Every finding on record at Community Hca, Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey dates: November 7, 8, and 12, 2024. Active Census: 168 At this Emergency Preparedness survey, Community Home Health Care, was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CRF 484.102.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Communication Plan included the physician’s name and contact information for each patient for 1 of 1 agency. Findings include: A review of the agency EP Communication Plan in binder included a list of agency patients that failed to evidence the names and contact information of each patients’ physician. During an interview on 11/12/24 at 3:50 PM, when asked to see the physician’s name and contact information for each patient in the EP, the alternate administrator indicated it was missing for most patients.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure initial EP policy and procedure training was completed at hire by all employees for 2 of 6 employee inservice records reviewed (Employee E, F). Findings include: 1.Record review of an agency document titled “Annual Re-Training In-Service Verification Form” included Emergency Preparedness Plan as an employee in-service to be completed annually. 2.Review of an agency report titled “Caregiver Inservice Details Report” for Employee E, with hire date of 06/30/2022, indicated completion of Annual Retraining Inservices on 12/04/2022 which was five months after date of hire. Documentation failed to evidence initial EP policy and procedure training was completed by Employee E. During an interview on 11/12/2024 at 1:35 PM, when asked to see the record of initial EP training for Employee E, the business operations manager indicated initial training was not done. 3.Personnel record review of Employee F, with hire date of 01/17/2023, evidenced an agency document titled “Inservice Verification Form” for the EP policy and procedure training inservice. Review included an agency document titled “EP Plan Inservice Test” that failed to evidence Employee F completed the inservice. During an interview on 11/12/2024 at 1:35 PM, when asked to see the record of initial EP training for Employee F, the business operations manager indicated Employee F did not finish the training.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to document the agency’s response following actual emergency events for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Preparedness Plan” indicated responses are the activities taken by the agency immediately before, during, and after an emergency/disaster to address the immediate and short-term effects of the emergency event. 2.Review of the agency EP binder identified the agency initiated the EP plan for the following actual natural disasters: 01/22/2024 – 01/23/2024 for a Winter weather advisory, 01/24/2023 fora Winter Storm Warning, and 06/14/2024 -06/16/2024 for a Derecho (a widespread, long-lived windstorm). Documentation failed to evidence the outcome of emergency interventions put in place during each natural disaster. During an interview on 11/12/2024 at 3:50 PM, when asked to see the agency documentation of the outcome of the emergency interventions put into place for emergency events, the alternate administrator indicated calls to patients were documented in client logging. When asked to see the agency's response of the actions put into place during an emergency event, the alternate administrator did not answer.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: November 7, 8, and 12, 2024. 12-Month Unduplicated Skilled Admissions: 30 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: EP Emergency Preparedness HHA Home Health Aide LPN Licensed Practical Nurse POC Plan of Care RN Registered Nurse SN Skilled Nurse QR 11/21/2024 A2

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC included medication orders that included the route, dose, frequency, and included the location of application for 2 of 5 active records reviewed (Patient #3, 5) and for 1 of 2 discharged records reviewed (Patient #6). Findings include: Review of an agency policy titled “Client Plan of Care” indicated the POC is established by the agency and reviewed by the physician to ensure the appropriate application of the services to the patient’s condition and the POC will include the Patient's medications. 2. Review of the clinical record of Patient #3 included a POC for certification period 07/29/2024 – 09/26/2024 signed by RN 2 that included a narrative for the initial assessment that indicated the patient was taking Jardiance (used to lower blood sugar levels in individuals with type 2 diabetes) and Acetaminophen (used for mild to moderate pain). The POC failed to evidence the dose, route, and frequency for taking the medications. During an interview on 11/08/2024 at 3:14 PM, when asked where to find the dose, route, and frequency for Jardiance and Acetaminophen, RN 2 indicated the dose, route, and frequency were not in the POC. Review of the POC of Patient #3 for certification period 09/27/2024 – 11/25/2024 signed by RN 1 included a narrative in the 60-day summary that indicated the patient was taking Jardiance and Acetaminophen. The POC failed to evidence the dose, route, and frequency for taking the medications. During an interview on 11/08/2024 at 4:35 PM, when asked where to find the dose, route, and frequency for Jardiance and Acetaminophen, RN 1 indicated was not in the POC. 3. Review of the clinical record of Patient #5 included a POC for certification period 09/16/2024 – 11/14/2024 signed by RN 1 that included topical (apply to skin) medications but were not limited to, Collagenase (breaks down collagen in damaged tissue to help healthy tissue grow), Promogran Matrix (wound dressing to assist with wound healing), and Sodium Hypochlorite (antiseptic used for wound care). The POC included duplicate medications but were not limited to, Gentamicin (antibiotic to treat a skin infection) applied topically, Ferrous Sulfate (iron supplement), and Albuterol Sulfate (used to prevent and treat wheezing and shortness of breath). The POC failed to evidence the location for the application of the topical medications and failed to evidence which duplicate medication was to be used by the patient. During an interview on 11/08/2024 at 4:35 PM, when asked where in the POC for Patient #5 the following topical medications, Collagenase, Promogran Matrix, and Sodium Hypochlorite, were to be applied, RN 1 indicated the locations were missing. When asked why Ferrous Sulfate, Albuterol, and Gentamicin were entered into the POC in duplicate, RN 1 indicated they should not have been entered as duplicates. 4. Review of the clinical record of Patient #6 included a POC for certification period 08/03/2024 – 10/01/2024 that included a narrative of the 60-day summary that indicated the patient was taking Ozempic for weight management control. The POC failed to evidence the dose, route, and frequency of the medication. During an interview on 11/12/2024 at 12:15 PM, when asked where in Patient #6's POC was the dose, route, and frequency of Ozempic, the alternate clinical supervisor indicated should have discontinued the order in the POC. IAC 17-13-1 (a)1(D)(ix)

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 record review and interview, the RN failed to ensure the ongoing interdisciplinary assessment included the staging of wounds for 1 of 3 active records reviewed of patients with wounds (Patient #2) and failed to include a pain assessment for 1 of 4 active records reviewed of patients taking scheduled pain medications (Patient #5). Findings include: Review of an agency policy titled “Comprehensive Client Assessment” indicated the comprehensive assessment must accurately reflect the patient’s current health status. 2. Review of the clinical record of Patient #2 indicated a diagnosis, but not limited to, quadriplegia (paralysis below the neck, including both arms and legs). Review included a recertification assessment completed on 08/29/2024 by RN 3 that identified pressure ulcers (skin injury caused by pressure on an area of the body and staged based on how deep the wound) to the right and left ischial (bony part of buttocks) areas. Review indicated the wounds were observed and the appearance of both wound beds was bone and indicated the staging for both wounds was not applicable. Documentation failed to evidence the staging of both pressure ulcers. During an interview on 11/08/2024 at 4:00 PM, when asked where to find the documentation of pressure ulcer staging in the recertification assessment, RN 3 indicated if the wound is documented as observed then the stage should be entered. 3. Review of the clinical record of Patient #5 indicated a diagnosis, but not limited to, chronic pain syndrome, and indicated patient takes Oxycontin (used to manage severe pain) every 8 hours for pain. Review included a recertification assessment completed on 09/11/2024 by RN 1 that included a pain assessment that indicated present level of pain was 0. Documentation of pain assessment failed to identify characteristics of pain which include the following: location, onset, how pain numbers were collected, worst pain gets on a 0-10 scale (0 is no pain and 10 is the worst), description, frequency, pattern, duration, and actions that make pain worse and better. During an interview on 11/08/2024 at 4:35 PM, when asked where to find the pain assessment in the recertification assessment of Patient #5, RN 1 indicated entered the pain score told by the patient at the visit. When asked if a thorough pain assessment should be completed and documented at a recertification assessment and for a patient who takes pain medications around the clock, RN 1 indicated yes. IAC 17-14-1(a)(1)(B)

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the SN failed to ensure orders were obtained for all services provided for 1 of 3 active records reviewed of patients with wounds (Patient #2). Findings include: Review of an agency policy titled “Physician Orders” indicated physician orders are required for all patient services including medical treatments. 2. Review of an agency job description for LPNs indicated the LPN provides nursing care that reflects the patients POC. 3. Review of the clinical record of Patient #2 included a POC for certification period 09/03/2024 – 11/01/2024 that included a diagnosis, but not limited to, quadriplegia (paralysis below the neck, including both arms and legs). The POC included wound care orders for the right ischial wound. Review of records included a recertification assessment completed on 08/29/2024 by RN 3 that identified pressure ulcers (skin injury caused by pressure on an area of the body) to the right and left ischial (bony part of buttocks) areas. Review of nursing flow sheets completed by LPN 1 on 09/13/2024, 09/20/2024, 10/18/2024, and 10/28/2024 indicated wound measurements for right and left ischial wounds, and application of wound dressing, Aquacel Ag (antimicrobial wound dressing) and dry sterile dressing, to both wounds. During an interview on 11/08/2024 at 4:00 PM, when asked where to find the wound care orders for the left pressure ulcer of Patient #2, RN 3 indicated the wound care order for the left pressure ulcer was not identified in the POC.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the HHA provided services included in the HHA POC and provided services consistent with home health aide training for 1 of 1 home visit observations of HHA providing care (Patient 3). Findings include: 1. During a home visit observation on 11/08/2024 beginning at 8:30 AM with HHA 1 and alternate clinical supervisor present, HHA 1 reminded Patient #3 to test his/her blood sugar. Observed Patient #3 stuck their finger with a lancet (small needle used to prick the skin to obtain a blood sample for testing blood sugar levels) and HHA 1 held glucometer (medical device to determine the concentration of glucose in the blood) with test strip (small, disposable plastic strip that measures blood sugar levels with a glucometer) and touched test strip to blood on patients’ finger. HHA reminded Patient #3 to take medications. Observed HHA 1 remove medications from the pillbox with a gloved hand and placed medications on a plate in front of the patient. During an interview on 11/08/2024 at 9:15 AM, when asked what a HHA can do regarding the use of the glucometer, the alternate clinical supervisor indicated hand-over hand (physically guiding individuals’ hands by placing their own hands over theirs to assist them with completing a task) actions by a HHA are alright. When asked what an HHA can do regarding medications, the alternate clinical supervisor indicated if a patient needs more assistance, the HHA can do a hand-over-hand assist such as pulling medications from the pillbox and placing them on patients' plate. Review of the HHA Assignment Sheet for Patient #3 included the task, medication reminder. Documentation failed to evidence the HHA task to physically pick up patients’ medications and place them in front of the patient. 3. Review of the agency HHA Competency Checklist completed by HHA 1 on 07/22/2024 failed to evidence HHA competency task for use of the glucometer and test strips to check patients’ blood sugar.

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 and interview, the agency failed to ensure the plan of care was updated to contain all physician orders in 1 of 3 records reviewed (Patient #1). Findings include: Review of an agency policy dated 01/2022, titled “Policy 3.011-Physician Orders” indicated “… physician orders are required for all client [patient] services including … medical treatments … for non-medication orders, a detailed description of the treatment or services … is documented on order ….” A record review for Patient #1, completed on 03/31/2022, contained a document titled “Home Health Certification and Plan of Care” for certification period 02/21/2022-04/21/2022, with other diagnosis (but not limited to), retention of urine. Review of an agency document dated 03/28/2022, titled “Nursing Visit Note-RN [registered nurse], indicated “… getting antibiotic for UTI [urinary tract infection] … antibiotic last dose today ….” During an interview on 03/31/2022 at 1:10 PM, when asked where the agency order for the antibiotic is located, employee B, administrator, indicated the order was received from the VA (veterans administration) and was uploaded into administrative documents but was not entered into the patients’ home health plan of care.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure policies and procedures implemented all elements of the COVID-19 vaccination mandate and failed to ensure 100% of their 88 active employees, completed the COVID-19 vaccine series, was granted a qualifying exemption, or received a temporary delay for 1 of 1 agency reviewed with the potential to affect all current patients and unvaccinated staff of the agency. Findings include: Review of an agency policy dated 11/2021, titled “Policy 8.017 Infection Control” indicated “… Subject: Mandatory COVID-19 … covered staff members … any staff in the following categories … agency employees … on or before, January 4, 2022, all covered staff members must either (i) provide proof that they are fully vaccinated; (ii) provide proof of a need for a temporary delay … (iii) have a pending request for an exemption … (iv) have been granted an exemption … covered staff who are not in compliance … by January 4, 2022, may not provide any care ….” Upon entrance to agency office on 03/29/2022 at 9:15 AM, observed sign on front door that indicated masks required. Employee E, scheduler, at front desk observed not wearing mask. Employee record review indicated employee E, the scheduler, had an approved non-medical exemption. During an interview on 03/29/2022 at 4:10 PM, when asked what measures employees such as employee E, scheduler, with approved non-medical exemption must follow, employee B, administrator, indicated exempted employees must wear a surgical mask at all times. Review of the Centers for Disease Control and Prevention (CDC) web page references, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Pfizer-BioNTech.html and https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Moderna.html, indicated “… Number of Shots: 2 doses in the primary series ….” Employee record review for employee C, HHA was completed on 03/29/2022, with date of hire 07/15/2021, and first patient contact 07/16/2021. The record failed to evidence the employee completed the Pfizer vaccine series with the second vaccine. Employee record review for employee E, HHA was completed on 03/30/2022, with date of hire 03/10/2022, and first patient contact 03/14/2022. The record failed to evidence the employee completed the Moderna vaccine series with the second vaccine. Employee record review for employee J, HHA was completed on 03/30/2022, with date of hire 03/24/2022, and first patient contact 03/28/2022. The record failed to evidence documentation for vaccination record, pending request for exemption, or approved medical or non-medical exemption.

And Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 43 CFR 494.62. Survey Dates: January 4, 5 ,6 ,7, 10, 2022 At this Emergency Preparedness survey, Community Home Health Care was found to be in compliance with 42 CFR 494.62 Emergency Preparedness Requirements, including staffing and the implementation of staffing during a Pandemic for Medicare Participating Providers and Suppliers. Quality Review Completed 2/16/22

This visit was for a Federal Recertification and State Re-licensure of a home health provider in conjunction with 1 complaint. The survey was announced as partially extended on 1/07/2022 at 10:15 AM. Complaint Number IN0061455: Substantiated; Federal and State Deficiencies were cited Survey Dates: January 4 ,5 ,6 ,7 ,10, 2022 Active Census: 160 Community Home Health Care was found to be out of compliance with the Conditions of Participation of 484.60 Care Planning, Coordination of Services; and 484.80 Home Health Aide Services. Based on the Condition-level deficiencies during the January 10, 2022 survey, your home health agency was subject to a partially extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act, on January 7, 2022. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency continues to be precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation program for a period of two years beginning January 10, 2022 and continuing through January 10, 2024. These deficiencies reflects State Findings cited in accordance with 410 IAC 17. Quality Review Completed on 2/16/22

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the safety of 4 of 4 patients (Patients #6, 9, 10, 12) and failed to ensure 2 of 2 patients (Patients #6 and 9) were free of injury when care was provided in 5 of 5 incidents reviewed involving one home health aide (Employee B) during a period of May 2021 to November 2021. Findings include: 1. Review of an agency job description dated 5/1/2019, titled “Policy 5.040 Job Description: Administrator and/ or Alternate Administrator” indicated “… ensures quality and safe delivery of home health care services ….” 2. Review of an agency policy dated 1/13/2018, titled “Policy 2.000-Patient/ Client Rights” indicated “… Rights of the patient … be free from ... including injuries of unknown source … the HHA [home health agency] must investigate complaints … treatment or care … that is furnished inappropriately … take action to prevent further potential violations ….” 3. Review of an agency policy dated 10/1/1998, titled “Policy 5.005 - Discipline of Home Health Care Staff Members” indicated “… the definition of inappropriate behavior is staff member actions that adversely affect the … personal safety … of clients … staff members may be considered for termination … for demonstrating critical inappropriate behavior ….” 4. A review of an agency document titled “Client Accident/ Incident Form” initiated by Employee B, HHA on 5/17/2021 for Patient #10 indicated “… date of incident 5/15/2021 … started to slide to the floor … eased … to the floor ….” the administrator indicated “… needs to report this to the agency as this is a near miss ….” A review of the Indiana Division of Disability and Rehabilitative Services document titled “Incident Initial Report” submitted by the administrator on 5/17/2021, indicated “… narrative … instructed HHA that … needed to report this on 5/15/21 as this is a near miss ….” 5. A review of an agency document titled “Client Accident/ Incident Form” initiated by Employee B for Patient #6 on 8/13/2021 indicated “… date of accident/ incident 8/12/21 … pulled shower chair tipping it over backwards … began to lift shower chair … back came off … fell backwards hitting … head on the floor of the shower room … had a seizure … put … in bed ….” Review of an untitled agency document dated 8/13/2021 and signed by Employee F, RN and Employee B indicated "... instructed on the correct use of DMES [medical equipment] (not tipping shower chair back) ... keeping helmet on aside from showering for safety ... general fall/ safety/ seizure precautions were reviewed. (using seat belt, locking brakes with transfers, using transfer belt if applicable) ...." 6. A Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B on 9/14/2021 for Patient #12 indicated “… date of incident 9/11/2021 … refuses to sit in shower chair … slipped and fell down ….” A review of an untitled agency document dated 9/14/2021 and signed by the administrator indicated “… the gait belt is used for safety … would be able to grab the belt to keep … from falling to the floor ….” 7. A review of an agency document titled “Client Accident/ Incident Form” initiated by Employee B on 11/2/2021 for Patient #9 indicated “… date of incident 10/30/2021 … giving … shower … started to go down … grabbed … lowered … to the floor ….” A review of an untitled document signed by the administrator on 11/2/2021 indicated “… client to doctor to be evaluated on Monday 11/01/21 … diagnosed with torn rotator cuff in … right shoulder … instructed HHA this is still considered a “Near Miss” which needs to be reported … instructed that any further incidents/reports of injuries or concerns … agency would need to terminate … employment ….” 8. A review of an agency document titled “Disciplinary Notice” dated 11/18/2021, indicated “… Employee Name: [Name of Employee B] … [X] Written Warning … Statement of the problem … Client [Patient #6] Improper use of shower chair equipment, resulting in clients fall and injuries … Client [Patient #12] Fell in the shower while employee was providing care, no gait belt used … Client [Patient #9] had a near fall, employee grabbed … as a result suffered a torn rotator cuff [rip in the muscles and tendons of the shoulder joint] ….” 9. A review of an agency document titled “Disciplinary Notice” dated 11/18/2021, indicated “… Employee Name: [Name of Employee B … [X] Final Warning … Statement of the problem … client complaint … while being transported by employee … employee ran over street cones, ran a red light, and almost side swiped a car … Statement of company subject … final warning with counseling/ training, proper procedure for client care. Continuing violations will waive intended probation and potential termination ….” 10. During an interview on 1/7/2022 at 3:45 PM, the Business Operations Manager indicated the written and final warnings were reviewed on 11/18/2021 with Employee B because employee wasn’t able to come into the office until that date. 11. During an interview on 1/10/2022 at 10:25 AM, when asked where the re-training on 8/13/2021 with Employee B took place, Employee F indicated it took place over the phone. The documentation failed to evidence the registered nurse made an on-site patient visit to observe and assess the home health aide while performing care. 12. During an interview on 1/10/2022 at 1:48 PM, when asked what procedures are put into place when a HHA fails to perform a task correctly, the administrator indicated the HHA has to be checked off as performing correctly by a registered nurse before performing that task again. When asked where that check off takes place, the administrator indicated if the client is not available where the incident occurred, the nurse will go on-site with the HHA.

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 agency failed to document the resolution of complaints for 3 of 6 complaints reviewed (Patients #15, 17, 18, 19, 20, and 21). Findings include: 1. Review of an agency policy titled “Policy 2.000-Patient/ Client Rights” effective January 13, 2018, revealed a statement that the agency must “Document both the existence of the complaint and the resolution of the complaint ….” 2. Review of a document titled “Community Home Health Care Client Handbook” dated 2018, revealed a statement that “The organization (CHHC) [Community Home Health Care] investigates the complaint and resolution of the same.” The handbook also revealed a statement that “… will investigate your complaint and make every effort to resolve your issues.” 3. Review of a binder serving as the agency complaint log revealed complaints with no resolution. The binder contained an email dated 6/15/2021, which revealed a complaint from a group home staff regarding the care provided to Patients 20 and 21 by Employee S, HHA. The administrator documented the aide was removed from the group home and the administrator, “… spoke with [Name of Employee O, Business Office Manager] in H.R. [human resources] regard [sic] this ….” The binder failed to evidence follow up from human resources. 4. The binder contained an email dated 6/18/2021, which documented a complaint about Employee R, HHA, discussing his/ her personal religious beliefs and changing the TV channel to a religious program while the clients were listening to music. The complainant requested Employee R no longer provide care to Patients 17, 18, and 19. The administrator documented the aide was removed from that location and the administrator had forwarded the information to “… H.R. department to follow up on ….” The binder failed to evidence follow up from human resources. 5. The binder contained an email dated 9/22/2021, which revealed a complaint from a group home that Employee G, HHA, did not treat Patient 15 with respect, as Employee G “… rough with [Name of Patient 15] when he/ she transferred [Name of Patient 15] ….” Additionally, the staff complained Employee G spent most of his/her time sitting on the couch. Employee D, administrator, documented “… instructed [Name of Employee G] to continue to be careful … and [Name of administrator] would go out to assess the situation with the shower and [Name of Patient 15] not fitting,” as Patient 15’s legs were not able to bend and banged into the shower. The complaint log failed to evidence the outcome of the assessment regarding the shower. 6. During an interview on 1/10/2021 at 4:30 PM, Employee O indicated he/she writes the human resource follow-up on the complaint. 7. During an interview on 1/10/2021 at 4:45 pm, the administrator confirmed their process did not adequately resolve the complaints. 410 IAC-17-12-3(c)(2)

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the registered nurse failed to update the comprehensive assessment when a patient had a change in condition following a fall for 1 of 7 incident reports reviewed (Patient #6). Findings include: A review of an agency policy dated 7/2015, titled “Policy 2.040-Update of Comprehensive Assessment” indicated “…Registered Nurses will update the Comprehensive Nursing Assessment … as frequently as the patient’s condition requires … significant change in condition ….” Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B, HHA on 8/13/2021 for Patient #6 indicated “… date of accident/incident 8/12/21 … pulled shower chair tipping it over backwards … began to lift shower chair … back came off … fell backwards hitting … head on the floor of the shower room … had a seizure … put … in bed ….” The documentation failed to evidence the registered nurse made a visit to assess patient following the fall. Review of an Indiana Division of Disability and Rehabilitative Services document for Incident dated 8/14/2021, titled “Incident Initial Report” indicated “… ER [emergency room] visit with hospitalization … ER visit for … diagnostic studies in an attempt to determine the cause of the sudden onset of breakthrough seizures [seizure which occur despite the use of seizure medication] ..…head CT [series of x-ray images] done at ER showed … intra-cranial hemorrhage [bleeding inside the brain] ….” Review of an Indiana Division of Disability and Rehabilitative Services document for Follow-Up for the incident dated 9/2/2021, titled “Incident Follow-Up Report” indicated “… hematoma [bruising injury that causes blood to collect and pool under the skin] had reduced but damage to … brain remained … could not breathe on … own … placed on comfort measures … ventilator was removed … Patient #6 passed away on 9/1/2021 ….” During an interview on 1/10/2022 at 3:03 PM, when asked why an agency nurse did not make a visit to assess this patient after the fall, the administrator indicated the home health aide called the office nurse on 8/12/2021 and reported the patient did not have any injuries so a nurse visit wasn’t necessary. 410 IAC 17-14-1(a)(1)(B)

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 interviews, the agency failed to ensure patients are accepted for treatment on the reasonable expectation that they can meet the needs of patients (See G570); failed to ensure home health aide visits were provided as ordered by the physician on the plan of care and not reduced due to the agency's inability to staff (See G572); failed to ensure all patients’ plans of care included all required elements, such as all medications, measurable goals, and the types of equipment required (See G574). These deficient practices affected 6 of 7 records reviewed (Patient 2, 3, 4, 5, 6, 7) and have to potential to affect all 160 patients receiving home health services from this provider. The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate care and services which could result in the agency not providing quality health care, thus being out of compliance with the Condition of Participation 42 CFR 484.60 Care planning, Coordination, Quality of Care. In regards to G570, findings include: Based on record review and interviews, the agency failed to ensure patients are accepted for treatment on the reasonable expectation that they can meet the needs of patients for 4 of 7 Patient records reviewed. (Patients #1, 3, 5, 7) Findings include: 1. Review of an agency policy titled “Policy 2.010-Client Plan of Care,” with a revision date of September 2014, stated, “CHHC [Community Home Health Care] services are furnished to clients: … based on a plan of care … to ensure appropriate application of the services to the client’s condition.” 2. Record review for Patient #1 was completed on 1/6/2022, start of care date 2/3/2020, certification period 11/24/2021-1/22/2022, with a primary diagnosis of unspecified intellectual disabilities (impairment to the intelligence an individual possesses), and other diagnoses (but not limited to), epilepsy (central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), and schizoaffective disorder (mental health condition characterized by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). A review of documents titled “Missed Visit Note” for dates 12/16/2021-1/3/2022, indicated “… Reason for Cancellation/ Missed Visit … Cancelled by Agency-No Available Staff ….” The agency failed to meet the needs of this patient. During an interview on 1/7/2022 at 10:15 AM, the administrator indicated the assigned home health aide (HHA) was off due to bed bug infestation in own home and the group home did not want any other HHA to provide care. 3. Record review for patient # 3 was completed on 1/6/2022, start of care date 11/9/2017, contained a document titled “Home Health Certification and Plan of Care,” for certification period 10/19/2021 – 12/17/2021, revealed orders for “… HHA hourly 1.00 Hour Daily for 1 Certification Period(s) starting 10/19/2021 ….” In the 60-day summary section, the document stated there were “17 missed visit [s] this certification period for no available staff.” A review of a document titled “Home Health Certification and Plan of Care,” for certification period 12/18/2021 – 2/15/2022, revealed orders for “… HHA hourly 1.00 Daily for 1 Certification Period(s) starting 12/18/2021.” In the 60-day summary section, the document indicated there were “10 missed visit[s] this certification period for no available staff.” The agency failed to meet the needs of this patient. A review of a document provided by the administrator that lists the aide services received for the certification period of 12/18/2021 – 2/15/2022. The document revealed missed aide visits on 12/19/2021, 12/22/2021, 12/23/2021, 12/24/2021, 12/25/2021, 12/26/2021, 12/27/2021, and 12/28/2021. The agency failed to meet the needs of this patient. 4. Record review for Patient #5 was completed on 1/6/2022, start of care date 2/26/2020, contained a document titled “Home Health Certification and Plan of Care,” for certification period 10/18/2021 – 12/16/2021, revealed orders for “… HHA hourly 3.00 Hour Daily for 1 Certification Period(s) starting 10/18/2021.” In the 60-day summary section, the document indicated there were “62 missed visit[s] due to no available staff/ employee cancellations ….” A review of an email titled “[Name of Patient 5] pm hrs [p.m. hours]” from Employee F, RN, to the administrator and other agency staff. Email stated “… requesting that we discontinue [his/ her] PM hrs. [p.m. hours] as [Name of Patient 5] is pretty much never staffed in the evenings.” A review of a document titled “Revision to Plan of Care” dated 12/2/2021, identified a change in orders for home health aide services to “… 1.00 - 2.00 Hour Daily … 12/2/2021 – 12/16/2021 … Per group home provider request decrease HHA hrs [hours] to 2 hrs daily.” A review of a document titled “Home Health Certification and Plan of Care,” for certification period 12/17/2021 – 2/14/2022, revealed orders for “… HHA Hourly 1.00-2.00 Hour[s] Daily for 1 Certification Period(s) starting 12/17/2021.” In the 60-day summary section, the document indicated there were “61 missed HHA visits due to no available staff/ employee cancellations ….” The agency failed to meet the needs of this patient. A review of a document provided by the administrator lists the aide services received for the certification period of 12/17/2021 – 2/14/2022. The document revealed missed aide visits on 12/18/2021, 12/19/2021, 12/23/2021, 12/25/2021, 12/26/2021, 12/27/2021, 12/28/2021, 12/29/2021, 12/31/2021, 1/1/2022, 1/2/2022, and 1/3/2022. The agency failed to meet the needs of this patient. 5. Record review for Patient #7 was completed on 1/6/2022, start of care date 6/13/2019, contained a document titled “Home Health Certification and Plan of Care,” for certification period 9/30/2021 – 11/28/2021, revealed orders for “… HHA hourly 1.00 Hour Daily for 1 Certification Period(s) starting 9/30/2021.” In the 60-day summary section, the document indicated there were 13 missed visits, “… 11 due to inadequate staffing, and 2 due to employee missed visit.” A review of a document provided by the administrator lists the aide services received for the certification period of 12/17/2021 – 2/14/2022. The document revealed missed aide visits on 12/18/2021, 12/19/2021, 12/23/2021, 12/25/2021, 12/26/2021, 12/27/2021, 12/28/2021, 12/29/2021, 12/31/2021, 1/1/2022, 1/2/2022, and 1/3/2022. The agency failed to meet the needs of this patient. 6. During an interview on 1/7/2022 at 3:30 PM, the administrator confirmed there were missing visits for Patients 3, 5, and 7. 410 IAC 17-13-1(a)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aide visits were provided as ordered by the physician on the plan of care and not reduced due to the agency's inability to staff in 4 of 7 Patients (#1, 3, 5, 7). Findings include: Record review for patient #1 was reviewed on 1/6/2022, start of care date 2/3/2020, certification period 11/24/2021-1/22/2022, with a primary diagnosis of unspecified intellectual disabilities (impairment to the intelligence an individual possesses), and other diagnoses (but not limited to), epilepsy (central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), and schizoaffective disorder (mental health condition characterized by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). Review of documents titled “Missed Visit Note” for dates 12/16/2021-1/3/2022, indicated “… Reason for Cancellation/Missed Visit … Cancelled by Agency-No Available Staff ….” During an interview with on 1/7/2022 at 10:15 AM, administrator indicated the assigned HHA was off due to bed bugs and the group home did not want any other HHA to provide care. Clinical record for patient #6 was reviewed on 1/6/2022, start of care date 9/20/2019, certification period 7/11/2021-9/8/2021, with primary diagnosis of moderate intellectual disabilities (have fair communication skills, but cannot typically communicate on complex levels. Can care for selves but might need more instruction and support than the typical person), and other diagnoses (but not limited to), autistic disorder (developmental disorder that affects communication and behavior), epilepsy (central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), and cerebral palsy (group of disorders that affect movement and muscle tone or posture). Review of a document titled “Home Health Certification and Plan of Care” for certification period 7/11/2021-9/8/2021, identified “… HHA 2 hours daily 5 to 7 days per week … 60 day summary … 4 missed visits this cert [certification] period ... 1 d/t [due to] client not at home … 3 d/t transfer to hospital ….” 1. Review of an agency policy titled “Policy 2.035-Priority or ‘Must Cover’ Client Status” with a revision date of 4/1/2013, stated “… All clients will have designated backup systems in place prior to the start of care if they are not independent in their own homes. If agency coverage cannot be provided, the backup system will be implemented to care for the client.” 2. Record review for patient # 3 was completed on 1/6/2022, start of care date 11/9/2017, certification period 12/18/2021 – 2/15/2022, with a diagnosis of profound intellectual disabilities (Have very limited communication skills. Dependent on others for all aspects of daily care. Usually require 24-hour care and support). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 10/19/2021 – 12/17/2021, identified orders for “… HHA [Home Health Aide] hourly 1.00 Hour Daily for 1 Certification Period(s) starting 10/19/2021 ….” In the 60-day summary section, the document stated there were “17 missed visit [s] this certification period for no available staff.” Review of a document titled “Home Health Certification and Plan of Care,” for certification period 12/18/2021 – 2/15/2022, identified orders for “… HHA [Home Health Aide] hourly 1.00 Daily for 1 Certification Period(s) starting 12/18/2021.” In the 60-day summary section, the document stated there were “10 missed visit[s] this certification period for no available staff.” Review of a document provided by the administrator that lists the aide services received for the certification period of 12/18/2021 – 2/15/2022. The document identified missed aide visits on 12/19/2021, 12/22/2021, 12/23/2021, 12/24/2021, 12/25/2021, 12/26/2021, 12/27/2021, and 12/28/2021. 3. Record review for patient #5 was completed on 1/6/2022, start of care date 2/26/2020, certification period 12/17/2021 – 2/14/2022, with a diagnosis of Parkinson’s Disease (a brain deterioration causing involuntary movements and progressive loss of functioning). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 10/18/2021 – 12/16/2021, identified orders for “… HHA [Home Health Aide] hourly 3.00 Hour Daily for 1 Certification Period(s) starting 10/18/2021.” In the 60-day summary section, the document stated there were “62 missed visit[s] due to no available staff/employee cancellations ….” Review of an email titled “[Patient 5] pm hrs [hours]” from RN F to the administrator and other agency staff. Email stated “… requesting that we discontinue her PM hrs. [hours] as she is pretty much never staffed in the evenings.” Review of a document titled “Revision to Plan of Care” dated 12/2/2021, identified a change in orders for home health aide services to “… 1.00 - 2.00 Hour Daily … 12/2/2021 – 12/16/2021 … Per group home provider request decrease HHA [Home Health Aide] hrs [hours] to 2 hrs daily.” Review of a document titled “Home Health Certification and Plan of Care,” for certification period 12/17/2021 – 2/14/2022, identified orders for “… HHA [Home Health Aide] Hourly 1.00-2.00 Hour[s] Daily for 1 Certification Period(s) starting 12/17/2021.” In the 60-day summary section, the document stated there were “61 missed HHA visits due to no available staff/employee cancellations ….” Review of a document provided by the administrator that lists the aide services received for the certification period of 12/17/2021 – 2/14/2022. The document identified missed aide visits on 12/18/2021, 12/19/2021, 12/23/2021, 12/25/2021, 12/26/2021, 12/27/2021, 12/28/2021, 12/29/2021, 12/31/2021, 1/1/2022, 1/2/2022, and 1/3/2022. 4. Record review for patient #7 was completed on 1/6/2022, start of care date 6/13/2019, certification period 9/30/2021 – 11/28/2021, with a diagnosis of profound intellectual disabilities (Have very limited communication skills. Dependent on others for all aspects of daily care. Usually require 24-hour care and support). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 9/30/2021 – 11/28/2021, identified orders for “… HHA [Home Health Aide] hourly 1.00 Hour Daily for 1 Certification Period(s) starting 9/30/2021.” In the 60-day summary section, the document stated there were 13 missed visits, “… 11 due to inadequate staffing, and 2 due to employee missed visit.” 5. During an interview on 1/7/2022 at 3:30 PM, the administrator confirmed there were missing visits and indicated patients in group homes would have more missed visits as the group home staff would provide the care instead of the agency, per the "Must Cover" policy.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients’ plans of care included all required elements, such as all medications, measurable goals, and the types of equipment required for 6 of 7 plans of care reviewed (Patients #2, 3, 4, 5, 6,7). Findings include: Record review for patient # 3 was completed on 1/6/2022, start of care date 11/9/2017, certification period 12/18/2021 – 2/15/2022, with a diagnosis of profound intellectual disabilities (Have very limited communication skills. Dependent on others for all aspects of daily care. Usually require 24-hour care and support). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 12/17/2021 – 2/14/2022, identified a non-measurable goal of “Fall Precaution/Home Safety.” Record review for patient #5 was completed on 1/6/2022, start of care date 2/26/2020, certification period 12/17/2021 – 2/14/2022, with a diagnosis of Parkinson’s Disease (a brain deterioration causing involuntary movements and progressive loss of functioning). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 12/17/2021 – 2/14/2022, identified a non-measurable goal of “ADLs [activities of daily living] and personal care needs will be met safely with the assistance of the Paraprofessional.” Record review for patient #7 was completed on 1/6/2022, start of care date 6/13/2019, certification period 9/30/2021 – 11/28/2021, with a diagnosis of profound intellectual disabilities (Have very limited communication skills. Dependent on others for all aspects of daily care. Usually require 24-hour care and support). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 9/30/2021 – 11/28/2021, identified a non-measurable goal of “ADLs [activities of daily living] and personal care needs will be met safely with the assistance of the Paraprofessional.” During an interview on 1/6/2022 at 1:30 PM, the administrator confirmed the goals were not measurable and could be more specific. Review of an agency policy dated 1/2018, titled “Policy 3.014 Maintenance of Clinical Records” indicated “… contents of clinical record … medication administration … goals in the client’s plans of care ….” Review of an agency policy dated 9/2014, titled “Policy 2.010 Client Plan of Care” indicated “… client plan of care … includes … medication … appliances necessary … Record review for patient #2 was completed on 1/6/2022, start of care date 6/29/2020, certification period 12/21/2021-2/18/2022, with a primary diagnosis of dysphagia (difficulty swallowing), and other diagnoses (but not limited to), unspecified sequelae of cerebral infarction (residual effects of disrupted blood flow to the brain), and vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain) Review of a document titled “Home Health Certification and Plan of Care,” for certification period 12/21/2021 – 2/18/2022, indicated “… medications … cetirizine tablet … oral …norvasc … buccal [inside the cheek] … clonidine … oral … hydrocodone-acetaminophen … oral … melatonin … oral … other nutritional requirements/restrictions: NPO [nothing by mouth] ….” During an interview on 1/10/2022 at 3:18 PM, when asked why staff would document administering oral and buccal medication to a patient who is to take nothing by mouth, the administration indicated staff were not paying attention to the situation. Record review for patient #4 was completed on 1/6/2022, start of care date 5/6/2013, certification period 11/15/2021-1/13/2022, with a primary diagnosis of muscular dystrophy (progressive weakness and loss of muscle mass), and other diagnoses (but not limited to), encounter for attention to gastrostomy (visit to manage surgical opening into the stomach from the abdominal wall for the introduction of food). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 11/15/2021-1/13/2022, identified non-measurable goals of “ADLs [activities of daily living are basic tasks that must be accomplished every day] and personal care needs will be met safely with the assistance of the Paraprofessional [home health aide], Adheres to treatment/medication regimen, and Verbalizes progressive plan to ensure success and address risks, and monitor vital signs ….” During an interview on 1/7/2022 at 11:42 AM, when asked if the goals were measurable, the administrator indicated they are not measurable. Clinical record for patient #6 was reviewed on 1/6/2022, start of care date 9/20/2019, certification period 7/11/2021-9/8/2021, with primary diagnosis of moderate intellectual disabilities (have fair communication skills, but cannot typically communicate on complex levels. Can care for selves but might need more instruction and support than the typical person), and other diagnoses (but not limited to), autistic disorder (developmental disorder that affects communication and behavior), epilepsy (central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), and cerebral palsy (group of disorders that affect movement and muscle tone or posture). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 7/11/2021-9/8/2021, identified non-measurable goals of “Fall precautions/Home Safety.” 410 17-13-1(a)(1)(D)(ii,ix,xiii)

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 record review and interview, the registered nurse failed to assess patients when notified of falls for 4 of 7 incident reports reviewed (Patients #6,11,12) Findings include: 1. Review of an agency policy dated 6/2015, titled “Policy 2.002 Client Accident/ Incident” indicated “… all client accidents/ incidents are reported as soon as possible … to provide necessary timely interventions for clients involved in … incidents ….” 2. Review of an agency document titled “Client Accident/ Incident Form” initiated by Employee B, HHA on 8/13/2021 for Patient #6 indicated “… date of accident/incident 8/12/21 … pulled shower chair tipping it over backwards … began to lift shower chair … back came off … fell backwards hitting … head on the floor of the shower room … had a seizure … put … in bed ….” The documentation failed to evidence the registered nurse made a visit to assess the patient following the fall. 3. Review of an agency document titled “Client Accident/ Incident Form” initiated by Employee B, HHA (home health aide) on 9/14/2021 for Patient #12 indicated “… date of incident 9/11/2021 … refuses to sit in shower chair … slipped and fell down ….” The documentation failed to evidence the registered nurse made a visit to assess the patient following the fall. 4. Review of an agency document titled “Client Accident/ Incident Form” initiated by Employee J, HHA on 11/5/2020 for Patient #11 indicated “… date of incident … giving client a shower … leg bent on chair … fell ….” The documentation failed to evidence the registered nurse made a visit to assess the patient following the fall. A review of an agency document titled “Client Accident/ Incident Form” initiated by Employee K, HHA on 11/4/2020 for Patient #11, indicated “… date of incident … when sitting on the shower chair within 5 mins a leg bended causing client to fall on bottom ….” The documentation failed to evidence the registered nurse made a visit to assess the patient following the fall. 5. During an interview on 1/10/2022 at 3:03 PM, when asked why an agency nurse would not make a visit to assess a patient after a fall, the administrator indicated if the patient had not sustained injuries with a fall a nurse visit would not be necessary. 410 IAC 17-12-2 (g)

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aide (HHA) care plans were appropriate and specific to the needs of the patient (See G798); the agency failed to ensure that home health aides do not practice out of their scope of practice in regards to determining if a patient has an injury after a fall (See G800); the home health aides failed to ensure they notiied the registered nurse and/ or clinical manager of patient falls immediately per agency policy (See G804); and the Supervising Nurse failed to ensure they made on an on-site visit to ensure competency of a home health aide involved in 5 incidents between May 2021 to November 21, in which 2 of the 5 incidents resulted in patient injury (See G810). These deficient practices affected 2 of 7 patients receiving home health aide services (Patients 3 and 6) and 5 of 7 incident reports (Patients #6, 8, 9, 10,12) have the potential to affect all patients who are currently receiving home health aide services from this provider. The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate care and services which could result in the agency not providing quality health care, thus being out of compliance with Condition of Participation 42 CFR 484.80.

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 aide (HHA) care plans were appropriate and specific to the needs of the patient for 2 of 5 records review with HHA services (Patients #3, 6). Findings include: Observation of a home visit for patient #3, who is dependent on others for all personal care, occurred on 1/5/2022 at 10:30 AM, for personal care provided by HHA C. Observed dandruff shampoo in patient’s hygiene basket. Record review for patient #3 was completed on 1/6/2022, start of care date 11/9/2017, certification period 12/18/2021 – 2/15/2022, with a diagnosis of profound intellectual disabilities (Have very limited communication skills. Dependent on others for all aspects of daily care. Usually require 24-hour care and support). Review of a document titled “Home Health Certification and Plan of Care,” for certification period 12/18/2021 – 2/15/2022, identified an order for selenium sulfide external shampoo, as needed 5 times every 1 week(s) use 2 to 5 times per week for dandruff. Review of a document titled “Paraprofessional Assignment Sheet [home health Aide care plan]” dated 12/31/2019, indicated “ADL [activity of daily living] … Hygiene … Shampoo … Every visit.” The document failed to provide directions for the home health aide regarding the use of dandruff shampoo. During an interview on 1/7/2022 at 3:31 PM, the administrator confirmed the order for dandruff shampoo did not provide the specifics for when the aide should use the shampoo. 1. Review of an agency job description dated 11/21/2006, titled “Policy 5.044 Job Description: Registered Nurse” indicated “… develops written staff assignments according to … client needs … information regarding client needs and client plans of care are given to home health care staff members ….” Clinical record for patient #6 was reviewed on 1/6/2022, start of care date 9/20/2019, certification period 7/11/2021-9/8/2021, with primary diagnosis of moderate intellectual disabilities (have fair communication skills, but cannot typically communicate on complex levels. Can care for selves but might need more instruction and support than the typical person), and other diagnoses (but not limited to), autistic disorder (developmental disorder that affects communication and behavior), epilepsy (central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), and cerebral palsy (group of disorders that affect movement and muscle tone or posture). Review for certification period 7/11/2021-9/8/2021 evidenced a document titled “Home Health Certification and Plan of Care” dated 7/14/2021 which indicated “… HHA for 2 hours daily 5 to 7 days per week … activities permitted … helmet when OOB (out of bed) … narratives/comments … had seizure while group home staff had client in shower chair … client has a helmet that is worn when up due to seizure disorder ….” Review evidenced a document titled “Paraprofessional Assignment Sheet [home health aide care plan]” dated 7/6/2021, which indicated “… safety precautions … helmet on when OOB … hair care … every visit … shampoo … every visit ….” The document failed to evidence for the HHA instructions on how to provide hair care and shampoo with helmet in place. During an interview on 1/7/2022 at 12:50 PM, when asked what directions are provided to the home health aide regarding the helmet during a shampoo, the administrator indicated the home health aide care plan in comments section should indicate removal of helmet during shower.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that home health aides do not practice out of their scope of practice in regards to determining if a patient has an injury after a fall for 4 of 7 (Patient #6, 9, 11, 12) incidents reviewed in which 2 of the 4 (Patient #6 and 9) incidents resulted in an injury. Findings include: 1. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B, HHA on 8/13/2021 for Patient #6 indicated “… date of accident/incident 8/12/21 … pulled shower chair tipping it over backwards … began to lift shower chair … back came off … fell backwards hitting … head on the floor of the shower room … had a seizure … put … in bed ….” Review of an Indiana Division of Disability and Rehabilitative Services document for Incident dated 8/14/2021, titled “Incident Initial Report” indicated “… ER [emergency room] visit with hospitalization … ER visit for … diagnostic studies in an attempt to determine the cause of the sudden onset of breakthrough seizures [seizure which occur despite the use of seizure medication] ..…head CT [series of x-ray images] done at ER showed … intra-cranial hemorrhage [bleeding inside the brain] ….” Review of an Indiana Division of Disability and Rehabilitative Services document for Follow-Up for the incident dated 9/2/2021, titled “Incident Follow-Up Report” indicated “… hematoma [bruising injury that causes blood to collect and pool under the skin] had reduced but damage to … brain remained … could not breathe on … own … placed on comfort measures … ventilator was removed … Patient #6 passed away on 9/1/2021 ….” 2. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B on 11/2/2021 for Patient #9 indicated “… date of incident 10/30/2021 … giving … shower … started to go down … grabbed … lowered … to the floor ….” A review of an untitled document signed by the administrator on 11/2/2021 indicated “… client to doctor to be evaluated on Monday 11/01/21 … diagnosed with torn rotator cuff in … right shoulder … “ 3. Review of an agency document titled “Client Accident/ Incident Form” initiated by Employee B, HHA (home health aide) on 9/14/2021 for Patient #12 indicated “… date of incident 9/11/2021 … refuses to sit in shower chair … slipped and fell down ….” 4. Review of an agency document titled “Client Accident/ Incident Form” initiated by Employee J, HHA on 11/5/2020 for Patient #11 indicated “… date of incident … giving client a shower … leg bent on chair … fell ….” A review of an agency document titled “Client Accident/ Incident Form” initiated by Employee K, HHA on 11/4/2020 for Patient #11, indicated “… date of incident … when sitting on the shower chair within 5 mins a leg bended [sic] causing client to fall on bottom ….” 5. During an interview on 1/10/2022 at 3:03 PM, when asked why an agency nurse did not make a visit to assess this patient after the fall, the administrator indicated the home health aide called the office nurse on 8/12/2021 and reported the patient did not have any injuries so a nurse visit wasn’t necessary.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health aides failed to ensure they notifed the registered nurse and/ or clinical manager of patient falls immediately per agency policy for 5 of 7 incident reports reviewed (Patients #6, 8, 9,10,12). Findings include: 1. Review of an agency policy dated 6/2015, titled “Policy 2.002 Client Accident/Incident” indicated “… all client accidents/incidents are reported as soon as possible ….” 2. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B, HHA (home health aide) on 8/13/2021 for Patient #6 indicated “… date of accident/incident 8/12/21 … pulled shower chair tipping it over backwards … began to lift shower chair … back came off … fell backwards hitting … head on the floor of the shower room … had a seizure … put … in bed ….” The documentation failed to evidence the HHA reported the fall to the registered nurse and/ or clinical manager in a timely manner. Review of Indiana Division of Disability and Rehabilitative Services document titled “Incident Initial Report” submitted by Employee F, RN on 8/13/2021, indicated “… narrative … HHA instructed on proper use of DMEs [durable medical equipment shower chair] as well as keeping helmet on aside from showering for safety … received education on submitting incident reports on same day ….” 3. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee C, HHA on 12/31/2021 for Patient #8 indicated “… date of accident/ incident 12/30/2021 … client getting ready to sit on the toilet … client slipped … to the floor ….” Employee N, RN [registered nurse] indicated “…HHA reported incident 12/31/21 which was late ….” The documentation failed to evidence the HHA reported the fall to the registered nurse and/ or clinical manager in a timely manner. 4. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B on 11/2/2021 for Patient #9 indicated “… date of incident 10/30/2021 … giving … shower … started to go down … grabbed … lowered … to the floor ….” The documentation failed to evidence the HHA reported the fall to the registered nurse and/ or clinical manager in a timely manner. Review of an untitled document signed by the administrator on 11/2/2021 indicated “… client to doctor to be evaluated on Monday 11/01/21 … diagnosed with torn rotator cuff in … right shoulder … instructed HHA this is still considered a “Near Miss” which needs to be reported … instructed that any further incidents/reports of injuries or concerns … agency would need to terminate … employment ….” 5. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B on 9/14/2021 for Patient #12 indicated “… date of incident 9/11/2021 … refuses to sit in shower chair … slipped and fell down ….” The documentation failed to evidence the HHA reported the fall to the registered nurse and/ or clinical manager in a timely manner. Review of Indiana Division of Disability and Rehabilitative Services document titled “Incident Initial Report” submitted by the administrator on 9/14/2021, indicated “… narrative … HHA contacted by writer [Name of Administrator], on Tuesday 9/14, to come today and complete incident form … instructed … using gait belt for safety during ambulation [walking] and showering ….” 6. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B on 5/17/2021 for Patient #10 indicated “… date of incident 5/15/2021 … started to slide to the floor … eased … to the floor ….” The administrator indicated “… needs to report this to the agency as this is a near miss ….” The documentation failed to evidence the HHA reported the fall to the registered nurse and/ or clinical manager in a timely manner. Review of Indiana Division of Disability and Rehabilitative Services document titled “Incident Initial Report” submitted by the administrator on 5/17/2021, indicated “… narrative … instructed HHA that … needed to report this on 5/15/21 as this is a near miss ….” 7. During an interview on 1/6/2022 at 11:30 AM, when asked who the HHA is to contact when a patient has an incident such as a fall, Employee F, RN indicated during office hours the HHA is to call into the office and notify an office nurse who will forward the information to registered nurse. 410 IAC 17-14-1 (m)

If concern identified, direct observation CFR(s): 484.80(h)(1)(ii) If an area of concern in aide services is noted by the supervising registered nurse or other appropriate skilled professional, then the supervising individual must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Supervising Nurse failed to ensure made on an on-site visit to ensure competency of a home health aide (Employee B) involved in 5 incidents between May 2021 to November 21, in which 2 of the 5 incidents resulted in patient injury (Patient #6, 9,10,12). Findings include: 1. Review of an agency job description dated 11/21/2006, titled "Policy 5.044 Job Description: Registered Nurse" indicated "... supervises ... Home Health Aides ... monitoring of home health services delivered by home health staff members is demonstrated ... participation in needs assessment of home health staff members is demonstrated … education programs to address home health care staff members’ needs is demonstrated ….” 2. Review of an agency document titled “Client Accident/ Incident Form” initiated by Employee B, HHA for Patient #6 on 8/13/2021 indicated “… date of accident/ incident 8/12/21 … pulled shower chair tipping it over backwards … began to lift shower chair … back came off … fell backwards hitting … head on the floor of the shower room … had a seizure … put … in bed ….” Review of an untitled agency document dated 8/13/2021 and signed by Employee F, RN and Employee B indicated "... instructed on the correct use of DMES [medical equipment] (not tipping shower chair back) ... keeping helmet on aside from showering for safety ... general fall/ safety/ seizure precautions were reviewed. (using seat belt, locking brakes with transfers, using transfer belt if applicable) ...." During an interview on 1/10/2022 at 10:25 AM, when asked where the re-training on 8/13/2021 with Employee B took place, Employee F indicated it took place over the phone. The documentation failed to evidence the registered nurse made an on-site patient visit to observe and assess the home health aide while performing care. 3. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B on 11/2/2021 for Patient #9 indicated “… date of incident 10/30/2021 … giving … shower … started to go down … grabbed … lowered … to the floor ….” Review of untitled document signed by the administrator on 11/2/2021 indicated “… client to doctor to be evaluated on Monday 11/01/21 … diagnosed with torn rotator cuff in … right shoulder … instructed HHA this is still considered a “Near Miss” which needs to be reported … instructed that any further incidents/reports of injuries or concerns … agency would need to terminate … employment ….” The documentation failed to evidence the registered nurse made an on-site patient visit to observe and assess the home health aide while performing care. 4. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B on 9/14/2021 for Patient #12 indicated “… date of incident 9/11/2021 … refuses to sit in shower chair … slipped and fell down ….” A review of an untitled agency document dated 9/14/2021 and signed by the administrator indicated “… the gait belt is used for safety … would be able to grab the belt to keep … from falling to the floor ….” The documentation failed to evidence the registered nurse made an on-site patient visit to observe and assess the home health aide while performing care. 5. Review of an agency document titled “Client Accident/Incident Form” initiated by Employee B, HHA on 5/17/2021 for Patient #10 indicated “… date of incident 5/15/2021 … started to slide to the floor … eased … to the floor ….” Employee D, administrator indicated “… needs to report this to the agency as this is a near miss ….” Review of Indiana Division of Disability and Rehabilitative Services document titled “Incident Initial Report” submitted by the administrator on 5/17/2021, indicated “… narrative … instructed HHA that … needed to report this on 5/15/21 as this is a near miss ….” The documentation failed to evidence the registered nurse made an on-site patient visit to observe and assess the home health aide while performing care. 6. During an interview on 1/10/2022 at 1:48 PM, when asked what procedures are put into place when a HHA fails to perform a task correctly, the administrator indicated the HHA has to be checked off as performing correctly by a registered nurse before performing that task again. When asked where that check off takes place, the administrator indicated if the client is not available where the incident occurred, the nurse will go on-site with the HHA.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review, the Governing Body failed to ensure their policy did not put the patient or patient representative responsible for providing care and failed to ensure their policy included a plan to ensure no patient went without services when the agency’s designated employee(s) was not available. Findings include: Review of an agency policy titled “Policy 2.035-Priority or ‘Must Cover’ Client Status” with a revision date of 4/1/2013, stated “… All clients will have designated backup systems in place prior to the start of care if they are not independent in their own homes. If agency coverage cannot be provided, the backup system will be implemented to care for the client.” According to 484.60 Condition of Participation for Care planning, coordination of Services, and quality of care, it states “Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative needs in his or her place of residence. The agency failed to ensure its policy reflects how the agency will provide services when the designated employee is not available to provide care.