Every finding on record at Elite Home & Nursing Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 12/02/2024 - 12/04/2024 Active Census: 10 At this Emergency Preparedness survey, Elite Home and Nursing Care LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR by A4 on 12/10/2024

This visit was for an Initial Federal Medicaid Certification and Initial State Licensure survey of a Home Health provider. Survey Dates: 12/02/2024 -12/04/2024 12-month Unduplicated Skilled Admissions: 13 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: HHA-Home Health Aide POC-Plan of Care SOC- Start of Care RN-Registered Nurse PSA-Personal Service Attendant

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patients received information regarding Federal and State funding information for 3 of 3 home visit observations. (Patient #2, #3, #4) Findings include: 1. An undated policy titled "Home Care Bill of Rights" indicated staff advises the patients of the addresses and phone numbers of federal and state-funded entities such as the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center, Quality Improvement Organization. 2. During a home visit on 12/03/2024 at 9:00 AM, Patient #3's admit packet did not include the addresses and phone numbers of the local, federal, and state-funded entities on the back of the admit packet. 3. During a home visit on 12/04/2024 at 10:00 AM, Patient #2's admit packet did not include the addresses and phone numbers of the local, federal, and state-funded entities on the back of the admit packet. 4. During a home visit on 12/04/2024 at 1:00 PM, Patient #4's admit packet did not include the addresses and phone numbers of the local, federal, and state-funded entities on the back of the admit packet. While at the home visit, the Alternate Administrator stated she could not find the addresses and phone numbers for the local, federal, and state-funded entities and was unsure why staff did not complete all forms in the admit packet. 5. During an interview on 12/04/2024 at 2:55 PM, the Alternate Clinical Supervisor reviewed the admit packet and could not find the addresses and phone numbers of the local, federal, and state-funded entities. The admit packet indicated the agency was to complete the information. 6. During a phone interview on 12/04/2024 at 2:56 PM, the Administrator stated the expectation was for the agency to complete all information in the admit packet.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to— (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide large print material for a patient with vision problems for 1 of 3 home visit observations. (Patient #3) Findings include: An undated policy title, "Home Care Bill of Rights," indicated that staff should provide information to accommodate their disability. During a home visit on 12/03/2024 at 9:00 AM, Patient #3 stated they could not read the admission packet provided. Patient #3 stated they would have to hold the packet 3 inches from their face to read it. At that time, the Alternate Clinical Supervisor stated Patient #3 was legally blind. During an interview on 12/04/2024 at 10:20 AM, the Alternate Clinical Supervisor stated they could provide large print material. She stated that the staff should have offered large print material for Patient #3.

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 other agencies providing patient care affecting 7 of 8 patients receiving HHA services (Patients #1, #4, #5, #6, #7, #9, #10). Findings include: 9 . A review of Patient #10's record, SOC date 09/23/2024, included a POC indicating Patient #10 was receiving Entity 1 PSA services. The agency failed to document the coordination of care between the agencies. During an interview on 12/03/2024 at 9:30 AM, the Alternate Administrator stated there would be no communication notes between the agencies because we did not know there needed to be. 10. During a home visit observation on 12/04/2024 at 1:00 PM, Patient #2 stated they were mad about not knowing when Entity 1 PSA was coming to see them. At that time, the Alternate Administrator stated she did not know the Entity 1 PSA schedule but would check into it. The agency failed to coordinate services with a PSA agency. During an interview on 12/03/2024 at 9:30 AM, the Alternate Administrator stated there would be no communication notes between the agencies because we did not know there needed to be. 410 IAC 410 17-14-1(a)(1)(F) 2. A review of Patient #1's record, SOC date 10/01/2024, included a POC indicating Patient #1 was receiving Entity 1 PSA services. The agency failed to document the coordination of care between the agencies. 9. A review of Patient #9's record, SOC date 10/16/2024, included a POC indicating Patient #9 was receiving Entity 1 PSA services. The agency failed to document the coordination of care between the agencies. 1. An undated policy titled "Coordination of Client Services" indicates After the initial assessment, the admitting Registered Nurse coordinates findings with other agencies and institutions; direct communication will be provided to caregivers related to the planning and change in the plan of care; documentation must address the coordination of activities between caregivers and how and when communication happens. 2. A review of Patient #4's record included a POC summary that indicated Entity 1 was providing in-home services to Patient #4. The record failed to evidence care coordination between the agency and Entity 1. During an interview on 12/04/2024 at 10:00 AM, Person 1 was present during home visit and indicated they worked for Entity 1 and provided care to Patient #4 three to four times per week. They indicated there had been no communication from the agency regarding Patient #4 since the agency started providing care to Patient #4. During an interview on 12/03/2024 at 8:50 AM, the Alternate Administrator indicated Patient #4's records did not have coordination notes documented in records; there was no documented communication between staff or the agency and Entity 1. 3. 2. A review of Patient #5's record included a POC summary that indicated Entity 1 was providing in-home services to Patient #5. The record failed to evidence care coordination between the agency and Entity 1. 4. A review of Patient #6's record included a POC summary that indicated Entity 1 was providing in-home services to Patient #6. The record failed to document care coordination between the agency and Entity 1. 5. A review of Patient #7's record included a POC summary that indicated Entity 1 was providing in-home services to Patient #7. The record failed to document care coordination between the agency and Entity 1. 8. During an interview on 12/04/2024 at 9:30 AM, the Alternate Administrator indicated no communication documented between the agency and Entity 1 will be found in patient records. The agency does communicate with Entity 1, but it is not documented. IAC 410 17-12-2(h)

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to ensure staff provided patients with a written copy of instructions regarding the frequency of visits for 2 of 3 home visit observations. (Patient #2, #4) Findings include: 3. During an observation on 12/04/2024 at 10:00 AM, Patient #4 provided an admission folder the agency had provided them, and a blank calendar was found in the admission packet. During an interview on 12/04/2024 at 10:00 AM, Patient #4 indicated the admission packet had all the papers the agency had provided to them. They indicated they did not have a calendar of upcoming scheduled visits; the agency typically calls the day before the visit to let them know the time of the visit. 1. An undated policy titled "Home Care Bill of Rights" indicates patients and their representatives are to be informed verbally and in writing regarding their care. 2. During a home visit observation on 12/03/2024 at 10:00 AM, Patient #2's admit packet failed to evidence that the Visit Schedule was completed and provided to the patient, including the discipline, frequency, and duration information. During an interview on 12/04/2024 at 1:15 PM, the Alternate Administrator stated that the staff should have filled out the information for the patient. She was not sure why the staff did not complete it. 4. During an interview on 12/04/2024 at 2:55 PM, the Administrator stated that the agency should complete all information in the admission packet.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to complete HHA supervisory visits every 14 days, affecting 2 of 2 patients receiving skilled nursing and HHA services (Patient #5, #7) Findings include: 1. An undated policy titled "Home Health Aide Supervision" Indicates when skilled services are being provided to a patient, the RN must make a supervisory visit no less frequently than every 14 days 2. A review of Patient # 5 record included a POC dated 10/08/2024 that evidenced HHA services two days per week and a verbal order dated 11/11/2024 for skilled nursing services one day per week for 3 weeks. The record failed to evidence that HHA supervisory visits were completed during nursing visits on 11/11/2024, 11/20/2024, and 11/25/2024. During an interview on 12/04/2024 at 1:06 PM, the Alternate Clinical Supervisor indicated she could not find documented HHA supervisory visits in Patient #5 chart; the HHA supervisory visits for Patient #5 should have been done on 11/25/2024. 3. A review of Patient # 7 record included a POC dated 10/23/2024 that evidenced skilled nursing service every other week, and HHA services 2 days/week. The record failed to evidence that HHA supervisory visits were completed during nursing visits on 11/07/2027 and 11/19/2024. During an interview on 12/04/2024 at 1:06 PM, the Alternate Clinical Supervisor indicated she was not able to find documented HHA supervisory visits in Patient #7 chart; HHA supervisory visits for Patient #7 should have been done on 11/07/2024 and 11/19/2024.

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 ensure all documentation was completed for 2 of 10 active record reviews. (Patients #8, #9) Findings include: 1. An undated policy titled "Face-To-Face Encounter" indicated but was not limited to, "To document that the client has a skilled need for nursing or therapy services … Ensuring documentation is completed." 2. A review of Patient #8's record, SOC 09/19/2024, evidenced a F2F Encounter for Home Health Services ordered 10/29/2024 and signed by a physician, however, it did not specify the discipline ordered (e.g., skilled nursing or home health aide services). During an interview on 12/04/2024 at 10:36 AM, the Alternate Clinical Supervisor stated that they reviewed records and must have missed that Patient #8's F2F was signed, but nothing was ordered. 3. A review of Patient #9's record, SOC 10/16/2024, evidenced that the F2F Encounter for Home Health Services had been sent to a physician but not returned within a time frame greater than 30 days. The agency failed to obtain a signed F2F order in a timely manner. During an interview on 12/04/2024 at 10:36 AM, the Alternate Clinical Supervisor stated that the physician had signed and returned the initial visit and POC but had not signed and returned the F2F. 410 IAC 17-15-1(a)(1) - (7)