, hypertension, morbid obesity (disorder that involves excess body fat that increases risk of health problems), history of brain cancer, and history of falls. The plan of care indicated service orders for skilled nursing of 2 visits per week for 8 weeks and 1 visit per week for 1 week for including but not limited to “wound care to right forehead.” The plan of care also indicated a service order for physical therapy of 2 visits per week for 3 weeks and 1 visit per week for 6 weeks for including but not limited to “transfers…gait assistance.” The plan of care also indicated service orders for occupational therapy of 1 visit per week for 2 weeks, 1 visit every other week for 2 weeks, 1 visit per week for 1 week, 1 visit every 2 weeks for 2 weeks, and 1 visit per week for 1 week for including but not limited to “increased independence in ADLs.” The plan of care indicated the patient’s goals of including but not limited to “…verbalizes/demonstrates wound management without complications as evidenced by improved wound status…verbalize/demonstrate ability to properly manage diabetic foot care…verbalize/demonstrate ability to properly manage pain…demonstrate improved function in response to specific exercise(s) as evidenced by increased independence in activities of daily living…will adopt and integrate home exercise program into daily routine as evidenced by…condition specific protocol…” The plan of care failed to evidence patient-specific and measurable goals. The plan of care indicated “…DC [discharge] Plans: DC to caregiver under supervision of MD when goals are met...” The discharge plan failed to be detailed and patient-specific. 6. The clinical record of Patient #6 was reviewed on 2/24/22 and 3/1/22 and indicated a start of care date of 1/04/22. The record included a plan of care for the certification period 1/14/22 to 3/14/22 with patient diagnoses including but not limited to Stage 2 pressure ulcer (the skin wears away, breaks open or an ulcer forms with the sore expanding into deeper skin layers) of the left buttock, deep vein thrombosis (DVT – a serious condition where a blood clot forms in a deep vein, most often in the leg) of left leg, post covid-19 condition, weakness, and history of falls. The plan of care indicated service orders for skilled nursing of 1 visit per week for 2 weeks for including but not limited to “perform/teach pressure ulcer care.” The plan of care also indicated service orders effective 1/16/22 for physical therapy of 2 visits per week for 3 weeks and 1 visit per week for 5 weeks for including but not limited to “provide gait training.” The plan of care also indicated service orders effective 1/16/22 for occupational therapy of 1 visit per week for 1 week, 1 visit every 2 weeks for 2 weeks, 1 visit per week for 3 weeks, and 1 visit every 2 weeks for 2 weeks for including but not limited to “provide therapeutic exercises designed to restore functional strength and ROM [range of motion].” The plan of care indicated the patient’s goals of including but not limited to “…verbalize/demonstrate an ability to manage skin health as evidenced by decreased symptoms…will adopt and integrate home exercise program into daily routine as evidenced by…condition specific protocol…will improve gait and ambulation as evidenced by improved score…” The plan of care failed to evidence patient-specific and measurable goals. The plan of care indicated “…DC [discharge] Plans: DC to self care under supervision of MD when goals are met...” The discharge plan failed to be detailed and patient-specific. 7. The clinical record of Patient #7 was reviewed on 2/24/22 and indicated a start of care date of 2/5/22. The record indicated a plan of care for the certification period 2/5/22 to 4/5/22 with patient diagnoses including but not limited to pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (area at the bottom of the spine above the tailbone) Stage 1 (has not yet broken through the skin), unstageable (the stage is not clear due to base being covered with other tissue and/or pus) pressure ulcer of right buttock, pressure ulcer left buttock unspecified stage, Parkinson’s disease (a disorder of the central nervous system that affects movement and often includes tremors [involuntary quivering movements]), diabetes mellitus, hypertension, irritable bowel syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation), osteoporosis (a condition where bones become brittle and weak), urinary incontinence, and history of falls. The plan of care indicated service orders for skilled nursing effective 2/6/22 of 1 visit per week for 1 week, 2 visits per week for 3 weeks, and 1 visit per week for 3 weeks for including but not limited to “pressure ulcer care” and “change dressing.” The plan of care also indicated service orders for physical therapy of 1 visit per week for 1 week, 2 visits for week for 4 weeks, and 1 visit per week for 4 weeks for including but not limited to “reduce fall risk…improve functional strength and power…improve functional mobility and transfers…improve ambulation and safety.” The plan of care indicated the patient’s goals including but not limited to “will adopt and integrate home exercise program into daily routine as evidenced by…condition specific protocol...will verbalize effective pain control and understand both pharmacologic and non-pharmacologic pain control methods…verbalize/demonstrate an ability to manage skin health as evidenced by decreased symptoms…” The plan of care failed to evidence patient-specific and measurable goals. The plan of care indicated “…DC [discharge] Plans: DC to caregiver under supervision of MD when goals are met...” The discharge plan failed to be detailed and patient-specific. 8. The clinical record of Patient #8 was reviewed on 2/24/22 and 3/1/22 and indicated a start of care date of 9/21/21. The record indicated a plan of care for the certification period 1/19/22 to 3/19/22 with patient diagnoses including but not limited to Parkinson’s disease, periapical abscess (a pocket filled with pus in a tooth caused by infection), hypertension, atherosclerotic coronary artery disease (plaque buildup in the wall of the blood vessels that supply blood to the heart), atrial flutter (condition where the upper chambers of the heart beat too fast), critical illness myopathy (a disease of respiratory and limb muscles that usually occurs in the intensive care unit causing weakness and difficulty breathing without mechanical ventilation), bilateral hearing loss, hyperlipidemia, depression, dependence on supplemental oxygen, history of Covid-19, and history of falls. The plan of care indicated service orders for skilled nursing of 1 visit per week for 3 weeks and 1 visit every 2 weeks for 6 weeks for including but not limited to “assess/evaluate co-morbid conditions including abscess of tooth in left upper gum, critical illness myopathy, Parkinson’s disease, and HTN, and other conditions that present themselves during the course of this episode.” The plan of care indicated the patient’s goals of including but not limited to “…verbalizes/demonstrates hypertension management as evidenced by improved blood pressure readings…verbalize/demonstrate ability to properly manage depression…verbalize/demonstrate ability to properly manage pain…” The plan of care failed to evidence patient-specific and measurable goals. The plan of care indicated “…DC [discharge] Plans: DC to family/self under supervision of MD when goals are met...” The discharge plan failed to be detailed and patient-specific. The medication list in the plan of care indicated an order for O2 – Oxygen PRN (as needed) for O2 supplement. The plan of care failed to indicate the route by which the patient should take the oxygen. 9. The clinical record of Patient #10 was reviewed on 2/28/22 and 3/1/22 and indicated a start of care date of 10/7/20. The record indicated a plan of care for the certification period 1/30/22 to 3/30/22 with patient diagnoses including but not limited to benign prostatic hyperplasia (enlargement of the prostate gland), urinary retention (difficulty urinating and completely emptying the bladder), laceration of left forearm, Parkinson’s disease, Alzheimer’s disease (progressive disease which causes degeneration of brain cell connections causing memory loss and destruction of other important mental functions), dementia (group of symptoms characterized by the impairment of at least two functions of the brain, for example memory loss and judgment), hypertensive chronic kidney disease stage 3 (high blood pressure and the function of the kidneys is cut in half), atherosclerotic heart disease, bilateral hearing loss, history of bilateral knee replacement, and history of falls. The plan of care indicated service orders for skilled nursing of 1 visit per week for 1 week, 1 visit every 2 weeks for 4 weeks, 1 visit every 3 weeks for 3 weeks, 1 visit per week for 1 week, for including but not limited to “insert/change/maintain suprapubic catheter…wound care”, and 2 PRN (as needed) visits “for suprapubic catheter malfunction.” The plan of care also indicated service orders for physical therapy of 1 visit per week for 1 week, 2 visits per week for 2 weeks, and 1 visit per week for 6 weeks for including but not limited to “provide therapeutic activity and exercise to improve functional strength and power…provide gait training to improve ambulation and safety…” The plan of care indicated the patient’s goals of including but not limited to “…verbalizes/demonstrates understanding of infection control measures…verbalize/demonstrate measures to prevent falls…verbalize/demonstrate ability to properly manage depression…verbalize/demonstrate ability to properly manage pain…verbalize/demonstrate measures to prevent pressure ulcers…adopt and integrate home exercise program into daily routine as evidenced by progression of activities and/or condition specific protocol…” The plan of care failed to evidence patient-specific and measurable goals. 10. The clinical record of Patient #11 was reviewed on 2/24/22 and indicated a start of care date of 2/2/22. The record indicated a plan of care for the certification period 2/2/22 to 4/2/22 with patient diagnoses including but not limited to post surgical amputation, Type 2 diabetes mellitus, chronic osteomyelitis (bone infection that does not go away with treatment) of left ankle and foot, hypertension, heart failure, atherosclerosis of coronary artery, urinary incontinence, GERD, and history of falls. The plan of care included orders for skilled nursing 1 visit per week for 7 weeks for including but not limited to “administer central line/implantable device IV [intravenous] therapy.” The plan of care indicated the patient’s goals of including but not limited to “…verbalizes/demonstrates understanding of infection control measures…verbalize/demonstrate ability to properly manage diabetic foot care…verbalize/demonstrate measures to prevent falls…verbalize/demonstrate ability to properly manage pain…verbalize/demonstrate measures to prevent pressure ulcers…” The plan of care failed to evidence patient-specific and measurable goals. The plan of care indicated “…DC [discharge] Plans: DC to caregiver under supervision of MD when goals are met...” The discharge plan failed to be detailed and patient-specific. 11. An interview was conducted on 3/2/22 at 1:03 pm with Administrator/Alternate Clinical Manager. During the interview Administrator/Alternate Clinical Manager confirmed that the Plan of Care should include diagnoses for all patient conditions, a medication list with specific directions on how to administer the medication, specific indication for administration of PRN medication, measurable and patient-specific goals, and a patient-specific discharge plan. 17-13-1(a)(1)(C) 17-13-1(a)(1)(D)(ix) 17-13-1(a)(1)(D)(xi)

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, policy review, and interview the agency failed to follow accepted standards of practice and their own policies to prevent the transmission of infections and communicable diseases for 6 of 7 patients observed (Patients #1, 2, 3, 5, 6, and 7.) 1. An agency policy 10-03 titled “Standard Precautions,” last revised 08/2021, indicated but was not limited to “All clinicians performing job-related responsibilities will observe Standard Precautions…Standard Precautions represent the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of patients…Standard Precautions include: hand hygiene…use of personal protective equipment (PPE) such as gloves, gowns, and face masks…waste disposal and safe handling of potentially contaminated equipment or surfaces in the patient environment including bag techniques…sterile instruments and devices…clean and disinfected environmental surfaces…Clinicians are to follow CDC [Centers for Disease Control and Prevention] recommendations…” 2. An agency policy 10-01 titled “Surveillance, Prevention, and Control of Infection,” last revised 12/2020, indicated but was not limited to “…Hand hygiene is the most effective means of preventing disease transmission in the home…” 3. An agency policy #10-05 titled “Engineering and Work Practice Controls,” last revised 12/2020, indicated but was not limited to “Hands will be washed with soap or approved sanitizer before donning gloves, after removing gloves, and prior to direct contact with patients or procedure…” 4. An agency job description for “LPN HH,” last revised 9/2020, indicated but was not limited to “…The LPN [Licensed Practical Nurse] will deliver care in compliance with State, Federal, and Medicare standards and the Kindred at Home policies and procedures…Provide care utilizing infection control measures that protect both staff and patient…” 5. A Centers for Disease Control and Prevention (CDC) article “Strategies for Optimizing the Supply of Disposable Medical Gloves,” last updated 12/23/2020 and received printed copy on 3/1/22 from agency administrator, indicated but was not limited to “…During a glove supply crisis, gloves can remain on but must be sanitized between patients…Once PPE supplies and availability return to normal, healthcare facilities should promptly resume conventional practices…” 6. A home visit observation was conducted on 2/23/22 at 2:42 pm with Patient #1 (start of care 6/10/21) and Registered Nurse (RN) #1. During the visit, RN #1 failed to perform hand hygiene prior to donning gloves 3 times and removed 1 glove, performed tasked, and then immediately donned another glove without performing hand hygiene 2 times. 7. A home visit observation was conducted on 2/24/22 at 9:00 am with Patient #2 (start of care 10/30/21) and Occupational Therapist (OT) #1. During the visit, OT #1 failed to perform hand hygiene after cleaning used equipment 2 times and failed to perform hand hygiene between touching their tablet and then touching the patient 2 times. 8. A home visit observation was conducted on 2/24/22 at 10:10 am with Patient #3 (start of care 10/4/21) and Certified Occupational Therapy Assistant (COTA) #1. During the visit, COTA #1 wiped their equipment and failed to allow equipment to dry before returning equipment to bag. 9. A home visit observation was conducted on 2/25/22 at 8:31 am with Patient #5 (start of care 1/2/22) and Home Health Aide (HHA) #1. During the visit, HHA #1 used alcohol-based hand sanitizer on gloves rather than changing them 2 times and failed to change gloves and perform hand hygiene after cleaning the patient and before touching the patient’s clean clothes and bedding. 10. A home visit observation was conducted on 2/25/22 at 11:00 am with Patient #6 (start of care 1/14/22) and Physical Therapy Assistant (PTA) #1. During the visit, PTA #1 used hand sanitizer on gloves instead of performing hand hygiene 2 times. 11. A home visit observation was conducted on 2/25/22 at 3:08 pm with Patient #7 (start of care 2/5/22) and LPN #1. During the visit, LPN #1 performed a dressing change and then failed to change gloves or perform hand hygiene prior to wiping equipment, picking up trash, and documenting on tablet. At end of visit, LPN #1 wiped tablet and then placed it immediately into their bag without allowing dry time. 12. An interview was conducted on 2/28/22 at 1:01 pm with Administrator/Alternate Clinical Manager. During the interview, Administrator/Alternate Clinical Manager confirmed staff should perform hand hygiene prior to donning gloves, staff should perform hand hygiene after cleaning equipment, equipment should be allowed to dry before being placed into bag, and staff should perform hand hygiene before and after touching the patient. The Administrator/Alternate Clinical Manager also indicated staff was “instructed both ways from corporate” regarding whether staff should use hand sanitizer on gloves or change gloves and perform hand hygiene. 13. An interview was conducted on 3/1/22 at 4:45pm with Administrator/Alternate Clinical Manager. During the interview, the Administrator/Alternate Clinical Manager confirmed that the agency was not experiencing a glove shortage at the time of the survey. 17-12-1(m)

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the Registered Nurse (RN) and Licensed Practical Nurse (LPN) failed to perform a complete and thorough assessment of all active medical diagnoses and patient conditions for 2 of 2 skilled nurse visit observations (Patients #1, 7) and the RN and Physical Therapist (PT) failed to perform a complete and through assessment of all active medical diagnoses and conditions for 6 of 12 active records reviewed (Patients #1, 3, 4, 6, 7, 8). 1. An agency policy #03-05 titled “Initial and Comprehensive Assessments,” last revised 01/2022, indicated but was not limited to “… Patient is assessed on an ongoing basis by the appropriate disciplines to evaluate the appropriateness of care…Agency will perform comprehensive reassessments… for all patients receiving skilled services as often as the patient’s condition warrants…” 2. An agency job description for “Case Manager Registered Nurse, HH,” last revised 9/2020, indicated but was not limited to “…Provides admission, case management, and follow-up skilled nursing visits for patients under Clinical Manager’s supervision in compliance with the state Registered Nurse Practice Act. Ensures compliance with applicable licensure/certification requirement, applicable health standards, governmental laws and regulations, and Company policies, procedures and philosophy of care… Assesses individual status and care/instruction needed by the patient… Provides skilled nursing care per the physician’s plan of care/treatment and in compliance with the Nurse Practice Act…” 3. An agency job description for “LPN HH,” last revised 9/2020, indicated but was not limited to “…The LPN will deliver care in compliance with State, Federal, and Medicare standards and the Kindred at Home policies and procedures… 4. Constantine, Salmon, & Maryniak (January 16, 2012). "Overview of Nursing Health Assessment." Retrieved 1/19/21 from RN.com. " ... Pulmonary Assessment ... 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..." 5. Mehta, M. (January 2010). “Assessing the Abdomen.” Retrieved 3/9/22 from https://journals.lww.com/nursingcriticalcare/toc/2010/01000 . “…Place the diaphragm of your stethoscope lightly over the right lower quadrant and listen for bowel sounds. If you don't hear any, continue listening for 5 minutes within that quadrant. Then, listen to the right upper quadrant, the left upper quadrant, and the left lower quadrant. Describe bowel sounds as absent, normoactive, hypoactive, or hyperactive.” 6.The clinical record of Patient #1 was reviewed on 2/24/22 and 2/25/22 and indicated a start of care date of 6/10/21 and a plan of care for the certification period 2/5/22 to 4/5/22 with patient diagnoses including but not limited to post-surgical amputation; diabetes mellitus; chronic kidney disease; heart failure; neoplasm (new and abnormal growth of tissue) of head, face, and neck; chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe); depression; anxiety; urinary incontinence (loss of bladder control); and GERD. The record included a recertification comprehensive assessment completed on 1/31/22 by RN #1. The assessment included a medication list which indicated a medication order for docusate sodium (stool softener) 100 mg capsule 2 times daily for constipation. The assessment indicated RN #1 assessed urinary incontinence but failed to document the type of urinary incontinence (stress, urge, etc.), failed to evidence RN #1 assessed for s/s of heart failure, failed to evidence RN #1 addressed COPD status, failed to evidence RN #1 assessed frequency of diarrhea or assessed whether patient was still taking stool softener, and failed to evidence RN #1 comprehensively assessed depression s/s with patient. A home visit observation was conducted on 2/23/22 at 2:42 pm with Patient #1 and RN #1. During the visit, RN #1 was informed the patient was on antibiotics for a sinus infection. RN #1 failed to ask any follow up questions to assess for s/s of a sinus infection. During the visit, the patient also reported diarrhea to RN #1. RN #1 failed to assess for stool frequency or consistency and failed to inquire whether the patient was still taking their stool softener according to the medication list. RN #1 failed to assess for skin breakdown or wounds other than of known active wounds. 7. The clinical record of Patient #3 was reviewed on 2/23/22 and 3/1/22 and indicated a start of care date of 10/4/21 and indicated a plan of care for the certification period 2/1/22 to 4/1/22 with patient diagnoses including but not limited to GERD, dysphagia (difficulty or discomfort swallowing), hypertension (high blood pressure), localized edema (puffiness due to excess fluid trapped in body tissues), anxiety disorder, rheumatoid arthritis (a progressive and chronic disease that causes inflammation [condition in which a body part becomes hot, swollen, red, and painful] in the joints and results in immobility and painful deformities most often in the fingers, feet, wrists, and ankles), osteoarthritis (breakdown of joint cartilage and bone causing pain and stiffness), and history of falls. The record included a comprehensive assessment completed on 1/28/22 by RN #1 which failed to indicate the patient’s use of supplemental oxygen and failed to specify the type of urinary incontinence within the comprehensive assessment. 8. The clinical record of Patient #4 was reviewed on 2/24/22 and 3/1/22 and indicated a start of care date of 6/4/21 and indicated a plan of care for the certification period 1/30/22 to 3/30/22 with patient diagnoses including but not limited to unspecified open wound of head, seizures, neuroleptic-induced parkinsonism (medication-induced Parkinson’s disease-like symptoms), Type 2 diabetes mellitus, hypertension, morbid obesity (disorder that involves excess body fat that increases risk of health problems), urinary incontinence, and history of falls. The record included a comprehensive assessment completed on 1/26/22 by RN #2 which failed to evidence an assessment of the patient’s current seizure activity. The assessment included a medication list which indicated an order for Nystatin (a topical medication to treat fungal infections) to be applied to the patient’s abdominal folds as needed for redness. The assessment failed to evidence the nurse assessed the patient’s abdominal folds for presence or absence of redness. 9. The clinical record of Patient #6 was reviewed on 2/24/22 and 3/1/22 and indicated a start of care date of 1/04/22 and indicated a plan of care for the certification period 1/14/22 to 3/14/22 with patient diagnoses including but not limited to Stage 2 pressure ulcer (the skin wears away, breaks open or an ulcer forms with the sore expanding into deeper skin layers) of the left buttock, deep vein thrombosis (DVT – a serious condition where a blood clot forms in a deep vein, most often in the leg) of left leg, post covid-19 condition, anxiety disorder, insomnia (difficulty sleeping), hyperlipidemia (high cholesterol), headaches, weakness, and history of falls. The record included a comprehensive assessment, completed on 1/14/22 by RN #2, which failed to evidence an assessment of a dressing, if any, on the pressure ulcer. 10. The clinical record of Patient #7 was reviewed on 2/24/22 and indicated a start of care date of 2/5/22 and indicated a plan of care for the certification period 2/5/22 to 4/5/22 with patient diagnoses, including but not limited to, multiple pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), Parkinson’s disease (a disorder of the central nervous system that affects movement and often includes tremors [involuntary quivering movements]), diabetes mellitus, hypertension, irritable bowel syndrome (IBS - an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation), hypothyroidism, osteoporosis (a condition where bones become brittle and weak), urinary incontinence, history of falls. The record included a comprehensive assessment completed on 2/5/22 by PT #2 which failed to evidence an assessment of the patient’s Parkinson’s disease status, IBS status, and specify the type of urinary incontinence identified. A home visit observation was conducted on 2/25/22 at 3:08 pm with Patient #7 and LPN #1. During the visit, the patient reported a low heart rate to LPN#1. LPN #1 asked the patient if they were ever dizzy or light-headed. The patient said, “no,” while the male in the home said, “yes.” The LPN relayed to the patient that they might not remember because they were starting to show signs of dementia; LPN #1 failed to follow up with further assessment questions. During the assessment, LPN #1 auscultated only the posterior (back) lung sounds and auscultated only 2 quadrants for bowel sounds. 11. The clinical record of Patient #8 was reviewed on 2/24/22 and 3/1/22 and indicated a start of care date of 9/21/21 and indicated a plan of care for the certification period 1/19/22 to 3/19/22 with patient diagnoses, including but not limited to, Parkinson’s disease, periapical abscess (a pocket filled with pus in a tooth caused by infection), hypertension, atherosclerotic coronary artery disease (plaque buildup in the wall of the blood vessels that supply blood to the heart), atrial flutter (condition where the upper chambers of the heart beat too fast), critical illness myopathy (a disease of respiratory and limb muscles that usually occurs in the intensive care unit causing weakness and difficulty breathing without mechanical ventilation), urinary incontinence, hyperlipidemia, dependence on supplemental oxygen, history of Covid-19, and history of falls. The record included a comprehensive assessment completed on 1/14/22 by RN #1 which failed to evidence that RN #1 assessed the route by which the patient took supplemental oxygen or the frequency of use, identified urinary incontinence but failed to assess the type of urinary incontinence, and failed to indicate RN #1 assessed the status of the patient’s tooth abscess. 12. An interview was conducted on 2/28/22 at 1:01 pm with Administrator/Alternate Clinical Manager. During the interview, Administrator/Alternate Clinical Manager confirmed that if a patient reported being on antibiotics the nurse should assess for signs and symptom of infection; if a patient reported diarrhea and was prescribed a stool softener the nurse should verify whether patient was taking the stool softener; if a patient’s vital signs were outside of the normal range the nurse should assess for signs and symptoms of the abnormal vital sign; the nurse should auscultate (listen to with a stethoscope) lung sounds of all lobes both front and back; and the nurse should auscultate bowel sounds of all 4 abdominal quadrants. 13. An interview was conducted on 3/2/22 at 1:03 pm with Administrator/Alternate Clinical Manager. During the interview the Administrator/Alternate Clinical Manager confirmed that the comprehensive assessment (initial or recertification) should include an assessment of the current status of all patient diagnoses and conditions.