Every finding on record at Elder's Journey Home Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 06/10/2024-06/14/2024 & 06/17/2024-06/18/2024 Active Census: 434 At this Emergency Preparedness survey, Elder's Journey Home Care LLC was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to implement a full-scale emergency training and testing program for 1 of 1 Emergency Preparedness Program reviewed. Findings include: A revised policy dated October 2017 titled "Emergency Operations Plan (EOP) Training Program" indicated the agency would provide emergency preparedness testing and training at least annually, to include a full-scale exercise that is community-based or a facility-based exercise; conduct an additional exercise that can be a second full-scale exercise that is community-based or a tabletop exercise led by a faciliatory; Exercises must sufficiently stress agency's plan to identify weaknesses. During an interview on 06/17/2024 at 1:45 PM, the Performance Improvement Manager indicated she attended the 2023 and 2024 Coalition, where multiple scenarios were conducted in multiple counties. The performance improvement manager indicated she was the only agency person who had attended the Coalition emergency preparedness drill. The performance Improvement Manager indicated she provided information about the Coalition experience to the agency during a Manager's Meeting on 06/01/2023 for the 2023 Coalition and 04/18/2024 Managers Meeting for the 2024 Coalition; the Managers then provided education to the nursing staff during the Nursing Case Conference on 06/13/2023 and 05/14/2024; during the 4th quarter of the year, an ADP training on Preparing for an Emergency was sent out to all aide staff. The Performance Improvement Manager indicated she did not know where to find Emergency Preparedness regulations.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 06/10/2024-06/14/2023 & 06/17/2024-06/18/2024 12 Month Unduplicated Skilled Admissions: 626 An Extended Survey was announced on 06/13/2024 at 8:40 AM. An Immediate Jeopardy related to 42 CFR §484.60: Care planning, coordination of services, and quality of care was identified on 06/06/2024 when it was identified that a PSA agency called the agency to report a patient wound. The agency did not coordinate with the physician to obtain an order for a visit and waited to evaluate the wound 6 days later. The agency did not ensure the home health aide followed the aide's plan of care regarding bathing and personal hygiene. The Administrator was notified of an Immediate Jeopardy on 06/17/2024 at 11:15 AM. An unacceptable removal plan for the Immediate Jeopardy was received on 06/18/2024 at 12:54 PM. The Immediate Jeopardy was unremoved at the time of exit on 06/18/2024. During this Federal Recertification Survey, Elder's Journey Home Care LLC was found to be out of compliance with Condition of Participation §484.45 Reporting OASIS information; Condition of Participation §484.50 Patient Rights; Condition of Participation §484.55: Comprehensive Assessment of Patients; Conditions of Participation §484.60 Care planning, coordination of services, and quality of care; and Condition of Participation §484.80 Home Health Aide Services. QR Completed 06/19/2024 by A4

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 1 of 1 Agency Error Summary Report review. Findings include: A policy titled "Encoding and Reporting OASIS Data" was provided by the Director of Clinical Services (DCS) on 06/10/2024. The policy indicated that the OASIS (Outcome and Assessment Information Set) was to be submitted to CMS within 30 days of completing the assessment of the patient. A review of the Agency Error Summary Report dated 10/01/2023 to 06/10/2024 indicated error -3333 (late assessment submissions). The report evidenced 443 assessments with errors, and the percentage of assessment errors was 37.7%. The agency failed to submit all OASIS assessments within 30 days of completing the patient's assessment. During an interview on 06/11/2024 at 11:30 AM, Quality Assurance 2 was asked to explain why the agency had late assessment submission errors. Quality Assurance 2 stated the late OASIS submission assessments were due to Covid-19 (virus) and the nursing crisis. The Director of Clinical Services stated that the agency was working on hiring more nurses to address the issue. During an interview on 06/18/2024 at 10:47 AM, the Administrator and Performance Improvement Manager stated that they do not track OASIS items such as potential avoidable events (discharge to community with pressure ulcers, behaviors, and medication errors) or OASIS submissions. They stated that this was information to them and were not previously aware of the number of late OASIS submissions obtained from CMS.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the agency provided services as ordered on the plan of care (See tag G436); failed to notify the patient or physician before discharge for cause (See tag G464); and failed to provide patients with contact information for providers able to provide care (See tag G448) The cumulative effect of this systemic problem resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.50 Patient Rights.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered on the plan of care (POC) for 2 of 6 active record reviews. (Patients #5 ,#6) Findings include: 3. A review of Patient #6's record, certification period 02/15/2023 to 04/15/2023, included a Home Health Certification and Plan of Care with orders for skilled nursing services 1 hour a day, one day a week for 26 duration of certification period and home health aide services 4 hours a day, three days a week for the duration of the certification period. The agency failed to provide skilled nursing services from 02/15/2023 to 03/21/2023 and failed to document a reason why. During an interview on 06/17/2024 at 2:18 PM, the QA Nurse 2 indicated the agency process from referral to first scheduled home visit is as follows: A referral is received. A visit is made to the patient's home, where a hands-off assessment is conducted (there is no date/time or record of this assessment). The agency then creates a Home Health Certification and Plan of Care/485 that is sent to physicians and Medicaid. No visits are provided to patients until Medicaid authorization has been received unless the patient has an immediate need, such as IV medication or wound care. Once Medicaid authorization is received, the agency will conduct an admission visit to collect the OASIS (Outcome and Assessment Information Set) assessment. A Home Health Plan of Care and Certification (New POC) is created with a new certification period. Services are started at that time. 1. An undated document titled "Patient Bill of Rights" was provided by the Administrator on 06/13/2024. The document indicated that the Patient should receive all services outlined in the plan of care (POC). 2. A review of Patient #5's record for the certification period of 03/23/2023 to 05/21/2023, with a SOC date of 03/09/2023, included a Home Health Certificate and Plan of Care with orders for home health aide (HHA) services two hours a day two days a week. The agency failed to provide HHA services from 03/09/2023 to 04/24/2023 and failed to provide evidence as to why the agency did not provide services. During an interview on 06/17/2024 at 2:18 PM, the Quality Assurance (QA) Nurse 2 indicated the Patient would not receive services until the agency received Medicaid authorization.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the patient or physician prior to discharge for cause for 1 of 5 closed records reviewed. (Patient #1). Findings include: A policy titled "Client Discharge Process" indicated, but was not limited to, "Criteria for discharge…The client's care has become such that it is unsafe and medically inappropriate to maintain the client in his/her home". The Clinical Record for Patient #1, certification period 01/14/2023-03/14/2023, Start of Care (SOC) date of 08/11/2022, included a discharge summary dated 03/07/2023 sent to the provider via fax indicating Patient #1's services were terminated due to unsanitary work environment. Patient #1’s record included a letter dated 03/07/2023 sent via certified mail to the patient indicating the agency had contacted the wound care center to request they assist the patient with finding another agency to provide care. The record included a Skilled Nursing Visit Note dated 02/13/2023 that indicated patient had deplorable living conditions and unsafe living condition. The record included Skilled Nursing Visit Notes between 02/17/2023-03/06/2023 from RN 6 failed to include documentation of unsafe or unsanitary home conditions. The record failed to evidence notification to the patient and/or physician prior to discharge for cause. During an interview on 06/12/2024 at 9:58 AM, the Director of Clinical Services indicated a discharge order and summary was sent to the wound center and requested this facility assist the patient with finding another home health agency to take over patient care, however, indicated this information was not documented in the patient's record. During a phone interview on 06/13/2024 at 12:24 PM, Patient #1 indicated patient was discharged on 03/07/2024 for unknown reason, never received a list of resources for providers to continue home health care, and the agency suddenly stopped coming to patient's home to provide care. During a phone interview on 06/13/2024 at 1:02 PM, RN 6 indicated Patient #1 had received a visit from RN 7 on 02/13/2023 that indicated patient had unsafe living conditions. RN 6 indicated Patient #1 home conditions had improved and RN 6 had continued patient care from 02/17/23 through 03/06/2023 and RN 6 felt comfortable to continue providing care to patient in patient's home. RN 6 indicated being unsure of who discharged the patient from the agency. RN 6 indicated neither patient nor physician was notified prior to patient being discharged. 410 IAC 17-12-2(i)

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide patients with contact information for providers able to provide care for 2 of 5 discharge record reviews (Patient #1, #2). Findings include: 3.A review of Patient #5's record for the certification period of 03/23/2023 to 05/21/2023, with a SOC date of 03/09/2023, included a Home Health Certificate and Plan of Care with orders for home health aide (HHA) services two hours a day two days a week. The agency failed to provide HHA services from 03/09/2023 to 04/24/2023 and failed to provide evidence as to why the agency did not provide services. During an interview on 06/17/2024 at 2:18 PM, the Quality Assurance (QA) Nurse 2 indicated the Patient would not receive services until the agency received Medicaid authorization. 4. A record review on Patient # 2, certification period 05/01/2024 to 06/30/2024, included a copy of a mailed letter sent to Patient #2 indicating the agency was discharging the patient but did not provide information on other agencies that could assist the patient with wound care at home. No other documentation of information on other agencies was available in the community found in Patient #2's chart. During an interview on 06/12/2024 at 9:15 AM, the Director of Clinical Services indicated the agency did not assist Patient #2 with getting other agencies to provide care. The Director of Clinical Services indicated she looked in emails and Patient #2's chart but could not locate information that the agency provided a list of other agencies to the patient. 5. During an interview on 06/12/2024 at 9:15 AM, the Director of Clinical Services indicated Patient #1 and Patient #2 do not have documentation in their charts of communication with other agencies to set up services before or after patients were discharged. 1. A policy titled "Client Discharge Process" indicated, but was not limited to, "The Registered Nurse shall review the clinical record to assure accuracy and completion. A Discharge Plan shall be developed that is documented in writing and includes all written/verbal instruction regarding the client's ongoing care needs and available resources provided to the client and family". 3. The Clinical Record for Patient #1, certification period 01/14/2023-03/14/2023, Start of Care (SOC) date of 08/11/2022, included a discharge summary dated 03/07/2023 indicating Patient #1's services were terminated due to unsanitary work environment. Patient #1 record included a letter dated 03/07/2023 sent via certified mail to the patient indicating the agency had contacted the wound care center to request they assist the patient with finding another agency to provide care. The record failed to evidence a detailed discharge summary that aligned with the agency discharge summary. The record failed to evidence resources being provided to the patient at the time of discharge. During an interview on 06/12/2024 at 9:58 AM, the Director of Clinical Services indicated a discharge order and summary was sent to Indiana University Health Wound Care Center and requested this facility assist the patient with finding another home health agency to take over patient care, however, indicated all of this information was not documented in the patient's record. During a phone interview on 06/13/2024 at 12:24 PM, Patient #1 indicated patient was discharged on 03/07/2024 for unknown reason, never received a list of resources for providers to continue home health care, and the agency suddenly stopped coming to patient's home to provide care. During a phone interview on 06/13/2024 at 1:02 PM, RN 6 indicated patient had not been given a list of resources to provide home health care prior to discharge.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to complete an initial assessment within 48 hours of a referral (See tag G514) and failed to ensure staff completed an accurate, comprehensive assessment that reflected the patient's health status (See tag G528). The cumulative effect of the deficient practice resulted in the agency's noncompliance with Condition of Participation §484.55: Comprehensive Assessment of Patients. The cumulative effect of the deficient practice resulted in the agency's noncompliance with Condition of Participation §484.55: Comprehensive Assessment of Patients.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to complete an initial assessment within 48 hours of a referral for 3 of 8 full chart reviews with skilled nursing services. (Patient #2, #5, #6) Findings include: 3. A review of Patient #5's record included a Home Health Plan of Care & Certification, certification period 03/23/2023 to 05/21/2024, SOC date 03/09/2023, and the Oasis assessment date of 03/23/2023. The record failed to evidence a physician referral order. The agency failed to contact the patient for the first visit or complete the initial assessment within 48 hours of the referral. During an interview on 06/17/2024 at 2:18 PM, QA Nurse 2 provided copies of emails that were sent to other Elder Journey employees that were not part of the Patient record and did not clearly identify a referral date. QA Nurse 2 was asked to identify which email was the referral date to which she pointed to "03/20". 410 IAC 17-14-1 (a)(1)(A) 1. An undated Policy titled "Admission Policy" indicated that Home care referrals should, at a minimum, include Client identifying data, medications, treatments required, Physician and reimbursement information, and other pertinent information; the initial assessment will be completed within forty-eight hours of referral. 2. A review of Patient #2's record included a Home Health Plan of Care & Certification with certification period 05/01/2023 to 06/27/2023, a start of care (SOC) date 05/01/2023, and the Oasis assessment date of 04/29/2023; no referral order from physician in patient chart; a Signup attempt 1, dated 04/17/2023. The agency failed to contact the patient for the first visit or complete the initial assessment within 48 hours of the referral. 4. A review of Patient #6's record included a Home Health Plan of Care & Certification with a certification period of 03/14/2023 to 05/12/2023, a start of care (SOC) date of 03/20/2023 and the Oasis assessment date of 03/20/2023; no referral order from a Physician in the patient chart. The agency failed to complete the initial assessment within 48 hours of the referral.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency staff failed to complete an accurate, comprehensive assessment that reflected the patient's health status for 1 of 2 home visit observations. (RN 1) Findings include: A policy titled "Comprehensive Client Assessment" indicated the purpose of the assessment was to determine appropriate care, treatment, and services to meet the patient's changing needs. The comprehensive assessment must accurately reflect the patient's status. A 2014 National Pressure Ulcer Advisory Panel (NPUAP) article titled Prevention and Treatment of Pressure Ulcers: Quick Reference Guide indicated a comprehensive skin assessment should be conducted as soon as possible but within 8 hours of reporting for individuals who are a risk for pressure ulcers. The skin assessment should include skin temperature, edema, and change in tissue consistency in relation to surrounding tissue. The assessment should differentiate whether the skin redness was blanchable or non-blanchable (redness or discoloration disappears when pressure is applied). On 6/6/2024, a Case Conference note indicated that Entity 2, a Personal Service Attendant (PSA) provider, called to report that Patient #5 had an open area on their buttocks. During a recertification home visit on 06/12/2024 at 10:30 AM, Registered Nurse (RN) 1 failed to assess Patient #5's chest, back, under breast, peri-area, bilateral upper and lower legs, soles of feet, and bottom portion of the buttocks. RN 1 failed to measure an open area surrounded by red/purple discoloration on Patient #5's right buttock and failed to measure red/purple discoloration on the left buttock and tailbone area. Patient #5 stated they lost their dentures. Patient #5 said they do not use the wheelchair because maneuvering is too hard. RN 1 asked the Patient if they could walk to their bed. Patient #5 stated they could but could pivot transfer with help to the seat of the rolling walker. Patient #5 then propelled the rolling walker backward using their feat. RN 1 wrote her notes in a notebook. RN 1 failed to use the OASIS (comprehensive assessment) form during the assessment. RN 1 failed to accurately complete a head-to-toe assessment and record the data on the OASIS. During an interview at the home visit, RN 1 stated that the wound looked like a bedsore and was about 3 cm x 2 cm. RN 1 stated that she thought she was able to walk. Entity 2, the PSA provider, said that she had cared for the Patient for a year and had never seen the Patient walk. At that time, RN 1 stated she was waiting to document her assessment at home on an electronic tablet. RN 1 stated she does not provide hands-on care. A review of Patient #5's record on 06/13/2024 included the OASIS document from the home visit on 06/12/2024. The OASIS indicated measurements of the open area to the right buttock as 3 cm length by 2 cm width with no depth recorded. The OASIS indicated that Patient #5 had dentures, no problems with eating, and was able to transfer to a wheelchair. At the home visit, Patient #5 stated they lost their dentures. During an interview on 06/13/2024 at 1:30 PM, home health aide (HHA) 1 stated that despite being ordered on the plan of care, they do not offer Patient #5 a shower, shampoo, or bath. If Patient #5 wanted a bath, they would have to ask. They only do what the patient tells them to do. HHA 1 stated she was not sure what the other provider does. During an interview on 06/12/2024 at 2:30 PM, the Director of Clinical Services (DCS) stated that the expectation was for the nurse to do a head-to-toe assessment at recertification. Staff are to use a plastic measuring tool to measure wounds. She stated that they use the OASIS form as the comprehensive assessment. DCS was not able to give a reason why she falsified the OASIS document. 410 IAC 17-4-1(a)(1)(A)

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 observation, record review, and interview, the agency failed to accurately assess, measure, and manage a patient's wound promptly, coordinate care effectively with the provider and PSA agency, and provide immediate care to meet the patient's overall needs (See tag G570); failed to have a signed plan of care (POC) or a verbal POC order from the primary Physician before providing services and treatments to patients (See tag G572); failed to ensure the Plan of Care (POC) included mental status specific to person, place, and time; failed to ensure the POC included all medications; and failed to ensure the POC included a current and complete list of Durable Medical Equipment (DME) and Supplies (See tag G574), failed to ensure the Registered Nurse (RN) provided services as ordered by the physician (See tag G580), and failed to coordinate care with a physician regarding a patient's wound. (See tag G608). An Immediate Jeopardy related to Condition of Participation §484.60: Care planning, coordination of services, and quality of care was identified on 06/06/2024 and announced on 06/17/2024 at 11:15 AM. An unacceptable removal plan for the Immediate Jeopardy was received on 06/18/2024 at 12:54 PM. The Immediate Jeopardy was unremoved at the time of exit on 06/18/2024. 410 IAc 17-13-1(a) 1. A policy titled "Plan of Care" was provided by the Director of Clinical Services (DCS) on 06/10/2024. The policy indicated that the agency addresses the care, treatment, and services provided. The Patient and other agency staff shall participate in the development of the plan of care and any changes that would alter it. Staff will obtain additional visit orders accompanied by a description of the Patient's needs that could warrant a visit. 2. A policy titled "Wound Measurement" was provided by the Director of Clinical Services (DCS) on 6/10/2024. The policy indicated that nursing staff were to measure wounds at minimum weekly. 3. A policy titled "Admission Policy" was provided by the Administrator on 06/14/2024. The policy indicated that skilled nursing and home health aide services should follow a written plan of care. 4. A job description titled "Home Health Aide" was provided by the Director of Clinical Services (DCS) on 06/11/2024. The description indicated that the aide was to report patient condition changes to the Registered Nurse (RN), perform personal care activities such as bathing, shampooing, skincare, and other related duties, and promote a safe patient environment. 5. A 2014 NPUAP article titled Prevention and Treatment of Pressure Ulcers: Quick Reference Guide indicated a comprehensive skin assessment should be conducted as soon as possible but within 8 hours of reporting for individuals who are a risk for pressure ulcers. The skin assessment should include skin temperature, edema, and change in tissue consistency in relation to surrounding tissue. The assessment should differentiate whether the skin redness was blanchable or non-blanchable ( redness or discoloration disappears when pressure is applied). 6. On 6/6/2024, a Case Conference note indicated that Entity 2, a Personal Service Attendant (PSA) provider, called to report that Patient #5 had an open area on their buttocks. The Registered Nurse Case Manager (RNCM), physician, and Case Manager (CM) were notified. The nurse advised Patient #5 to contact their physician for an appointment if they felt the area needed attention before the RNCM visit. The next RNCM visit, scheduled for 06/12/2024, was for a recertification visit for home health aide services. The agency failed to evidence documentation that an order was obtained to assess the patient's wound promptly. Surveyors accompanied RN 1 during a home visit on 06/12/2024. During a recertification home visit for Patient #5 on 06/12/2024 at 10:30 AM, RN 1 failed to measure the open area and surrounding deep, purple-redness with a measuring tool on Patient #5's right buttock. RN 1 indicated it resembled a bedsore and estimated it to be about 3 centimeters (cm) X 2cm. RN 1 instructed the Patient to apply Destin (skin barrier cream) or A & D (ointment) over the open area until the Patient called the physician. RN 1 mentioned that she does not provide direct hands-on care. RN 1 failed to assess the wound per professional standards and failed to notify the physician at the home visit. The agency failed to measure the bedsore correctly. During an interview at the home visit on 06/12/2024 at 10:30 AM, Patient #5 said they could not recall the last time they had a shower, bed bath, or shampoo. RN 1, HHA 1, and the PSA provider were present during the interview. Patient #5 mentioned experiencing diarrhea every time they eat. Patient #5 said they avoid lying in bed because people keep putting things on it. Entity 2, the PSA provider, said that the Patient remains in the reclining chair all day and does not lie down or walk. Patient #5 sits in their urine and waits until the caregiver from Elders Journey is finished caring for a family member. The PSA provider expressed concerns about the Patient not receiving the necessary care. The PSA provider stated she does not know when the Patient received a bath and that there was poor communication and coordination with the home health aide and nurse from Elders Journey. RN 1 stated there has been a decline in Patient #5's overall health. During an interview at the home visit on 06/12/2024 at 10:30 AM, neither Entity 2, the PSA provider, nor Home Health Aide (HHA) 1 could remember the last time they bathed Patient #5. RN 1 did not know when the staff bathed the Patient. A review of the Aide's Plan of Care indicated the Patient was to receive shower/bath and toileting assistance at every visit. The agency failed to meet the Patient's needs outlined in the Aide POC. During an interview on 06/12/2024 at 2:30 PM, the Director of Clinical Services (DCS) stated that the agency provides hands-off care. Staff can visually assess the wound, but the agency does not manage it. The agency can ask the Patient if they want skilled nursing services. During a phone interview on 06/13/2024 at 1:30 PM, HHA 1 indicated they do not offer a shower or bath to Patient #5 despite it being ordered on the plan of care. She stated that if Patient #5 wanted a bath, they would ask. HHA 1 said they do what the Patient tells them to do. HHA 1 stated that if the Patient refused care, they would mark it as refused and report it to the nurse. The agency HHA failed to follow the Aide POC. A Review of Patient #5's Aide Visit Notes between 04/20/2024 and 06/14/2024 indicated that specific tasks such as showering, bathing, shampooing hair, and checking for pressure points were to be performed at each visit. The Aide Visit Notes indicated that these tasks were not completed for 15 consecutive visits because they were deemed unnecessary. There was no documentation showing the Patient refusing care. Patient #5 receives home health aide services two hours a day, two days a week. The agency HHA failed to report to the nurse why the Patient was not receiving care at each visit as outlined in the Aide Plan of Care. On 06/13/2024, the Case Conference Notes indicated that RN 4 reported a defined stage II pressure ulcer measuring 1 cm x 1 cm on Patient #5's right medial buttock. Zinc paste has been regularly applied to the affected area. A photograph was taken showing open areas on both buttocks with zinc paste. The document failed to evidence a measurement for the second-acquired wound to the left buttock and could not indicate the change in measurements to the previous measurement to the right medial buttock. On 06/13/2024, RN 4's Amend POC Note was reviewed. The note indicated that the home health aide services would increase to 4 hours a day, 5 days a week, due to a decline in Patient #5's condition. RN 5 signed the note. A review of the wound photo taken on 06/13/2024 and reviewed on 06/14/2024 revealed two open areas, one on each buttock, surrounded by purple/redness. During an interview on 06/14/2024 at 9:30 AM, the Administrator stated that 90% of their patients are non-compliant and do what they want to do. If Patients had to switch to Medicare for wound treatment, they would lose our services. The RN Education Nurse stated that if the nurse knows about a wound ahead of the visit, they should get a verbal order and initiate TAO (triple antibiotic ointment) and a dry dressing. During a phone interview on 06/14/2024 at 3:16 PM, Patient #5 stated they had a doctor's appointment on Monday, 06/17/2024, at 3:20 PM to address their pressure ulcers. Patient #5 said two nurses visited their home yesterday. Patient #5 said they stood up and showed them the pressure ulcer. Patient #5 said they were instructed to lay in bed and lay on their side. Patient #5 said they were in pain and did not have any pain medication. Patient #5's record failed to indicate if the nurse addressed the patient's pain. During an interview on 06/14/2024 at 3:00 PM, the Administrator and QA Nurse 2 stated that the doctor does not want anything done until the Patient comes in to see them. "We asked the MD to call the Patient to schedule an appointment. We do not set up appointments for the Patient." The Administrator indicated that the patient "is just trying to live her life, and health and safety has always been an issue for them." During an interview on 06/14/2024, the Administrator and Quality Nurse 2 stated the agency does not provide hands-on care. QA 2 said they have admitted 10 patients, five of whom acquired wounds after admission. A review of a Wound [Appointment] Note dated 06/17/2024 indicated the Nurse Practitioner stated she was sending Patient #5 to the emergency room (ER) for an evaluation. There was no indication of why the Patient was sent to the ER. The note was signed by QA Nurse 2. Emergency Room notes were provided by QA Nurse 2 on 06/18/2024. The notes indicated Patient #5’s chief complaint was a complicated wound evaluation that developed two weeks ago. Patient #5 ranked pain as a 10 on a 1-10 pain scale (10 is worse). Patient #5 was prescribed a 7-day course of Ultram (pain pill) by a new primary physician today. The medication administered while in the ER included: bacitracin (antibiotic), ointment, ceftriaxone (antibiotic), intravenous infusion (IV) push for cellulitis/bites, Morphine (pain medication) IV push, and sodium chloride solution. Discharge instructions for Patient #5 included cleaning the buttocks and applying mupirocin (antibiotic) ointment three times a day, taking Keflex (antibiotic), Bactrim (antibiotic), Ultram (pain pill), and calling the primary care physician tomorrow and requesting a wound care consult in the next 1-2 days.

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 interviews, the agency failed to have a signed plan of care (POC) or a verbal POC order from the primary physician before providing services and treatments to patients for 5 of 9 full record reviews. (Patient #2, #5, #6, #8, #9) Findings include: 6. During an observation on 06/12/2024 at 1:04 PM, RN 2 provided wound care for Patient #7 by cleaning and applying Zinc barrier cream in the creases of both legs and ammonium lactate lotion 12% to bilateral lower extremities (BLE). RN 2 failed to follow wound care orders on Patient #7 Plan of Care. The Clinical Record for Patient #7, certification period 05/19/2024-07/17/2024, included a Plan of Care (POC) that indicated wound care orders for BLE to include applying Eucerin cream after cleansing area. A verbal order communication placed by RN 2 on 06/12/2024 at 5:52 PM was located in the patient record indicating applying zinc oxide paste to skin folds and ammonium lactate 12% lotion to BLE. The Clinical Record failed to evidence orders for applying Zinc barrier cream and ammonium lactate lotion 12% to bilateral lower extremities prior to 06/12/2024. During an interview on 06/12/2024 at 1:50 PM, RN 2 indicated already notifying the Nurse Practitioner (NP) for updated orders on wound care with taking Eucerin off due to Patient #7 breaking out from cream, and the NP ordered ammonium lactate 12% and zinc barrier cream. RN 2 indicated being unsure if these changes were moved over to the POC. During an interview on 06/12/2024 at 2:46 PM, the Director of Clinical Services indicated expecting RN 2 should follow wound care orders or request an updated wound care order from the provider prior to administering the changes in medication. During an interview on 06/13/2024 at 11:12 AM, the Director of Clinical Services indicated RN 2 had contacted office and informed reached out to the Nurse Practitioner to get a verbal order for medication and wound care order changes on Plan of Care on 06/12/2024 at 5:52 PM. 4. The record review for Patient #5, certification period 04/18/2024 to 06/16/2024, included a Verbal Order Recertification (VO-Recert) fax dated 04/16/2024, signed by the physician on 04/23/2024. The VO-Recert indicated the agency will continue using the expired plan of care (POC) from the prior certification period until the updated POC was signed by the physician. The record evidenced that patient care was provided to Patient #5 without a verbal or physician-signed order on 04/20/2024, 04/23/2024, 04/24/2024, 05/01/2024, 05/02/2024, 05/08/2024, 05/09/2024, 05/16/2024, 05/18/2024, 05/24/2024, 05/30/2024, and 06/01/2024. 410 IAC 17-131(a) 1. An undated Policy titled "Admission Policy" indicates a physician order for skilled nursing must be obtained from the Client's Physician before the start of care date. Skilled Nursing and Home Health Aide services must follow a written Plan of Care established and reviewed by a Doctor of Medicine. 2. An undated Policy titled "Plan of Care" indicates that if a physician refers a patient under a Plan that cannot be completed until after an assessment visit, the Physician shall be consulted to approve additions and modifications to the original plan. The Plan of Care/ 485 will be developed following the initial assessment and sent to the Physician for signature. 3. The record review for Patient #2, certification period 05/01/2024 to 06/30/2024, revealed that patient care was provided to Patient #2 without a verbal or physician-signed order on 05/03/2024, 05/05/2024, 05/08/2024, and 05/10/2024. 6. The record review for Patient #6, certification period 05/13/2024 to 07/11/2024, included a Recert fax sent to the Physician on 05/08/2024, signed by the Physician on 05/14/2023, indicating the agency will continue using expired POC from the prior certification period until Physician signs updated POC. The agency failed to obtain a verbal order or current signed POC. The record revealed that patient care was provided to Patient #6 without a verbal or physician-signed order on 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, 05/18/2024, 05/19/2024, 05/20/2024, and 05/21/2024. During an interview on 06/11/2024 at 9:05 AM, RN 3 indicated he does not notify the Physician. QA Nurse 1 or QA Nurse 2 would notify the Physician by email to report the start of care, recertification of care, or resumption of care. He does not communicate with the Physician. 8. The record review for Patient #8, certification period 10/25/2023 to 12/23/2023, revealed that patient care was provided to Patient #8 without a verbal or physician-signed order on 10/26/2023, 10/27/2023, 10/29/2023, 10/30/2023, and 10/31/2023. 9. The record review for Patient #9, certification period 10/28/2023 to 12/26/2023, included a Recert fax sent to the Physician on 10/28/2023, signed by the Physician on 12/28/2023, indicating the agency will continue using expired POC from prior certification period until Physician signs updated POC. The agency failed to obtain a verbal order or current signed POC. The record revealed that patient care was provided to Patient #9 without a verbal or physician-signed order on 10/28/2023, 10/29/2023, 10/30/2023, 10/31/2023, 11/01/2023, 11/02/2023, 11/03/2023, 11/04/2023, 11/05/2023, 11/06/2023, 11/07/2023, 11/08/2023, 11/10/2023, 11/11/2023, and 11/12/2023. During an interview on 6/13/2024 at 9:30 AM, the Director of Clinical Services indicated that Patient #9's POC was signed on 11/28/2024 and acknowledged this was after the patient was discharged from service. Services were provided for the entire certification period with no signed POC by the Physician. 10. During an interview on 6/11/2024 at 12:25, Quality Assurance Nurse 2 indicated that the POC is sent to the Physician to get signed, and the Admission nurses should call the Physician to discuss the POC. She indicated that during recertification, a fax is sent to the patient's Physician on the same day as the POC. The fax reads, "Recertification visit completed. Elder's Journey to continue the current plan of care until the updated care plan is signed per MD."

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 observation, record review, and interview, the agency failed to ensure the Plan of Care (POC) included mental status specific to person, place, and time for 5 of 9 full record reviews (Patient #2, #6, #7, #8, #9), failed to ensure the POC included all medications for 2 of 6 active patients with home visits (Patient #6, #7), and failed to ensure the POC included a current and complete list of Durable Medical Equipment (DME) and Supplies for 2 of 6 active patients with home visits (Patient #6, #7). Findings include: did not write this tag 2. The record review for Patient #2, certification period 05/01/2024 to 06/30/2024, included a POC with Oriented checked on POC as Patient #2's mental status but failed to identify if Patient #2 is oriented to Person, Place, or Time. The agency failed to document Patient #2's oriented status on POC accurately. 4. During an observation on 06/11/2024 at 9:05 AM, Patient #6 had a rollator (wheeled walker) and shower chair in the home. The agency failed to accurately list DME supplies on POC. The medications in the home were reviewed with RN 3. Mucinex DM (control for cough, thin and loose mucus) was being used by the patient as needed, but the patient was not on the POC or medication profile. The agency failed to have an accurate medication list on the POC or medication profile. The record review for Patient #6, certification period 05/13/2024 to 07/11/2024, included a POC with a list of DME (Durable Medical Equipment) tht Patient #6 had in the home. Neither the shower chair nor the rollator, used by the patient, are listed on the DME and Supplies list on POC. The POC does not list Mucinex on the medication list, which patient #6 takes as needed. Oriented, forgetful is checked on POC as patient's mental status, but fails to identify if Patient #6 is oriented to Person, Place, or Time. The agency failed to have an accurate list of all available DME, medication taken by patients, and patients-oriented status on POC. 6. The record review for Patient #8, certification period 10/25/2023 to 12/23/2023, included a POC with Oriented and Forgetful checked on POC as Patient #8's mental status but fails to identify if Patient #8 is oriented to Person, Place, or Time. The agency failed to document Patient #8's oriented status on POC accurately. 7. The record review for Patient #9, certification period 10/28/2023 to 12/26/2023, included a POC with Oriented, Forgetful, and Disoriented checked on POC as Patient #9's mental status but failed to identify if Patient #9 is oriented to Person, Place or Time. The agency failed to document Patient #9's oriented status on POC accurately. 8. During an interview on 6/12/2024 at 9:15 AM, the Director of Clinical Services indicated the medical record system the agency currently uses has a check box for "orientated" but no option for orientated to "person, place, or time" but indicated there are free text box that staff could type in what patient is orientated to. She indicated that nurses should be asking about new or changed medication at each visit, physicians should be notified of new or changed medications, and that new orders should be written. 9. During an interview on 6/12/2024 at 2:45 AM, the Director of Clinical Services indicated that the DME list on POC should be updated at recertification, and medication reconciliation should be done every 60 days and as needed. 1. A policy titled "Plan of Care" indicated, but was not limited to, POC will be updated as necessary, include mental status, home medical equipment and assistive devices, and medications. "The Plan of Care shall be completed in full to include…mental status… need for/presence of home medical equipment and assistive devices…medications". 3. The Clinical Record for Patient #7, certification period 05/19/2024-07/17/2024, included a Plan of Care (POC) that indicated wound care and medication orders for BLE to include applying Eucerin cream after cleansing area and a list of DME that patient #7 had in home. The electric wheelchair, used by patient, was not listed on the DME and Supplies list on POC and there were urinary ostomy supplies on POC. The POC does not list zinc oxide or ammonium lactate 12% on medication list, which patient #7 has applied to BLE with wound care. The agency failed to have an accurate list of all available DME and medication used by patient on POC. During an interview on 06/12/2024 at 1:33 PM, Patient #7 indicated medications listed on POC for wound care were not current, now uses zinc oxide and ammonium lactate 12%, denies having a history of urinary ostomy supplies, has a powered wheelchair in the home for use. During an interview on 06/12/2024 at 1:50 PM, RN 2 indicated Patient #7 has never had a urinary ostomy to RN 2 knowledge, Patient #7 wound care order with medications is not up to date but RN 2 had previously reached out to the Nurse Practitioner for an updated medication order to incorporate the change. RN 2 indicated this case conference note from RN 2 reaching out to the Nurse Practitioner would be in Patient #7's medical record. During an interview on 06/12/2024 at 2:46 PM, the Director of Clinical Services indicated DME on Patient #7 POC was not correct, as the DME listed a urinary ostomy and this was a clerical error that should not have been on the POC for Patient #7 and the RN should follow wound care orders or contact the Nurse Practitioner prior to administering other medications on wounds. During an interview on 06/12/2024 at 3:20 PM, the Director of Clinical Services indicated POC contained in Patient #7 record was the most up to date order regarding wound care and medications.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Registered Nurse (RN) failed to provide services as ordered by the physician, affecting 2 of 2 observed RN home visits. (Patient #5, #6) Findings include: 5. During a recertification home visit on 06/12/2024 at 10:30 AM, Registered Nurse (RN) 1 failed to assess Patient #5's chest, back, under breast, peri-area, bilateral upper and lower legs, soles of feet, and bottom portion of the buttocks. RN 1 failed to measure an open area surrounded with red/purple discoloration on Patient #5's right buttock and failed to measure red/purple discoloration to the left buttock and tailbone area. RN 1 stated it looked like a bedsore and was about 3 cm x 2 cm. RN 1 failed to accurately complete a head-to-toe assessment and record the data on the OASIS (comprehensive assessment). During an interview on 06/12/2024 at 3:47 PM, the Director of Clinical Services stated that the nurse should perform a head-to-toe assessment at the recertification visit. 410 IAC 17-13-1(a) 1. An undated policy titled "Admission Policy" indicated that skilled nursing and home health aide services must follow a written plan of care established and reviewed by a Doctor of Medicine. 3. During an observation on 06/11/2024 at 9:05 AM, RN 3 did not perform a head-to-toe assessment on Patient #6 to evaluate all systems (Respiratory, Cardiovascular, Integrity, Genitourinary, and Gastrointestinal) as outlined on the POC. The RN failed to provide services as ordered by the physician. The record review for Patient #6, certification period 05/13/2024 to 07/11/2024, included a POC that indicated skilled nursing services should assess respiratory status. During an interview on 06/11/2024 at 9:15 AM, RN 3 indicated the visit was completed at 9:15 AM (the visit started at 9:05 AM) and had the patient sign a tablet. RN 3 indicated he sees the patient every day for insulin administration and once per week on Monday for medication set-up and that no other services are provided by the RN. 4. During an interview on 06/12/24 at 2:00 PM, the Director of Clinical Services indicated that the agency did not have a home visit policy or an assessment policy. She indicated that the home visit assessments should follow the patient's plan of care and that all systems on the plan of care should be assessed during each visit.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to coordinate care with the physician regarding a patient's wound for 1 of 6 active record reviews. (Patient #5) Findings include: 1. A policy titled "Plan of Care" was provided by the Director of Clinical Services (DCS) on 06/10/2024. The policy indicated that the agency addresses the care, treatment, and services provided. The Patient and other agency staff shall participate in the development of the plan of care and any changes that would alter it. Staff will obtain additional visit orders accompanied by a description of the Patient's needs that could warrant a visit. 2. A policy titled "Wound Measurement" was provided by the Director of Clinical Services (DCS) on 6/10/2024. The policy indicated that nursing staff were to measure wounds at a minimum weekly. 3. A job description titled "Home Health Aide" was provided by the Director of Clinical Services (DCS) on 06/11/2024. The description indicated that the aide was to report patient condition changes to the Registered Nurse (RN), perform personal care activities such as bathing, shampooing, skincare, and other related duties, and promote a safe patient environment. 4. A 2014 NPUAP article titled Prevention and Treatment of Pressure Ulcers: Quick Reference Guide indicated a comprehensive skin assessment should be conducted as soon as possible but within 8 hours of reporting for individuals who are a risk for pressure ulcers. The skin assessment should include skin temperature, edema, and change in tissue consistency in relation to surrounding tissue. The assessment should differentiate whether the skin redness was blanchable or non-blanchable ( redness or discoloration disappears when pressure is applied). 5. On 6/6/2024, a Case Conference note indicated that Entity 2, a Personal Service Attendant (PSA) provider, called to report that Patient #5 had an open area on their buttocks. The Registered Nurse Case Manager (RNCM), physician, and Case Manager (CM) were notified. The nurse advised Patient #5 to contact their physician for an appointment if they felt the area needed attention before the RNCM visit. The next RNCM visit, scheduled for 06/12/2024, was for a recertification visit for home health aide services. The agency failed to evidence documentation that an order was obtained to assess the patient's wound promptly. Surveyors accompanied RN 1 during a home visit on 06/12/2024. During a recertification home visit for Patient #5 on 06/12/2024 at 10:30 AM, RN 1 failed to measure the open area and surrounding deep, purple-redness with a measuring tool on Patient #5's right buttock. RN 1 indicated it resembled a bedsore and estimated it to be about 3 centimeters (cm) X 2cm. RN 1 instructed the Patient to apply Destin (skin barrier cream) or A & D (ointment) over the open area until the Patient called the physician. RN 1 mentioned that she does not provide direct hands-on care. RN 1 failed to assess the wound per professional standards and failed to notify the physician at the home visit. On 06/13/2024, the Case Conference Notes indicated that RN 4 reported a defined stage II pressure ulcer measuring 1 cm x 1 cm on Patient #5's right medial buttock. Zinc paste has been regularly applied to the affected area. A photograph was taken showing open areas on both buttocks with zinc paste. The document failed to evidence a measurement for the second-acquired wound to the left buttock and could not indicate the change in measurements to the previous measurement to the right medial buttock. A review of the wound photo taken on 06/13/2024 and reviewed on 06/14/2024 revealed two open areas, one on each buttock, surrounded by purple/redness. During an interview on 06/14/2024 at 9:30 AM, the Administrator stated that 90% of their patients are non-compliant and do what they want to do. If Patients had to switch to Medicare for wound treatment, they would lose our services. The RN Education Nurse stated that if the nurse knows about a wound ahead of the visit, they should get a verbal order and initiate TAO (triple antibiotic ointment) and a dry dressing. During an interview on 06/14/2024 at 3:00 PM, the Administrator and QA Nurse 2 stated that the doctor does not want anything done until the Patient comes in to see them. "We asked the MD to call the Patient to schedule an appointment. We do not set up appointments for the Patient." The Administrator indicated that the patient "is just trying to live her life, and health and safety has always been an issue for them." A review of a Wound [Appointment] Note dated 06/17/2024 indicated the Nurse Practitioner stated she was sending Patient #5 to the emergency room (ER) for an evaluation. There was no indication of why the Patient was sent to the ER. The note was signed by QA Nurse 2. 410 IAC 17-14-1(a)(1)(F)

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to include measures derived from OASIS and incorporate them into the QAPI program for 1 of 1 Quality Assessment Performance Improvement (QAPI) reviews. Findings include: A policy titled "Quality Assessment Performance Improvement" was provided by the Administrator on 06/18/2024. The policy indicated the agency should utilize OASIS reports that included the following: Home Health Compare, Potential Avoidable Events and Patient Listings, Outcome-Based Quality Improvement Report, Patient/Agency Characteristics Report, Submission Status by Agency Report, and Error Summary Report by the home health agency. The policy indicated data may be collected from measures derived from the OASIS data. On 06/18/2024 at 10:47 AM, the Performance Improvement Manager and the Administrator reviewed the 2023 and 2024 QAPI programs with the surveyor. The agency failed to provide evidence that it included OASIS reports in the programs. During an interview on 06/18/2024 at 11:00 AM, the Program Improvement Manager was asked why the agency did not include late submission reports and potentially avoidable events in the QAPI program, such as discharging a patient into the community with pressure ulcers, behaviors, or improper medications in the QAPI program. The Performance Improvement Manager and the Administrator stated they were unaware those items needed to be included in the program. 410 IAC 17-12-2(a)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure standard infection control precautions were followed regarding bag technique for 2 of 5 home observations with a Registered Nurse (RN 1, RN 3); failed to ensure gloves were removed and hand hygiene performed throughout the entire home visit or failed to perform hand hygiene after glove removal for 3 of 5 home visit observations with a nurse (RN 1, RN 2, RN 3): and failed to follow manufacturer's instructions on disinfecting equipment for 3 of 5 home visit observations with a nurse. (RN 1, RN 2, RN 3) Finding include: 5. During an observation on 06/12/2024 at 1:04 PM, RN 2 provided wound care for Patient #7 following completion of assessment during the home visit. RN 2 failed to properly disinfect stethoscope and blood pressure cuff for 4 minutes following completion of Patient #7 vital signs, and failed to change gloves and complete hand hygiene between cleaning and applying Zinc barrier cream in the creases of both legs and ammonium lactate lotion 12% on wound sites. During an observation on 06/12/2024 at 1:50 PM, RN 2 provided the Lysol Wipes package that RN 2 used to wipe stethoscope and blood pressure cuff. The Lysol Wipes package instructions indicated dry times for sanitizing was 10 seconds and for disinfection was 4 minutes. During an interview on 06/12/2024 at 1:50 PM, RN 2 indicated wiping stethoscope and blood pressure cuff with personal Lysol wipes. RN 2 indicated dry time for Lysol wipes to sanitize was 10 seconds and for disinfection was 4 minutes according to the Lysol wipes package. RN 2 indicated not allowing the stethoscope and blood pressure cuff to dry for 4 minutes prior to placing stethoscope around the neck and blood pressure cuff back in the supply bag. RN 2 indicated not changing gloves between cleaning wound site and application of lotion. During an interview on 06/12/2024 at 2:46 PM, the Director of Clinical Services indicated RN 2 should have changed gloves and completed hand hygiene between cleaning and applying lotion, and again following the application of lotion. The Director of Clinical Services indicated would expect RN 2 to disinfect stethoscope and blood pressure cuff between patient use, Lysol wipes were permitted for proper disinfection of equipment when following package instructions. 4. During an observation on 06/11/2024 at 9:05 AM, RN 3 donned gloves before retrieving equipment from the nursing bag. Patient #6's vitals were taken, and the equipment returned to the bag; medication was prepared and administered, and gloves were removed. RN 3 failed to change gloves after entering the nursing bag, before and after contact with the patient, and before administering medication. RN 3 did not disinfect the equipment (Blood Pressure cuff, Oximeter, and Thermometer) before or after the equipment was used to take patient #6's vitals. RN 3 Failed to follow instructions on disinfecting equipment between patients. During an interview on 6/12/2024 at 2:45 AM, the Director of Clinical Services indicated blood pressure cuffs and other equipment used during home visits should be disinfected between patient use 1. A policy titled "Hand Washing & Hand Hygiene" was provided by the Director of Clinical Services (DCS) on 06/12/2024. The policy indicated that staff should wash their hands between tasks on the same patient and after glove removal. 2. A document titled "Competency Evaluation, Supply Bag Technique" was provided by DCS on 06/12/2024. The policy indicated that staff should wash their hands before entering the supply bag and clean the equipment before returning to the bag. 4. During an observation on 06/12/2024 at 10:30 AM, Registered Nurse (RN) 1 applied gloves and assessed Patient #5's bed sore on their right buttocks. RN 1 kept her soiled gloves while assisting Patient #5 from the bed and documenting on her notepad. RN 1 failed to remove her gloves and perform hand hygiene after assessing the patient's bedsore and before touching her notepad. RN 1 cleaned her vital sign equipment (stethoscope and oxygen saturation device) with an alcohol wipe and placed them directly into her equipment while wet. RN 1 failed to allow the equipment to dry before placing it into the bag. During an interview on 06/12/2024 at 2:00 PM, the Director of Clinical Services (DCS) stated that the expectation was for the nurse to perform hand hygiene after removing their gloves and before touching clean items. DCS stated that vital sign equipment should be left to dry after disinfecting and before returning it to its bag. 410 IAC 17-12-1(m)

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 observation, record review, and interview, the agency failed to follow the Home Health Aide (HHA) Plan of Care (POC) as ordered by the Physician (See tag G800); failed to ensure the home health aide provided hands-on direct patient care (See tag G802); and failed to ensure the home health aide reported changes in the patient's condition and needs to a nurse (See tag G804). The cumulative effect of the deficient practice resulted in the agency's noncompliance with Condition of Participation §484.80 Home Health Aide Services. .

Inservice training supervised by RN CFR(s): 484.80(d)(1) In-service training may be offered by any organization and must be supervised by a registered nurse. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure in-service training for Home Health Aides (HHA) were provided under the supervision of a Registered Nurse (RN) for 1 of 4 HHA personnel records reviewed (HHA 3). Findings include: 1. A policy titled, "In-Service Education and Staff Development" indicated the agency is responsible for maintaining the records of the in-service education programs and the agency will follow Medicaid Conditions of Participation or as states require with in-service HHA education: Training must be provided by or under the direction of a Registered Nurse. 2. A document titled, "Annual TB Education sent out Oct. 2023, 1 hour" failed to evidence annual TB (tuberculosis) in-services an RN supervised training. 3. During an interview on 06/18/2024 at 12:40 PM, a document titled "Elder's Journey Home Care Newsletter", indicated the newsletter would be counted as in-service and is sent by email each month, no evidence was provided that staff members read email, or newsletter is supervised by RN, per in-service requirements. 4. During an interview with HR Director on 06/18/2024 at 1:00 PM, the HR Director indicated the agency fails to maintain sign-in records of In-Service Training because they are completed online by staff. HR Director stated this was started during COVID and has not resumed in person. HR Director stated the Clinical Director is the RN who "oversees" in-service training. 410 IAC 17-14-1

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 follow the Home Health Aide (HHA) Plan of Care (POC) as ordered by the Physician, for 5 of 6 patients with HHA services. (Patient #3, #5, #6, #9 #11) Findings include: 7. During an observation on 06/14/2024 at 10:30 AM, Home Health Aide (HHA) 12 only provided light housekeeping duties for Patient #11 during the home visit. HHA 12 failed to offer Patient #11 hair care, mouth/denture care, and dressing. The Clinical Record for Patient #11, certification period 06/14/2024-08/12/2024, included an Aide Plan of Care (POC) that indicated HHA was to complete hair care, skin care, mouth/denture care, and dressing at each visit, as well as light housekeeping duties. An Aide visit note dated 06/14/2024 indicated that Patient #11 had received hair care, mouth/denture care, and dressing completed by HHA 12. HHA 12 failed to follow the Aide POC as ordered by the physician. During an interview on 06/14/2024 at 10:35 AM, Patient #11 indicated refusing shower at this visit due to being too tired, and the HHA would only be doing light housekeeping at this visit. During an interview on 06/14/2024 at 10:50 AM, HHA 12 indicated Patient #11 refused a shower and would only be receiving light housekeeping at this visit. HHA 12 indicated not providing mouth/denture care to Patient #11, as patient does this independently. 2. A review of Patient #3's record included an Aide Plan of Care dated 12/12/2023 that was electronically signed by Registered Nurse (RN) 6. The Aide Plan of Care indicated a frequency of ten hours a day, five days a week, for home health aide (HHA) services. The section titled "Assignment" indicated the HHA was to do the following tasks at each visit: hair care, skin care, mouth/denture care, foot care, dressing, preparing a meal, encouraging fluids, personal care, bed bath, check for pressure points, toileting/hygiene, and medication reminders, assist with walker and bedside commode, and reposition in bed. A review of Patient #3's "Aide Visit Note-Daily" dated 12/16/2023, 12/18/2024, 12/22/2023 evidenced skin care, dressing, and personal care was marked as not completed/not needed, and on 12/30/2023 evidenced shampoo, mouth/denture care, nail care, shower, bed bath, linen change was marked not completed/not needed. Additionally, on the following dates: 12/13/2024, 12/14/2024, 12/15/2024, 12/19/2024, 12/20/2024, 12/21/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 01/0/2024, 01/03/2024, and 01/04/2024 the aide provided hair care and dressing, but all other tasks were refused without reason. HHA #13, #17, and #18 failed to follow the aide POC, provided a reason why the Patient did not need care and failed to inform the nurse of the Patient's refusal of care. 3. During an interview at the home visit on 06/12/2024 at 10:30 AM, Patient #5 said they could not recall the last time they had a shower, bed bath, or shampoo. RN 1, HHA 1, and the PSA provider were present during the interview. A review of Patient #5's record included an Aide Plan of Care dated 04/16/2024, electronically signed by RN 1. The Aide Plan of Care indicated a frequency of two hours a day, two days a week, for HHA services. The section titled "Assignment" indicated the HHA was to do the following tasks at each visit: vital signs (temperature, respirations, blood pressure pulse rate), hair care, shampooing, skin care, mouth/denture care, foot care, dressing, prepare a meal, encourage fluids, personal care, shower, sponge bath (up in a chair), check for pressure points, toileting/hygiene, and medication reminders, assist with walker and wheelchair. A review of Patient #5's "Aide Visit Note-Daily" failed to evidence that HHA 1 and HHA 19 provided care as assigned on the aide plan of care for the following aide visit dates: On 06/14/2024, evidenced vital signs, hair care, skin care, mouth/denture care, foot care, dressing, preparing a meal, encouraged fluids, personal care, shower, sponge bath (up in a chair), check for pressure points, toileting/hygiene, and medication reminders, assist with walker and wheelchair was marked not completed/not needed/or other caregiver did. On 06/12/2024, evidenced vital signs, hair care, skin care, mouth/denture care, foot care, dressing, personal care, shower, sponge bath (up in a chair), check for pressure points, toileting/hygiene, medication reminders, and assistance with walker and wheelchair were marked not completed/not needed. On 06/04/2024, vital signs were not taken due to not being requested and no equipment. The document also evidenced that shampooing, nail care, personal care, showering, and assistance with a wheelchair were not requested /not needed. On 06/01/2024, evidenced vital signs, hair care, skin care, mouth/denture care, foot care, dressing, preparing a meal, encouraging fluids, personal care, shower, sponge bath (up in a chair), check for pressure points, toileting/hygiene, and wheelchair were marked not completed/not needed. On 05/30/2024, evidenced vital signs, hair care, skin care, mouth/denture care, foot care, nail care, preparing a meal, encouraging fluids, showers, sponge baths (in a chair), and assistance with a wheelchair were marked as not needed. On 05/24/2024, evidenced vital signs, shampooing, mouth/denture care, foot care, dressing, preparing a meal, encouraging fluids, personal care, shower, sponge bath (up in a chair), check for pressure points, toileting/hygiene, and medication reminders, assisted with walkers and wheelchair were marked as not needed. On 05/18/2024, evidenced vital signs, hair care, shampooing, skin care, mouth/denture care, foot care, dressing, preparing a meal, encouraging fluids, personal care, shower, sponge bath (up in a chair), assisting with a wheelchair were marked as not needed. On 05/16/2024, evidenced vital signs, shampooing, mouth/denture care, foot care, preparing a meal, encouraging fluids, showering, sponge bath (up in a chair), checking for pressure points, and assisting with a wheelchair were marked as not needed. On 05/09/2024, evidenced vital signs, hair care, shampooing, mouth/denture care, foot care, preparing a meal, encouraging fluids, showers, sponge baths (up in a chair), checking for pressure points, and assisting with a wheelchair were marked as not needed. On 05/08/2024, evidenced vital signs, hair care, shampooing, mouth/denture care, foot care, preparing a meal, encouraging fluids, showers, sponge baths (up in a chair), preparing meals, assisting with the wheelchair were marked as not needed. On 05/02/2024, evidenced vital signs, shampooing, mouth/denture care, foot care, preparing a meal, encouraging fluids, showers, sponge baths (up in a chair), and assistance with a wheelchair were marked as not needed. On 05/01/2024, evidenced vital signs, hair care, shampooing, skin care, mouth/denture care, foot care, dressing, preparing meals, encouraging fluids, personal care, showers, sponge baths (up in a chair), and assistance with a wheelchair were marked as not needed. On 04/24/2024, evidenced vital signs, shampooing, skin care, mouth/denture care, foot care, nail care, preparing a meal, encouraging fluids, showers, sponge baths (up in a chair), and assistance with a wheelchair were marked as not needed. During a phone interview on 06/13/2024 at 1:30 PM, HHA 1 indicated they do not offer a shower or bath to Patient #5 despite it being ordered on the plan of care. She stated that if Patient #5 wanted a bath, they would ask. HHA 1 said they would do what the Patient told them to do, and if the patient refused care, they would mark it as refused and report it to the nurse. The agency HHA failed to follow the Aide POC. 1. An undated document titled "Position: Home Health Aide" indicates the Home Health Aide must follow a written POC. 4. During an observation on 06/14/2024 at 10:54 AM, Patient #6 was sitting in a living room chair with a TV on, while Home Health Aide (HHA) 4 was found sitting in the hallway of Patient #6's apartment using a cell phone conducting personal business with phone speaker on from 10:54 AM to 11:06 AM. After HHA 4 completed the phone call, HHA 4 provided a tour of the apartment and pointed out the bathroom was not clean, indicating if she cleaned it today, it would look the same again tomorrow. The bathroom had towels lying on the floor, bowel specimens along the rim of the toilet, and a strong odor of urine. HHA 4 indicated she was not going to get house cleaning done today; she usually mops and takes the trash out if it is full and usually does cleaning between 10:30 AM and 12:00 AM. HHA said three times during the observation visit: make sure to tell them that a lot of housekeeping is done at the end of the visit, but I ran out of time today. (She was referring to notes being taken during the visit). The record review for Patient #6, certification period 05/13/2024 to 07/11/2024, included an Aide Plan of Care with an effective date of 05/13/2024, indicated Patient #6 was to receive the following services: shampoo, skin care, mouth care, dressing, other (shaving verbal cues), shower, toileting/hygiene, and medication reminders every visit. The Aide Visit Note - Daily indicated all Aide Plan of Care services was not offered on 05/13/2024, 05/22/2024, 05/24/2024, 05/29/2024,05/31/2024, 06/04/2024, 06/07/2024 or 06/12/2024 During an interview on 06/14/2024 at 11:06 AM, Home Health Aide (HHA) 4 indicated her job was to prepare meals, housekeeping, laundry, and grooming. HHA 4 indicated she could not remember the last time she helped Patient #6 with a shower; she did not offer Patient #6 a shower during today's visit. He gets showers every week, and he has a friend who comes on Saturday to help with showers. HHA 4 indicated she arrived at 8:00 AM today, had coffee with the patient, watched TV, a nurse arrived for a home visit, and then the surveyor arrived. HHA 4 indicated the agency provides a sheet of what HHA 4 should offer patients during visits, but she was unable to locate the paper; she indicated she can see what the patient needs and provides it and can also look at the phone where charting is done. During an interview on 06/14/2024 at 10:35 AM, Patient #6 was asked if they are offered a shower every visit the HHA is there. Patient #6 stated, "I guess I'm offered a shower every day." They indicated they have a buddy who comes on weekends and helps with showering, but they did not take a shower today. They indicated the HHA sometimes cooks and cleans the bathroom. 5. The record review for Patient #9, certification period 10/28/2023 to 12/26/2023, included an Aide Plan of Care with an effective date of 10/28/2023, indicated Patient #9 was to receive the following services: hair care, shampoo, skin care, mouth care, foot care, nail care, dressing, personal care, sponge bath in a chair, assist with walker and cane, prepare meals, encourage fluid intake, and toilet hygiene are ordered each visit. The Aide Visit Note - Daily indicated all Aide Plan of Care services were not offered on 10/29/2023, 10/30/2023, 11/2/2023, 11/02/2023, 11/05/2023, 11/06/2023, and 11/11/2023.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency home health aide (HHA) failed to provide hands-on direct patient care for 3 of 5 record reviews with home health aide services. (HHA 1, HHA 4, HHA 12) Findings include: 6. During an observation on 06/14/2024 at 10:30 AM, Home Health Aide (HHA) 12 only provided light housekeeping duties for Patient #11 during the home visit. HHA 12 failed to offer Patient #11 hair care, mouth/denture care, and dressing. The Clinical Record for Patient #11, certification period 06/14/2024-08/12/2024, included an Aide Plan of Care (POC) that indicated HHA was to complete hair care, skin care, mouth/denture care, and dressing at each visit, as well as light housekeeping duties. An Aide visit note dated 06/14/2024 indicated that Patient #11 had received hair care, mouth/denture care, and dressing completed by HHA 12. HHA 12 failed to provide hands on care to Patient #11 during this home visit. During an interview on 06/14/2024 at 10:35 AM, Patient #11 indicated refusing shower at this visit due to being too tired, and the HHA would only be doing light housekeeping at this visit. During an interview on 06/14/2024 at 10:50 AM, HHA 12 indicated Patient #11 refused a shower and would only be receiving light housekeeping at this visit. HHA 12 indicated not providing mouth/denture care to Patient #11, as patient does this independently. 1. An undated document titled "Position: Home Health Aide" indicated that the Home Health Aide must follow a written plan of care. The HHA was to follow the plan and complete the tasks assigned to it, such as bathing, shampooing, skincare/hair care, oral hygiene, shaving, and dressing. 2. A review of Patient #3's record included an Aide Plan of Care dated 12/12/2023 that was electronically signed by Registered Nurse (RN) 6. The Aide Plan of Care indicated a frequency of ten hours a day five days a week for home health aide services. The section titled "Assignment" indicated the HHA was to do the following tasks at each visit: hair care, skin care, mouth/denture care, foot care, dressing, preparing a meal, encouraging fluids, personal care, bed bath, check for pressure points, toileting/hygiene, and medication reminders, assist with walker and bedside commode, and reposition in bed. A review of the "Aide Visit Note-Daily" dated 12/16/2023, 12/18/2024, 12/22/2023 evidenced skin care, dressing, and personal care was marked as not completed/not needed, and on 12/30/2023 evidenced shampoo, mouth/denture care, nail care, shower, bed bath, linen change were marked not completed/not needed. Additionally, on the following dates: 12/13/2024, 12/14/2024, 12/15/2024, 12/19/2024, 12/20/2024, 12/21/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 01/0/2024, 01/03/2024, and 01/04/2024 the aide failed to provide all direct hands-on care as assigned on the aide plan of care. 3. A review of Patient #5's record included an Aide Plan of Care dated 04/18/2024 that was electronically signed by RN 1. The Aide Plan of Care indicated a frequency of two hours a day, two times a week for home health aide (HHA) services. The section titled “Assignment” indicated the HHA was to do the following each visit: obtain temperature, respirations, blood pressure, pulse rate, hair care, skin care, mouth/denture care, foot care, nail care, dressing, prepare a meal, encourage fluids, personal care, shower, sponge bath in a chair, check for pressure points, toileting/hygiene, and medication reminders, assist with walker and wheelchair. A review of the “Aide Visit Note-Daily” dated 04/20/2024, 04/23/2024, 04/24/2024, 05/01/2024, 05/02/2024, 05/08/2024, 05/09/2024, 05/16/2024, 05/18/2024, 05/24/2024, 05/30/2024, 06/01/2024, 06/04/2024, 06/12/2024, and 06/14/2024, failed to evidence HHA 1 followed the Aide Plan of Care and provided hands-on personal care tasks assigned at each visit. During a phone interview on 06/13/2024 at 1:30 PM, HHA 1 was asked why the aide visit notes indicated the tasks of showering, bathing, mouth/denture care, foot/nail care, shampooing, and preparing meals were marked as not completed and not needed. HHA 1 stated she does not offer a shower or bath to Patient #5 despite it being ordered on the aide plan of care. She stated that if Patient #5 wanted a bath, they would ask. HHA 1 said they do what the Patient tells them to do. HHA 1 stated that if the Patient refused care, they would mark it as refused and report it to the nurse. The agency HHA failed to follow the Aide POC. 4. During an observation on 06/14/2024 at 10:54 AM, Patient #6 was sitting in a living room chair with a TV on, while Home Health Aide (HHA) 4 was found sitting in the hallway of Patient #6's apartment using a cell phone conducting personal business with phone speaker on from 10:54 AM to 11:06 AM. After HHA 4 completed the phone call, HHA 4 provided a tour of the apartment and pointed out the bathroom was not clean, indicating if she cleaned it today, it would look the same again tomorrow. The bathroom had towels lying on the floor, bowel specimens along the rim of the toilet, and a strong odor of urine. HHA 4 indicated she was not going to get house cleaning done today; she usually mops and takes the trash out if it is full and usually does cleaning between 10:30 AM and 12:00 AM. HHA said three times during the observation visit: make sure to tell them that a lot of housekeeping is done at the end of the visit, but I ran out of time today. (She was referring to notes being taken during the visit). The record review for Patient #6, certification period 05/13/2024 to 07/11/2024, included an Aide Plan of Care with an effective date of 05/13/2024, indicated Patient #6 was to receive the following services: shampoo, skin care, mouth care, dressing, other (shaving verbal cues), shower, toileting/hygiene, and medication reminders every visit. The Aide Visit Note - Daily indicated all Aide Plan of Care services was not offered on 05/13/2024, 05/22/2024, 05/24/2024, 05/29/2024,05/31/2024, 06/04/2024, 06/07/2024 or 06/12/2024 During an interview on 06/14/2024 at 11:06 AM, Home Health Aide (HHA) 4 indicated her job was to prepare meals, housekeeping, laundry, and grooming. HHA 4 indicated she could not remember the last time she helped Patient #6 with a shower; she did not offer Patient #6 a shower during today's visit. He gets showers every week, and he has a friend who comes on Saturday to help with showers. HHA 4 indicated she arrived at 8:00 AM today, had coffee with the patient, watched TV, a nurse arrived for a home visit, and then the surveyor arrived. HHA 4 indicated the agency provides a sheet of what HHA 4 should offer patients during visits, but she was unable to locate the paper; she indicated she can see what the patient needs and provides it and can also look at the phone where charting is done. During an interview on 06/14/2024 at 10:35 AM, Patient #6 was asked if they are offered a shower every visit the HHA is there. Patient #6 stated, "I guess I'm offered a shower every day." They indicated they have a buddy who comes on weekends and helps with showering, but they did not take a shower today. They indicated the HHA sometimes cooks and cleans the bathroom. 410 IAC 17-14-1(h)(1)-(14)

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 agency home health aide (HHA) failed to report changes in the patient's condition and needs to a nurse for 1 of 5 record reviews with HHA services. (HHA 1) Findings include: A review of a job description titled "Home Health Aide" was provided by the Director of Clinical Services (DCS) on 06/12/2024. The aide job description indicated but was not limited to the home health aide reports to the clinical supervisor or the case manager. The policy indicated the HHA was to report any changes in the patient's condition and needs to the nurse. During an interview at a recertification home visit on 06/12/2024 at 10:30 AM, the Personal Service Attendant (PSA) provider stated Patient #5 refuses showers and bed baths. The PSA provider stated she does not know what the other HHA does while in the home. During the visit, HHA 1 entered the home and was asked about the bathing schedule, to which she stated I don't know when the Patient had a bath last. HHA 1 stated she was off on the 13th but could give the patient a bath on the 14th. At that time, HHA 1 did not offer Patient #5 a bath for the day. Registered Nurse (RN) 1 was not aware the patient was not receiving a bath. HHA 1 failed to ensure bathing and hygiene tasks were performed at each visit and failed to report to the nurse when care was not provided. During a phone interview on 06/13/2024 at 1:30 PM, HHA 1 indicated Patient #5 does not ask for help. HHA 1 said they do not offer a shower or bath to Patient #5 despite it being ordered on the aide plan of care. She stated that if Patient #5 wanted a bath, they would ask. HHA 1 said they do what the Patient tells them to do. HHA 1 stated that if the Patient refused care, they would mark it as refused and report it to the nurse. HHA 1 said they do not know what the PSA provider does but assume they are to give her a bath. HHA 1 was asked how she knows what to do for the Patient while in the home. HHA 1 said the tasks can be found in Alora (electronic medical record). HHA 1 was asked what specifically they do for Patient #5, to which she said she cleans her up, changes her clothes, and if she has the "runs," she wipes the patient's buttocks. HHA 1 stated she has been taking care of Patient #5 for over a year as well as her family. HHA 1 was asked if Patient #5 walks, to which she said, "Not really, I have never seen [patient] walk." HHA 1 said the patient stands, turns, and sits on the seat of a rolling walker, and then I push the walker. The agency HHA failed to follow the Aide POC and document why care was not provided. The HHA failed to report to the nurse why the tasks assigned at each visit, such as bathing and hygiene, were not needed or offered to the patient. During an interview on 06/14/2024 at 9:30 AM, the Registered Nurse (RN) Educational Nurse stated the aide should report to the nurse or office when the patient was refusing care when care was not completed on the aide plan of care, and if there was a change in condition. She stated it was not appropriate for the nurse or aide to use a rolling walker as a wheelchair and would need re-education. At that time, the Administrator stated that 90% of their patients are non-compliant and do what they want to do. If Patients had to switch to Medicare, they would lose our services. 410 IAC 17-14-1(1)(m)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency Administrator failed to ensure that the home health agency met all the rules and regulations for licensure and failed to ensure compliance with Center of Medicare & Medicaid Services (CMS) Conditions of Participation for 1 of 1 home health agency. Findings include: 410 IAC 17-12-1(c)(1) A policy titled "Governing Body" was provided by the Administrator on 06/18/2024. The policy indicated that the Administrator was responsible for the agency's day-to-day operations of the agency in accordance with all state and federal regulations. The Administrator failed to implement full-scale emergency training and testing, which stressed the agency's emergency preparedness program. The Administrator failed to ensure agency staff encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient. The Administrator failed to ensure the agency provided services as ordered on the plan of care, failed to notify the patient or physician before discharge for cause, and failed to provide patients with contact information for providers able to provide care. The Administrator failed to ensure staff completed an initial assessment within 48 hours of a referral. The Administrator failed to ensure agency staff completed an accurate, comprehensive assessment that reflected the patient's health status The Administrator failed to ensure staff accurately assess, measure, and manage a patient's wound promptly, coordinate care effectively with the provider and PSA agency, and provide immediate care to meet the patient's overall needs. The Administrator failed to ensure a signed plan of care (POC) or a verbal POC order from the primary Physician before providing services and treatments to patients. The Administrator failed to ensure that the Plan of Care (POC) included mental status specific to person, place, and time, all medications, a current and complete list of Durable Medical Equipment (DME) and Supplies, and the Registered Nurse (RN) provided services as ordered by the physician. The Administrator failed to ensure standard infection control precautions were followed regarding bag technique, failed to ensure gloves were removed, and hand hygiene was performed throughout the entire home visit, failed to perform hand hygiene after glove removal, and failed to ensure staff followed the manufacturer's instructions on disinfecting equipment. The Administrator failed to ensure agency staff followed the Home Health Aide (HHA) Plan of Care (POC) as ordered by the Physician, failed to ensure the home health aide provided hands-on direct patient care, and failed to ensure the home health aide reported changes in the patient's condition and needs to a nurse. The Administrator failed to ensure the agency's organizational structure, administrative control, and lines of authority and delegation responsibility were down to the patient care level. The Administrator failed to ensure agency staff completed accurate clinical record documentation. The Administrator failed to ensure staff completed a detailed discharge summary and failed to document all communication with the patient regarding discharge.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure staff completed accurate clinical record documentation for 2 of 6 patients with home visits (Patient #6, #11). Findings include: 2. During an observation on 06/11/2024 at 9:05 AM, RN 3 administered 18 units of Basaglar insulin subcutaneously (under the skin) to Patient #6 during a home visit. A record review of Patient #6's certification from 5/13/2024 to 7/11/2024 included a POC that indicated skilled nursing was to administer Basaglar insulin 14 units to be given every morning, the medication list on the POC indicated Basaglar insulin 18 units to be give every morning. The POC, with a certification from 05/14/2024 to 04/12/2024, indicated that skilled nursing was to administer Basaglar insulin 14 units daily. The medication list on the POC indicated Basaglar insulin 18 units to be given every morning. The agency failed to have an accurate POC for two consecutive certification periods. An Aide Plan of Care with an effective date of 05/13/2024 indicated Patient #6 was to have a shower every visit. An Aide Visit Note, Daily, dated 06/10/2024, indicated the shower was completed on 06/10/2024; an interview with HHA 4 contradicts this. HHA 4 failed to accurately document home visit services offered/provided. An Aide Visit note - dated 06/14/2024 indicated a shower was offered and refused. HHA 4 failed to document home visit services offered/provided accurately. During an interview on 6/14/2024 at 10:54 AM, HHA 4 indicated that she did not offer a shower to Patient #6 today because he does his showers on Saturdays when a friend comes to help him. HHA 4 indicated she could not remember the last time she helped the patient with a shower. 1. A policy titled "Clinical Documentation" indicated, but was not limited to, "Purpose: To ensure that there is an accurate record of the services provided, client response and ongoing need for care". 3. During an observation on 06/14/2024 at 10:30 AM, Home Health Aide (HHA) 12 provided light housekeeping duties for Patient #11 during the home visit. The Clinical Record for Patient #11, certification period 06/14/2024-08/12/2024, included an Aide Plan of Care (POC) that indicated HHA was to complete hair care, skin care, mouth/denture care, and dressing at each visit, as well as light housekeeping duties. An Aide visit note dated 06/14/2024 indicated that Patient #11 had received hair care, mouth/denture care, and dressing completed by HHA 12. HHA 12 failed to accurately document events during the home visit. During an interview on 06/14/2024 at 10:35 AM, Patient #11 indicated refusing shower at this visit due to being too tired, and the HHA would only be doing light housekeeping at this visit. During an interview on 06/14/2024 at 10:50 AM, HHA 12 indicated Patient #11 refused a shower and would only be receiving light housekeeping at this visit. HHA 12 indicated not providing mouth/denture care to Patient #11, as patient does this independently.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to maintain referral documents in the patient's clinical records for 5 of 8 full record reviews with skilled nursing services (Patient #1, #2, #5, #6, #9) Findings include: 5. A document provided by Quality Nurse 2 was a printed email dated 08/09/2022. Next to the date was handwriting that was placed on the document prior to receiving "took referral." The email was sent to multiple Elder's Journey employees and was from Quality Nurse 2 regarding Patient #1. The agency was unable to provide a Physician referral order for Patient #1. The Clinical Record for Patient #1, certification period 01/14/2023-03/14/2023, Start of Care (SOC) date of 08/11/2022, failed to evidence a Physician referral order. 1. An undated policy titled "Clinical Documentation" indicated that communication with physicians will be documented in clinical progress notes or other interagency communication forms. 2. An undated policy titled "Physician/allowed Non-Physician Practitioner (NNP) orders" indicated that a copy of the order must be placed in the chart. All entries must be appropriately authenticated and dated. Authentication must include signatures, written initials, or computer-secured entries. 5. A review of Patient #5's record included a Home Health Plan of Care & Certification, certification period 03/23/2023 to 05/21/2024, SOC date 03/09/2023. The record failed to evidence a referral order from the physician. During an interview on 06/17/2024 at 2:18 PM, QA Nurse 2 provided copies of emails that were sent to other Elder Journey employees that were not part of the Patient record and did not clearly identify a referral date. QA Nurse 2 was asked to identify which email was the referral date to which she pointed to "03/20". The agency failed to ensure referral information was maintained in the clinical record. 410 IAC 17-15-1(a)(1)-(7)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff completed a detailed discharge summary and failed to document all communication with the patient regarding discharge for 5 of 5 closed record reviews. (Patients #1,#2, #3, #8, #9) Findings include: 3. A review of Patient #2's record included a Home Health Plan of Care & Certification, certification period 05/01/2023 to 06/30/2023, included a discharge summary dated 06/30/2023, which indicated Patient 2 was discharged from home health services Per the Wound Care Center, Patient had been discharged due to behaviors and non-compliance with care. The record failed to evidence a detailed discharge summary that aligned with the agency discharge policy. 5. A review of Patient #8's record included a Home Health Plan of Care & Certification with a certification period of 10/25/2023 to 12/23/2023. The record also included a discharge summary dated 11/13/2023 that indicated Patient 8 was being discharged from skilled nursing services due to the patient's ability to self-administer insulin. The record failed to evidence a detailed discharge summary that aligned with the agency discharge policy. 6. A review of Patient #9's record included a Home Health Plan of Care & Certification with a certification period of 10/28/2024 to 22/26/2023, included a discharge summary dated 01/23/2023 stating Patient 9 was being discharged from home health due to the patient not being safe to remain in the home and is non-compliant with care, which risks patients’ health. The record failed to evidence a detailed discharge summary that aligned with the agency discharge policy. 7. During an interview on 6/11/2024 at 11:40, the Director of Clinical Services indicated that the discharge summary should summarize the care provided and explain why the patient is being discharged. =. During an interview on 6/12/2024 at 9:15 AM, the Director of Clinical Services indicated the discharge summary should include the care the patient received from the agency during the certification period =. During an interview on 6/12/2024 at 2:00 PM, the Director of Clinical Service indicated the discharge summary is created by support staff in the office (Quality Assurance Nurses) who send it to the physician, not the Registered Nurse (RN) who performs the discharge visit. 2. The Clinical Record for Patient #1, certification period 01/14/2023-03/14/2023, Start of Care (SOC) date of 08/11/2022, included a discharge summary dated 03/07/2023 indicating Patient #1's services were terminated due to unsanitary work environment. The record failed to evidence a detailed discharge summary that aligned with the agency discharge summary. 1. A policy titled "Client Discharge Process" was provided by the Director of Clinical Services (DCS) on 06/10/2024. The policy indicated that the agency should document if goals were met at the time of discharge. The policy indicated all communication with the patient, including a rationale for discharge, must be maintained in the patient's record. Staff are to complete a discharge summary that includes the following: Patient status at the time of admission to the agency, statement of care and interventions provided and outcomes of care, status at discharge/last visit/current medications, and continuing care needs, name of person or organizations assuming responsibility for care, instructions and referrals given to the patient/family/caregiver, reason for discharge and date of discharge. 4. A review of Patient #3's record included a Home Health Plan of Care & Certification, certification period 12/13/2024 to 02/10/2024, SOC date 05/23/2016, included a discharge summary dated 01/23/2024 stating Patient 3 was ineligible for Medicaid and were unable to renew. The record failed to evidence a detailed discharge summary that aligned with the agency discharge policy. 410 IAC 17-15-1-(a)(6)

This visit was for a Federal and State complaint survey of a Home Health Agency Provider. Survey Date: 4/27/2022 Complaint: 62329 - unsubstantiated, Federal and State deficiencies were not cited. Unrelated deficiencies were cited. Census: 379 active patients This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR Completed 5/10/2022 A4

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 and interviews, the agency failed to ensure policies and procedures were developed and implemented regarding additional precautions to mitigate the spread of COVID-19 for unvaccinated staff that provide direct patient care for 3 of 3 unvaccinated staff interviews (RN G, LPN H, HHA J), with the potential to affect all patients. Findings include: A January 17, 2022 policy titled Mandatory COVID-19 Vaccine Policy and Procedure was provided by the Administrator on 4/27/2022 at 12:40 p.m. The policy indicated, but was not limited to, "Additional Precautions for Vaccine Exempt Staff ... vaccination policy will be required to take the following steps as a reasonable accommodation in place of becoming Fully Vaccinated: Daily self-screening for symptoms, use of masks, hand sanitizer and other PPE, social distancing, when possible, daily disinfecting of personal work space, quarantining when exposed or symptomatic per CDC guidelines. Physical distancing from co-workers and patients, re-assignment or modification of duties, teleworking, or a combination of these actions." Review of the agency Covid-19 vaccination exemption records indicated 67 religious exemptions and 0 medical exemptions. During an interview on 4/27/2022 at 1:20 p.m. the Administrator indicated all unvaccinated staff are not required to wear N95 / K95 masks, weekly Covid testing, or additional measures outside of the CDC guidelines. The Administrator indicated unvaccinated staff are to self-screen for Covid-19, report signs and symptoms of Covid-19, self-distance, hand washing, and wear a regular surgical mask. The agency failed to ensure additional precautions to mitigate the spread of Covid-19 were developed and implemented within agency policy. During an interview on 4/27/2022 at 2:09 p.m. Licensed Practical Nurse (LPN) H indicated he/she wore a regular standard hospital blue mask and self-screens for Covid-19 before providing direct patient care. LPN H indicated he/she does not wear a well-fitted mask such as an N95/K95 mask, test weekly for Covid-19 or perform additional precautions due to being exempt from the Covid-19 vaccination. During an interview on 4/27/2022 at 2:16 p.m. Registered Nurse (RN) G indicated he/she wears a regular surgical mask on home visits. RN G indicated the agency had offered staff N95 masks but don't require exempt staff to wear it. RN G indicated he/she performed hand hygiene, self-screens for Covid-19, but does not do Covid testing due to being exempt from taking the vaccine. During an interview on 4/27/2022 at 2:20 p.m. Home Health Aide (HHA) J indicated he/she wears a regular surgical mask and does a self-screen for Covid-19 as an additional precaution. HHA J indicated he/she does not wear a well-fitted mask such as a N95 / K95 mask or performed weekly Covid-19 testing due to being exempt from taking the vaccine. During exit conference on 4/27/2022 at 5:40 p.m. the Administrator indicated if unvaccinated staff had signs or symptoms of Covid-19 they would be taken off the schedule. The Administrator indicated the literature on the additional precautions for exempt staff was optional. 410 IAC 17-12-1(m)

This visit was for a Federal/State Complaint Survey, in conjunction with a focused infection control COVID-19 survey. Survey Dates: 8/2 and 8/3 of 2021 Complaint IN00358988 - Unsubstantiated with unrelated findings cited Facility Number: 012972 This deficiency reflects State Findings cited in accordance with 410 IAC 17. QR completed 8/18/2021 A4

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was provided and signed off on by the patient prior to documenting in the clinical record for 2 of 4 patients with home health aide visits. (Patients 2 & 3) Findings include: 1. A review of the initial training for the Electronic Medical Record Aide Connect in AloraPlus required by all Home Health Aides instructed as follows: 2) The Pencil Icon - Click on the Pencil Icon. The scheduled visit will open and give the option to start a scheduled visit. b) At the end of the visit, log back in and scroll down to the "Aide Visit Note" c) The visit note will display the items on the Aide Plan of Care for the user to complete d) Check the correct option (completed/not completed/patient refused) save and close e) Obtain patient's signature using the touch screen or mouse f) The patient should sign with actual signature or digital signature g) End the visit 2. The clinical record for patient 2 was reviewed on 8/2/2021. The certification period reviewed was 3/16/2021 to 5/14/2021 with 2 Home Health Aides (HHA) providing services per the Plan of Care. The clinical record evidenced the following: On 3/16/2021, HHA B had a scheduled shift for 8:00 a.m.-2:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:57 a.m. On 3/17/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:59 a.m. On 3/18/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:42 a.m. On 3/19/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:57 a.m. On 3/20/2021, HHA B had a scheduled shift for 8:00 a.m.-12:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 10:19 a.m. On 3/21/2021, HHA B had a scheduled shift for 8:00 a.m.-12:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:53 a.m. On 3/22/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:03 a.m. On 3/23/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:56 a.m. On 3/24/2021, HHA B had a scheduled shift for 8:00 a.m.-12:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:25 a.m. On 3/25/2021, HHA B had a scheduled shift for 8:00 a.m.-1:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 9:38 a.m. On 3/26/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 9:33 a.m. On 3/27/2021, HHA D had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA D and patient 2 signed off on the implementation of all completed tasks at 9:09 a.m. On 3/29/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:57 a.m. On 3/30/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:55 a.m. On 3/31/2021, HHA B had a scheduled shift for 7:30 a.m.-12:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:24 a.m. On 4/1/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:56 a.m. On 4/2/2021, HHA B had a scheduled shift for 9:00 a.m.-5:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:56 a.m. On 4/3/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:54 a.m. On 4/5/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:58 a.m. On 4/6/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:53 a.m. On 4/7/2021, HHA B had a scheduled shift for 7:30 a.m.-12:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:27 a.m. On 4/8/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:55 a.m. On 4/9/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:52 a.m. On 4/12/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:28 a.m. On 4/13/2021, HHA B had a scheduled shift for 8:00 a.m.-4:0 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:00 a.m. On 4/14/2021, HHA B had a scheduled shift for 7:30 a.m.-12:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:24 a.m. On 4/15/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:56 a.m. On 4/16/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:51 a.m. On 4/17/2021, HHA D had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA D and patient 2 signed off on the implementation of all completed tasks at 9:14 a.m. On 4/18/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 9:00 a.m. On 4/19/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:07 a.m. On 4/20/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:49 a.m. On 4/21/2021, HHA B had a scheduled shift for 7:30 a.m.-12:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:28 a.m. On 4/22/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:45 a.m. On 4/23/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:49 a.m. On 4/26/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 12:50 p.m. On 4/27/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:54 a.m. On 4/28/2021, HHA B had a scheduled shift for 7:30 a.m.-12:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:26 a.m. On 4/29/2021, HHA B had a scheduled shift for 9:00 a.m.-2:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 9:04 a.m. On 4/30/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 12:14 a.m. On 5/1/2021, HHA D had a scheduled shift for 9:00 a.m.-1:30 p.m., but HHA D and patient 2 signed off on the implementation of all completed tasks at 9:16 a.m. On 5/2/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 1:26 p.m. On 5/3/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:58 a.m. On 5/4/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 9:14 a.m. On 5/5/2021, HHA B had a scheduled shift for 7:30 a.m.-12:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:44 a.m. On 5/6/2021, HHA B had a scheduled shift for 9:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 9:09 a.m. On 5/7/2021, HHA B had a scheduled shift for 9:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:36 a.m. On 5/10/2021, HHA B had a scheduled shift for 8:00 a.m.-4:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:01 a.m. On 5/11/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 10:33 a.m. On 5/12/2021, HHA B had a scheduled shift for 7:30 a.m.-12:30 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 7:23 a.m. On 5/13/2021, HHA B had a scheduled shift for 9:00 a.m.-5:00 p.m., but HHA B and patient 2 signed off on the implementation of all completed tasks at 8:55 a.m. 3. The clinical record for patient 3 was reviewed on 8/2/2021. The certification period reviewed was 6/15/2021 to 8/13/2021 with 5 Home Health Aides (HHA) providing services per the Plan of Care. The clinical record evidenced the following: On 6/15/2021, HHA F had a scheduled shift for 2:00 p.m.-4:00 p.m., but HHA F and patient 2 signed off on the implementation of all completed tasks at 1:57 p.m. On 6/20/2021, HHA G had a scheduled shift for 12:00 p.m.-3:00 p.m., but HHA G and patient 2 signed off on the implementation of all completed tasks at 12:43 p.m. On 6/22/2021, HHA H had a scheduled shift for 2:00 p.m.-5:00 p.m., but HHA H and patient 2 signed off on the implementation of all completed tasks at 2:28 p.m. On 6/24/2021, HHA H had a scheduled shift for 2:00 a.m.-5:00 p.m., but HHA H and patient 2 signed off on the implementation of all completed tasks at 2:15 p.m. On 6/26/2021, HHA H had a scheduled shift for 2:00 p.m.-5:00 p.m., but HHA H and patient 2 signed off on the implementation of all completed tasks at 2:32 p.m. On 6/28/2021, HHA H had a scheduled shift for 2:45 p.m.-4:30 p.m., but HHA H and patient 2 signed off on the implementation of all completed tasks at 2:46 p.m. On 7/5/2021, HHA H had a scheduled shift for 1:30 p.m.-4:15 p.m., but HHA H and patient 2 signed off on the implementation of all completed tasks at 2:20 p.m. On 7/7/2021, HHA H had a scheduled shift for 1:30 p.m.-3:45 p.m., but HHA H and patient 2 signed off on the implementation of all completed tasks at 1:30 p.m. On 7/8/2021, HHA H had a scheduled shift for 1:30 p.m.-4:30 p.m., but HHA H and patient 2 signed off on the implementation of all completed tasks at 1:43 p.m. 4. During an interview on 8/3/2021 at 12:48 p.m. Director of Clinical Services (DCS) K indicated that aides should not sign off or have the patient sign off on Plan of Care skills performed until the end of the visit. 5. During an interview on 8/3/2021 at 3:55 p.m. the Administrator and DCS K indicated the standard expected for aides during visits is to have the patient and the aide to sign off on completion of the plan of care at the end of the visit. DCS K also stated several in-services have been done discussing this as well to reiterate the initial training provided to aides when hired. 17-15-1(a)(7)