Every finding on record at Cj's Home Care Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: October 28, 29, 30, 31, and November 1, 2024 Active Census: 29 At this Emergency Preparedness survey, CJ’s Abundant Care 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 Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: October 28, 29, 30, 31, and November 1, 2024 12-Month Unduplicated Skilled Admissions: 2 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide QAPI Quality Assurance Performance Improvement QR 11/12/24 A2

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure OASIS transmissions were sent on time for 1 of 1 agency. Findings include: 1. Review of the undated Encoding and Reporting OASIS Data policy, indicated “… Agency will encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the client, Validation reports will be obtained and reviewed to determine if corrections are needed. 2. Review of an OASIS Agency Final Validation report for the period 01/01/2023 to 12/31/2023 indicated the following: On 12/05/2022 an OASIS assessment of Patient #5 was completed and was transmitted on 01/27/2023, 53 days later. On 12/19/2022 an OASIS assessment of Patient #5 was completed and was transmitted on 01/27/2023, 39 days later. On 12/26/2022 an OASIS assessment of Patient #5 was completed and was transmitted on 01/27/2023, 32 days later. On 11/22/2022 an OASIS assessment of Patient #3 was completed and was transmitted on 01/27/2023, 66 days later. On 01/03/2023 an OASIS assessment of Patient #10 was completed and was transmitted on 03/03/2023, 60 days later. On 01/20/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 03/03/2023, 43 days later. On 03/21/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 05/11/2023, 51 days later. On 05/04/2023 an OASIS assessment of Patient #6 was completed and was transmitted on 06/06/2023, 33 days later. On 05/23/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 07/06/2023, 44 days later. On 06/30/2023 an OASIS assessment of Patient #10 was completed and was transmitted on 08/08/2023, 39 days later. On 06/29/2023 an OASIS assessment of Patient #6 was completed and was transmitted on 08/08/2023, 40 days later. On 08/24/2023 an OASIS assessment of Patient #5 was completed and was transmitted on 10/23/2023, 60 days later. On 08/29/2023 an OASIS assessment of Patient #10 was completed and was transmitted on 10/23/2023, 55 days later. On 09/19/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 10/23/2023, 34 days later. On 08/31/2023 an OASIS assessment of Patient #6 was completed and was transmitted on 10/23/2023, 53 days later. On 08/11/2023 an OASIS assessment of Patient #11 was completed and was transmitted on 10/23/2023, 73 days later. On 08/31/2023 an OASIS assessment of Patient #12 was completed and was transmitted on 10/23/2023, 53 days later. 3. Review of an OASIS Agency Final Validation report for the period 01/01/2024 to 10/29/2023 indicated the following: On 10/24/2023 an OASIS assessment of Patient #5 was completed and was transmitted on 01/18/2024, 86 days later. On 11/07/2023 an OASIS assessment of Patient #5 was completed and was transmitted on 01/18/2024, 72 days later. On 11/17/2023 an OASIS assessment of Patient #5 was completed and was transmitted on 01/18/2024, 62 days later. On 10/31/2023 an OASIS assessment of Patient #10 was completed and was transmitted on 01/18/2024, 79 days later. On 10/31/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 01/18/2024, 79 days later. On 10/31/2023 an OASIS assessment of Patient #6 was completed and was transmitted on 01/18/2024, 79 days later. On 12/05/2023 an OASIS assessment of Patient #2 was completed and was transmitted on 01/18/2024, 44 days later. On 10/31/2023 an OASIS assessment of Patient #12 was completed and was transmitted on 01/18/2024, 79 days later. 4. Review of QAPI meeting minutes indicated the following: In the 2023 Quarter 1 minutes, dated 04/19/2023, two of the six late transmissions were identified as late. No trends were noted. In the 2023 Quarter 2 minutes, dated 07/12/2023, one of the two late transmissions was identified as late. No trends were noted. In the 2023 Quarter 3 minutes, dated 10/23/2023, none of the three late transmissions were identified. No trends were noted. In the 2023 Quarter 4 minutes, dated 01/31/2024, none of the six late transmissions were identified. No trends were noted. In the 2024 Quarter 1 minutes, dated 04/22/2024, none of the eight late transmissions were identified. No trends were noted. 5. During an interview on 10/29/2024 at 3:16 PM, the Biller indicated she checks whether there are any OASIS assessments to submit about every six weeks. The Biller further indicated she thought OASIS assessments were supposed to be submitted within 30 days of the assessment and that some of the transmissions may have been late because they were put in late or some might have just gotten transferred late. The Biller indicated the Administrator was responsible for obtaining and reviewing the validation reports. 6. During an interview on 10/29/24 at 3:20 PM, the Administrator indicated she oversees the OASIS transmissions by receiving the printout from the Biller and reviews them in QAPI.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients were provided with the Administrator’s contact information, including name, in order to receive complaints for 1 of 1 agency. Findings include: 1. Review of the undated Home Care Bill of Rights policy indicated “Clients and their representatives will be informed of their rights as a consumer of home care services prior to the start of care.” 2. Review of the agency admission packet included a section titled "Patient's Rights & Responsibilities" which indicated complaints or questions may be registered with Person 1, a former agency Administrator. 3. During an interview on 10/29/24 at 1:46 PM, the Administrator indicated the old Administrator was listed in the admission packet, and it should have been the current Administrator. The Administrator further indicated the Human Resources staff copied it from the master and must have forgotten to change the Administrator. 4. During an interview on 10/29/24 at 1:51 PM, the Human Resources person indicated the master copy was the same as what was in the admission packet, and she must have missed that when she updated the packet.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR S 484.102. Survey Dates: February 1, 2, 9, 10, 11, 14, 15; 2022 At this Emergency Preparedness survey, CJ's Abundant Care was found not in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 2 on 3/11/2022

This was a Federal recertification, State re-licensure of a home health agency The survey was partially extended on February 11, 2022 at 3:45 PM. Survey Dates: February 1, 2, 9, 10, 11, 14, 15; 2022 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. QA by Area 2 on 3/11/2022

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 contained all pertinent diagnoses and patient-specific and measurable goals for 5 of 5 active records reviewed (Patients #1, 2, 3, 4, 5). 1. An agency policy titled “Plan of Care” and numbered C-580 included but not limited to “… Special Instructions: 1. An individualized Plan of Care signed by a physician shall be required for each client receiving home health and personal care services. 2. The Plan of Care shall be completed in full to include: a. All pertinent diagnosis(es), principle and secondary, including dates of onset … p. Treatment goals ….” 2. The clinical record of Patient #1 was reviewed on 02/9/2022 and indicated a start of care date 6/13/17 with patient diagnoses including but not limited to chronic pain syndrome, fibromyalgia, urinary incontinence (inability to control urination), Irritable Bowel Syndrome (IBS) with diarrhea, and high blood pressure. The record included a plan of care for the certification period 01/18/22 – 3/18/22 and comprehensive recertification assessment completed on 01/14/22 by the Alternate Clinical Manager. The comprehensive assessment included an active medication list which indicated the patient was taking ammonium lactate (cream or lotion used to treat dry skin conditions), ketoconazole (used to treat fungal skin infections), levetiracetam (given to treat seizures), pantoprazole (used to treat Gastro Esophageal Reflux Disease (GERD)), and venlafaxine (given to treat depression). The plan of care failed to evidence diagnoses related to the above medications. The plan of care indicated the patient’s goals included but were not limited to “Patent suprapubic [catheter, used to empty the bladder through a surgically made stoma in the lower abdomen]” with no signs and symptoms of infection, the patient “will remain safe in home” throughout certification period, “personal hygiene needs” would be met throughout certification period, “adequate nutrition” throughout certification period, “stable cardiopulmonary status” as evidenced by vital signs within normal limits, and blood sugars to remain “within normal limits” throughout the certification period. The goals failed to be measurable and patient specific. A home visit observation was conducted on 2/2/2022 at 10:30 AM with Patient #1 and Home Health Aide #1. No suprapubic catheter was noted during the home visit. 3. The clinical record of Patient #2 was reviewed on 2/9/22 and indicated a start of care date 8/25/2020 with patient diagnoses including but not limited to macular degeneration, Type 2 Diabetes Mellitus, and chronic pain syndrome. The record included a plan of care for the certification period 12/18/21 – 2/15/22. The plan of care indicated the patient’s goals included blood sugar within normal limits throughout the certification period, “adequate hygiene” maintained with home health aide assist throughout the certification period, patient “will remain safe at home with agency assist” throughout the certification period, and “stable cardiopulmonary status” as evidenced by vital signs within normal limits. The goals failed to be patient specific and measurable. 4. The clinical record of Patient #3 was reviewed on 2/10/22 and indicated a start of care date 7/14/21 with patient diagnoses including but not limited to Chronic Obstructive Pulmonary Disease (COPD), osteoarthritis, high blood pressure, and lung cancer. The record included a plan of care for the certification period 1/10/22 – 3/10/22. The plan of care indicated the patient’s goals included but were not limited to the patient’s “personal hygiene needs met with agency assist” throughout the certification period and vital signs within normal limits throughout the certification period. The goals failed to be patient specific and measurable. 5. The clinical record of Patient #4 was reviewed on 2/11/22 and indicated a start of care date 7/30/18 with patient diagnoses including but not limited to Type 2 Diabetes Mellitus, anxiety, depression, and high blood pressure. The record included a plan of care for the certification period 1/10/22 – 3/10/22. The plan of care included an active medication list which indicated the patient was taking alendronate (given to treat osteoporosis), betamethasone valerate (given to treat various skin conditions, typically as a cream or ointment applied to the skin), Calcitrate (given to treat osteoporosis or low calcium levels), gentamicin topical cream (antibiotic given to treat bacterial infections), and nystatin topical cream and powder (given to treat fungal infections). The plan of care failed to evidence diagnoses related to the above medications. The plan of care indicated the patient’s goals included but were not limited to the patient’s “personal hygiene needs met with agency assist” throughout certification period, the patient would be “compliant with medications” throughout the certification period, “stable cardiopulmonary function” as evidenced by vital signs within normal limits, and blood sugars “within normal limits” throughout the certification period. The goals failed to be patient specific and measurable. 6. The clinical record of Patient #5 was reviewed on 2/11/22 and indicated a start of care date 2/18/21 with patient diagnoses including but not limited to COPD, lung cancer, Type 2 Diabetes Mellitus, and alcohol dependence. The record included a plan of care for the certification period 12/15/21 – 2/12/22. The plan of care indicated the patient’s goals included but were not limited to the patient would “remain safe in home with assist from agency,”, the patient would have a “stable cardiopulmonary status” as evidenced by vital signs within normal limits, patient “maintains blood sugar” within normal limits throughout the certification period, and the patient will maintain “adequate nutrition” throughout the certification period. The goals failed to be patient specific and measurable. 7. An interview was conducted on 2/15/22 at 2:15 PM with the Clinical Manager and Office Manager #1. During the interview, the Clinical Manager confirmed the plan of care should include diagnoses for all patient conditions and if a patient was on a medication without a corresponding diagnosis, the agency expectation was the nurse should request a diagnosis from the patient’s physician. The Clinical Manager also confirmed the plan of care should include measurable and patient specific goals. 17-13-1(a)(1)(B)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all staff followed standard precautions and agency infection prevention policies and procedures for 3 of 3 home visit observations conducted (Patients #1, 2). 1. An agency policy titled “Infection Prevention/Control,” numbered B-403, included but not limited to “Policy: Agency will observe the recommended precautions for home care as identified by the Centers for Disease Control and Prevention (CDC) … Standard Precautions – Tier One … 2. Hands are washed if contaminated with blood or body fluid, immediately after gloves are removed, between client contacts, and when indicated to prevent transfer of microorganisms between other clients or the environment ….” 2. Centers for Disease Control and Prevention (Updated 4/30/21). “Wearing a Mask.” Retrieved 2/16/22 from www.cdc.gov. “Wear a Mask the Right Way … The mask must cover your nose. The mask must cover your mouth … The mask must be snug on your face….” 3. McGoldrick (1/2014). “Bag Technique: Preventing and Controlling Infections in Home Care and Hospice.” Retrieved 2/16/22 from www.journals.lww.com. “… Bag Technique … 5. Clean the equipment and supplies ….” 4. A home visit observation was conducted on 2/2/2022 at 10:30 AM with Patient #1 (start of care 6/13/17) and Home Health Aide #1. During the visit, Home Health Aide #1 was observed on one occasion failing to perform hand hygiene prior to donning gloves. 5. A home visit observation was conducted on 2/2/2022 at 11:45 AM with Patient #2 (start of care 8/25/2020) and Home Health Aide #2. During the visit, Home Health Aide #2 was observed on two occasions with her surgical mask below her nose. The aide failed to promptly adjust the mask to the appropriate location (covering both nose and mouth). 6. A home visit observation was conducted on 02/11/2022 at 10:30 AM with Patient #2 and the Alternate Clinical Manager. At the end of the visit, as the Alternate Clinical Manager was collecting her belongings, the nurse was observed cleaning her laptop, folder, and pen, and then immediately placed the items back into her nursing bag. 7. An interview was conducted on 2/11/2022 at 12:40 PM with the Clinical Manager and Office Manager #1. During the interview, the Clinical Manager confirmed staff should perform hand hygiene prior to donning gloves, staff should perform hand hygiene then adjust the face mask immediately if it moves from covering their nose and mouth, and staff should allow cleaned equipment to dry prior to returning the items to the nursing bag. 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) failed to conduct a complete and thorough physical assessment for 1 of 1 home visit observations of a skilled nurse visit (Patient #2) and 3 of 5 active records reviewed (Patients #1, 2, 5). 1. An undated agency job description titled “Registered Nurse” indicated but was not limited to “Primary Purpose: The primary purpose of the registered nurse (RN) is to provide high quality nursing care to assigned patients in their place of residence … Performance Responsibilities: … 9. Perform initial and on-going patient assessments ….” 2. The clinical record of Patient #1 was reviewed on 2/9/2022 and indicated a start of care date 6/13/17 with patient diagnoses including but not limited to chronic pain syndrome, fibromyalgia, osteoarthritis, lumbar disc degeneration, urinary incontinence (inability to control urination), Irritable Bowel Syndrome (IBS) with diarrhea, and high blood pressure. The record included a plan of care for the certification period 1/18/22 – 3/18/22 and comprehensive recertification assessment completed on 1/14/22 by the Alternate Clinical Manager. The assessment failed to evidence a complete and thorough assessment of the patient’s musculoskeletal status and conditions (fibromyalgia, osteoarthritis, lumbar disc degeneration). The comprehensive assessment included an active medication list which indicated the patient was taking ammonium lactate (cream or lotion used to treat dry skin conditions), ketoconazole (used to treat fungal skin infections), levetiracetam (given to treat seizures), pantoprazole (used to treat Gastro Esophageal Reflux Disease (GERD)), and venlafaxine (given to treat depression). The assessment failed to evidence the nurse assessed and documented the patient’s current status and the presence or absence of signs and symptoms for the above conditions. 3. The clinical record of Patient #2 was reviewed on 2/9/22 and indicated a start of care date 8/25/2020 with patient diagnoses including but not limited to macular degeneration, Type 2 Diabetes Mellitus, and chronic pain syndrome. The record included a plan of care for the certification period 12/18/21 – 2/15/22 and comprehensive recertification assessment completed on 12/14/21 by the Alternate Clinical Manager. The assessment indicated the patient was prescribed an antibiotic and cough suppressant due to an upper respiratory infection (URI). The assessment failed to evidence a complete assessment for signs and symptoms of the URI (runny nose, sneezing, congestion, fatigue, etc). A home visit observation was conducted on 2/11/2022 at 10:30 AM with Patient #2 and the Alternate Clinical Manager. During the visit, the Alternate Clinical Manager was observed assessing the patient’s lung sounds by listening to 4 lung lobes posteriorly and 1 lobe anteriorly. The patient reported diarrhea and the nurse noted redness but no open areas to the patient’s inner gluteal folds (buttocks). The nurse failed to assess the patient’s diarrhea symptoms (frequency and consistency of stool, presence or absence of blood, etc) and failed to assess if the patient was applying any topical creams or ointments to the irritated skin. The Alternate Clinical Manager also conducted a medication reconciliation during the visit. The nurse failed to verify the patient’s prescription for benzonatate (medication given to suppress cough) during the visit, which was listed on the patient’s medication list and observed in the home. 4. The clinical record of Patient #5 was reviewed on 2/11/22 and indicated a start of care date 2/18/21 with patient diagnoses including but not limited to COPD, lung cancer, Type 2 Diabetes Mellitus, and alcohol dependence. The record included a plan of care for the certification period 12/15/21 – 2/12/22 and recertification comprehensive assessment completed on 12/10/21 by the Alternate Clinical Manager. The assessment included a medication list which indicated the patient was taking mirtazapine (given to treat depression). The assessment failed to evidence the status of the patient’s depression and the presence or absence of depression symptoms. 5. An interview was conducted on 2/11/22 at 12:40 PM with the Clinical Manager and Office Manager #1. During the interview, the Clinical Manager confirmed the nurse should listen to “all lobes” both anteriorly and posteriorly when assessing the patient’s lung sounds, should conduct a thorough assessment if a patient reported diarrhea, and should assess whether a patient was applying any treatment to a new skin irritation or wound. The Clinical Manager also confirmed the nurse should verify all medications on the medication list and present within the patient’s home when conducting a medication reconciliation. 6. An interview was conducted on 2/15/22 at 2:15 PM with the Clinical Manager and Office Manager #1. During the interview, the Clinical Manager confirmed the comprehensive assessment should include an assessment of any new diagnoses or indicate any newly resolved diagnosis.