Every finding on record at Favor Healthcare Services Inc

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for a Home Health Provider and Suppliers. Survey Dates: 11/14/2022, 11/15/2022, 11/16/2022, 11/17/2022, 11/18/2022, 11/21/2022, 11/22/2022, 11/23/2022 Census: 22 At this Emergency Preparedness survey, Favor Healthcare was found to not be in compliance with Conditions of Participation 42 CFR 484.102 Emergency Preparedness requirements for Medicare Participating Providers and Suppliers.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to develop an individualized emergency preparedness plan for 3 of 3 patients where a home visit was conducted. (#1, #2, #3) The findings include: 1. Record review of a policy retrieved on 11/23/2022, titled “Emergency Operations Plan and Policies” revised in 2014, stated “Policy … The Agency Administrator, Director of Clinical Services and staff implement emergency operations plan, as appropriate … Procedure 1. The Agency complies with all applicable federal, state, and local emergency preparedness requirements … 5. Mitigation activities (designed to reduce the risk of and potential damage from an emergency) will be undertaken in an effort to lessen the severity and impact of a potential emergency. Such activities include: … Developing an individual emergency preparedness plan for each patient as part of the comprehensive assessment. Individual patient preparation: prioritizing patients who might require care/service during emergency and advanced planning for extra supplies, equipment, medications, food, and home evacuation … Assisting patient and families to develop a home emergency plan ….” 2. Record review of a policy retrieved on 11/23/2022, titled “Patient Education” revised in 2014, stated “Policy … Agency staff will provide initial and ongoing education to meet each individual patient’s needs … Procedure … 2. Based on patient condition, physician ordered care and assessed needs, patient/family will receive education, as appropriate, about: … Basic health practices and safety … Basic physical and structural home safety … Procedures to follow for a natural disaster or other emergency disrupts Agency’s services … 3. The patient education provided will be: Presented in a manner that the patient understands … Documented ….” 3. An observation of a home visit was conducted on 11/15/2022, from 9:57 AM – 11:09 AM, for patient #1, start of care, 10/15/2022, with Home Health Aide #1. During the observation, the patient’s home admission folder was reviewed for an individualized emergency preparedness plan. Observation evidenced an emergency preparedness form which had not been completed by the clinician. Observation failed to evidence the emergency preparedness plan was completed to include individualized patient plan. 4. An observation of a home visit was conducted on 11/16/2022, from 10:04 AM – 10:53 AM, for patient #2, start of care 8/20/2022, with Physical Therapist (PT) #1. During the observation, the patient’s home admission folder was reviewed for an individualized emergency preparedness plan. Observation evidenced an emergency preparedness form which had not been completed by the clinician. Observation failed to evidence the emergency preparedness plan was completed to include individualized patient plan. 5. An observation of a home visit was conducted on 11/18/2022, from 2:53 PM – 3:48 PM, for patient #3, start of care 10/12/2022 with Registered Nurse #2. During the observation, the patient’s home admission folder was reviewed for an individualized emergency preparedness plan. Observation evidenced an emergency preparedness form which had not been completed by the clinician. Observation failed to evidence the emergency preparedness plan was completed to include individualized patient plan. During an interview on 11/18/2022, at 3:43 PM, patient #3 indicated their life alert button was the emergency preparedness plan. 6. During an interview on 11/22/2022, at 3:48 PM, administrator #1 indicated the emergency preparedness plan should be discussed and created at the start of care assessment.

This visit was for a Federal Recertification and State Re-licensure Survey of a Home Health provider. Survey Dates: 11/14/2022, 11/15/2022, 11/16/2022, 11/17/2022, 11/18/2022, 11/21/2022, 11/22/2022, 11/23/2022 Census: 22 Facility # 013005 These deficiencies reflect State Findings cited in accordance with 410 IAC [Indiana Administrative Code] 17. Quality Review Completed 12/12/2022

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care had individualized safety precautions to meet the patients’ needs for 3 of 4 patients prescribed antithrombotic medications, from a total sample of 5 active clinical records reviewed. (patient #2, #3, #6) The findings include: 1. Record review of a policy retrieved on 11/23/2022, titled “Plan of Care – CMS [Center for Medicare/Medicaid Services] #485 and Physician Orders” revised in 2015, stated “Policy … Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long range needs and resources … Procedure … 11. … The Plan of Care includes: … Specific procedures deemed essential for the health and safety of the patient … Safety measures to protect against injury ….” 2. Clinical record review for patient #2, start of care 8/20/2022, pertinent diagnosis included, but was not limited to, long term use of antithrombotic/antiplatelets [medications that reduce blood clotting], evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 10/19/2022 – 12/17/2022, electronically signed by Registered Nurse (RN) #1 on 10/14/2022. This document had an area subtitled “Medications” which stated “… Clopidogrel [antiplatelet medication] … 1 tablet daily by mouth ….” Another area subtitled “Safety” failed to evidence bleeding precautions. Record review failed to evidence the plan of care was individualized to the patient’s safety needs. During an interview on 11/22/2022, at 4:14 PM, administrator #1 indicated they would expect to see patient #2 on bleeding precautions. 3. Clinical record review for patient #3, start of care 10/12/2022, pertinent diagnosis included, but was not limited to, a history of pulmonary embolism (condition where one or more arteries in the lungs become blocked by a blood clot), evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 10/12/2022 – 12/10/2022, electronically signed by RN #2 on 10/12/2022. This document had an area subtitled “Medications” which stated “…Warfarin [antiplatelet medication] … Take 1 tablet daily by mouth ….” Another area subtitled “Safety” failed to evidence bleeding precautions. Record review failed to evidence the plan of care was individualized to the patient’s safety needs. During an interview on 11/22/2022, at 4:26 PM, administrator #1 indicated a patient taking warfarin would be expected to have bleeding precautions on the plan of care. 4. Clinical record review for patient #6, start of care 6/20/2022, pertinent diagnosis included, but was not limited to, use of long term anticoagulants (blood thinning medication), evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 10/18/2022 – 12/16/2022, electronically signed by RN #2 on 10/17/2022. This document had an area subtitled “Medications” which stated “…Warfarin … 1 tablet daily by mouth ….” Another area subtitled “Safety” failed to evidence bleeding precautions. Record review failed to evidence the plan of care was individualized to the patient’s safety needs. 5. During an interview on 11/22/2022, at 3:47 PM, administrator #1 indicated any patient taking blood thinning medications including but not limited to Clopidogrel and warfarin should have bleeding precautions. 410 IAC 17-13-1(a)(1)(D)(xi)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure that all clinicians providing patient care on behalf of Favor Healthcare prevented the spread of infectious diseases by using proper hand hygiene according to agency policy for 1 of 1 contracted employee observed. (Physical Therapist #1) The findings include: Record review of a policy retrieved on 11/23/2022, titled “Hand Hygiene Policy and Compliance Program” revised in 2016, stated “Policy … Hand hygiene will be done by all employees to reduce the transfer of microbes to patients and to prevent growth of microorganisms on the nails, hands, and forearms … Procedure … 1. Indications for staff performing hand hygiene are: Before and after direct patient care. Before each procedure … 2. All employees are responsible for implementing hand hygiene procedures in an ongoing attempt to prevent and/or contain infectious processes and communicable diseases … 4. The proper procedure for handwashing when using soap and water is as follows: … Hold hands under running water so they get completely wet … Lather hands well with liquid, antimicrobial soap … Using a clean paper towel, dry hands thoroughly … Turn off water faucet using towel ….” An observation of a home visit was conducted on 11/16/2022, from 10:04 AM – 10:53 AM, for patient #2, start of care 8/20/2022, with Physical Therapist (PT) #1. At 10:08 AM, PT #1 walked into the bathroom and turned sink faucet on, removed a bottle from their pocket, applied the liquid to their left hand, and put the bottle back in the right pocket. PT #1 lathered and scrubbed their hands and wrists with friction, then rinsed until all bubbles were gone. With bare hands, PT #1 turned the sink faucet off and left the bathroom without drying their hands. At 10:52 AM, PT #1 went into the bathroom to wash hands at the end of the visit, turned on the sink faucet, removed bottle from pocket and applied liquid to left hand. PT #1 set the bottle on the counter, rubbed hands together with friction, lathered hands and wrists, then rinsed hands under running water until bubbles were gone. PT#1turned water off with bare hands, removed paper towel from jacket pocket, dried hands and wiped bottle from counter. Observation failed to evidence the clinician providing patient care used proper hand hygiene as stated in agency policy. Observation failed to evidence the clinician used a paper towel to turn the sink off. Observation failed to evidence the clinician dried their hands thoroughly. Observation failed to evidence the clinician used techniques to prevent the spread of infectious microbes. During an interview on 11/22/2022, at 4:20 PM, administrator #1 indicated the agencies hand hygiene policy instructed the clinicians to take hand washing supplies to the sink, turn on the faucet, wash hands with soap and water, wipe hands dry with paper towel, then turn off faucet with a new paper towel. 410 IAC 17-12-1(m)

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure all clinicians documented accurately and completely for 1 of 1 patient reviewed who received physical therapy services, from a total sample of 7 clinical records reviewed. (patient #2) The findings include: Record review of a policy retrieved on 11/23/2022, titled “Nursing Services” revised in 2014, stated “Policy … Patients receiving nursing services will have appropriate assessments, reassessments, care planning and established outcomes performed … Procedure … 2. Professional nursing service will be provided by a registered nurse and include: … Initial and ongoing comprehensive assessments of the patient’s needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points … Preparing clinical and progress notes ….” Record review of a policy retrieved on 11/23/2022, titled “Plan of Care – CMS #485 and Physician Orders” revised in 2015, stated “Policy … Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long range needs and resources … Procedure … 23. Orders for services to be furnished “as needed” or “PRN” must be accompanied by a description of the patient’s medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician order would have to be obtained ….” Record review of a policy retrieved on 11/23/2022, titled “Emergency Operations Plan and Policies” revised in 2017, stated “Policy … The Agency primarily serves elderly, homebound patients. Vulnerabilities for patients may include no caregivers to provide assistance and/or no way to evacuate home safely … Procedure … 5. Mitigation activities (designed to reduce the risk of and potential damage from an emergency) …Such activities include: … Developing an individual emergency preparedness plan for each patient as part of the comprehensive assessment … Assisting patients and families to develop a home emergency plan ….” An observation of a home visit was conducted on 11/16/2022, from 10:04 AM – 10:53 AM, for patient #2, start of care 8/20/2022, with Physical Therapist (PT) #1. During the observation, the patient’s home admission folder was reviewed for an individualized emergency preparedness plan. Observation evidenced an emergency preparedness form which had not been completed by an agency clinician. Clinical record review on 11/17/2022, evidenced an agency document titled “OASIS-D1 Recertification” electronically signed by Registered Nurse (RN) #1 on 10/14/2022. This document had an area subtitled “Risk Assessment” which stated “… Emergency Preparedness Performed ….” Record review failed to evidence the skilled professional documented accurately to the information observed at the home visit. During an interview on 11/22/2022, at 3:48 PM, administrator #1 indicated the emergency preparedness plan should be discussed and created at the start of care assessment. During an interview on 11/22/2022, at 4:16 PM, when queried if the clinician should document Emergency Preparedness was performed after it was completed, administrator #1 stated “Yes.” Record review on 11/17/2022, evidenced an agency document titled “PT Plan of Care” which was electronically signed by PT #1 on 11/14/2022. This document had an area subtitled “Treatment Plan” which had a checked box next to tasks that should be performed including but not limited to “Pulse oximetry PRN [measurement of oxygen in the blood as needed] ….” Record review failed to evidence an indication for when the pulse oximetry should have been performed. Record review failed to evidence the skilled professional documented completely and accurately to meet the patient’s needs. During an interview on 11/22/2022, at 4:19 PM, when queried why a pulse oximetry measurement should be performed as needed, administrator #1 indicated it might be needed after an exercise or if a patient was short of breath. Administrator #1 stated “It should say why.” 410 IAC 17-14-1(a)(1)(E)-RN

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 home health agency failed to ensure every home health aide (HHA) followed the assigned care plan for 1 of 1 patient where a home visit was conducted with a HHA. (patient #1) The findings include: Record review of a policy retrieved on 11/23/2022, titled “Home Health Aide Documentation” revised in 2015, stated “Policy … The Agency will ensure accurate documentation of home health aide services … Procedure … 1. The HHA will document services rendered to the patient on the appropriate Home Health Aide charting form ….” An observation of a home visit was conducted on 11/15/2022, from 9:57 AM – 11:09 AM, for patient #1, start of care, 10/15/2022, with Home Health Aide (HHA) #1. During the observation, HHA #1 performed vital signs, light housekeeping, and medication reminder. Clinical record review evidenced an agency document titled “HHA Care Plan” for episode/period 10/15/2022 – 12/13/2022, which stated “… Skin Care … Pericare [care pertaining to the genital area] ….” Record review evidenced an agency document titled “HHA Visit” from 11/15/2022, and electronically signed by HHA #1. This document had an area subtitled “Tasks” which had checked boxes to indicate they were completed, including but not limited to skin care and pericare. Observation failed to evidence skin care and pericare was performed. Record review failed to evidence documentation indicating a reason for the tasks not being completed. Observation and record review failed to evidence all tasks were completed on the care plan as assigned. During an interview on 11/22/2022, at 4:05 PM, administrator #1 indicated “QV” on the HHA Care Plan meant every visit. At 4:08 PM, administrator #1 indicated skin care should include applying lotion to the patient’s skin, pericare should include washing the patient’s groin and genital area, and the HHA could write a comment if a task was not completed for any reason.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure a home health aide (HHA) supervisory visit was performed every 14 days for 1 of 1 patient where a home visit was conducted HHA. (patient #1) The findings include: Record review of a policy retrieved on 11/23/2022, titled “Home Health Aide Supervision” revised in 2015, stated “Policy …All home health aide supervisory visits will be made at least every 14 days … Procedure … 1. Home Health Aides are closely supervised to ensure their competence in providing care. At least every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met ….” Clinical record review on 11/18/2022, for patient #1, start of care 10/15/2022, evidenced an unsigned document titled “HHA Supervisory Visit” dated 11/15/2022. This document was retrieved on 11/18/2022, at 12:54 PM, and failed to evidence 9 of 9 evaluation questions had been answered. Record review failed to evidence the supervisory visit was completed. Record review evidenced the previous HHA supervisory visit was completed on 11/1/2022. Record review failed to evidence the HHA supervisory visit was completed at least every 14 days. During an interview on 11/22/2022, at 4:03 PM, administrator #1 indicated a HHA supervisory visit should be completed every 14 days.