Every finding on record at First Horizon Home Health Care LLC

This visit was for a Federal/State complaint survey of a Deemed Home Health Agency Provider. Survey Dates: 09/18/2025, 09/19/2025, and 09/22/2025 Compalint IN002618759 12 Month Unduplicated Skilled Admissions: 174 Approved Abbreviations: RN - Registered Nurse POC - Plan of Care HHA - Home Health Aide

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure anticoagulation (blood thinner) interventions were on each individualized POC in 3 of 3 active patients' clinical records reviewed recieving anticoagulation therapy, (Patients 1, 2, and 4); and failed to ensure aspiration (swallowing difficulties) interventions were on the individualized POC of 1 of 1 active record reviewed with aspiration precautions, (Patient #5). Findings include: 1. A review of a policy titled 'Care Plans' stated, "... 3. The Care Plan shall include ... c. A list of specific interventions with plans for implementation ..." A review of a policy titled 'Plan of Care' stated, "... 2. The Plan of Care shall be completed in full to include: ... o. Any safety measures to protect against injury ..." 2. A review of the clinical record of Patient #1 evidenced a Plan of Care dated 08/25/2025 for the re-certification period of 08/27/2025 through 10/25/2025 indicated safety measures were not limited to Anticoagulation precautions. The record failed to evidence goals or interventions for the Anticoagulation precautions. 3. A review of the clinical record of Patient #2 evidenced a Plan of Care dated 08/06/2025 for the re-certification period of 08/11/2025 through 10/09/2025 indicated safety measures were not limited to Anticoagulation precautions. The record failed to evidence goals or interventions for the Anticoagulation precautions. 4. A review of the clinical record of Patient #4 evidenced a Plan of Care dated 08/01/2025 for the re-certification period of 08/04/2025 through 10/02/2045 indicated safety measures were but not limited to Anticoagulation precautions. The record failed to evidence goals or interventions for the Anticoagulation precautions. 5. A review of the clinical record of Patient #5 evidenced a Plan of Care dated 07/30/2025 for the re-certification period of 08/02/2025 through 09/30/2025 indicated safety measures were but not limited to Aspiration precautions. The record failed to evidence goals or interventions for the Aspiration precautions. 6. On 09/18/2025 at 09/18/2025, when queried if interventions should be in place and what interventions should be conducted for anticoagulation precautions, RN 1 indicated they should avoid anything that might make a patient bleed. 7. On 09/22/2025 at 1:12 PM, when queried if interventions should be in place for anticoagulation therapy or aspiration precautions, the Clinical Director indicated absolutely interventions should be on Patient's POC. 410 IAC 17-3-1 (i-xiii)

Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure home health training was of an adequate duration, before placing trainees on the Indiana State Aide Registry for active 5 of 8 personnel files reviewed. (HHA 1, 2, 3, 4, and 7) and 2 of 2 inactive personnel (Persons 1 and 2) Findings include: 1. A review of a policy title 'Home Health Aide Services' stated, "Home Health Aide Qualifications ... successfully completed: a. a training program that includes classroom and supervised practical training in a laboratory or other setting ... trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse Classroom and supervised practical training must total at least 75 hours ..." 2. A review of the personnel record of HHA 1 evidenced an application for employment dated 03/27/2025, a certified HHA/CNA Skills Check list completed on and dated 03/27/2025, signed by Person 3, a registered nurse, contracted by the Agency to perform HHA training and competency and by HHA 1, a Certified HHA /CNA test dated 03/27/2025 signed by Person 3, and the Home Health Aide Registry Application signed by HHA 1 and Person 3 on 03/27/2025; HHA 1 received their HHA Certificate on 04/01/2025. The record failed to evidence the classroom and supervised practical training totaled 75 hours. 3. A review of the personnel record of HHA 2 evidenced an application for employment dated 03/17/2025, a certified HHA/CNA Skills Check list completed on and dated 08/01/2025, signed by Person 3, and by HHA 2, a Certified HHA /CNA test dated 06/23/2025 signed by Person 3, and the Home Health Aide Registry Application signed by HHA 2 and Person 3 on 08/01/2025; HHA 3 received their HHA Certificate on 08/05/2025. The record failed to evidence the classroom and supervised practical training totaled 75 hours. 3. A review of the personnel record of HHA 3 evidenced an application for employment dated 03/17/2025, a certified HHA/CNA Skills Check list completed on and dated 03/17/2025, signed by Person 3, and by HHA 3, a Certified HHA /CNA test dated 03/21/2025 signed by Person 3, and the Home Health Aide Registry Application signed by HHA 3 and Person 3 on 03/17/2025; HHA 3 received their HHA Certificate on 03/18/2025. The record failed to evidence the classroom and supervised practical training totaled 75 hours. 4. A review of the personnel record of HHA 4 evidenced an application for employment dated 05/29/2025, a certified HHA/CNA Skills Check list completed on and dated 05/29/2025, signed by Person 3, and by HHA 4, a Certified HHA /CNA test dated 05/27/2025 signed by Person 3, and the Home Health Aide Registry Application signed by HHA 4 and Person 3 on 05/29/2025; HHA 4 received their HHA Certificate on 06/05/2025. The record failed to evidence the classroom and supervised practical training totaled 75 hours. 5. A review of the personnel record of HHA 7 evidenced an application for employment dated 07/23/2025, a certified HHA/CNA Skills Check list completed on and dated 07/23/2025, signed by Person 3, and by HHA 7, a Certified HHA /CNA test dated 06/23/2025 signed by Person 3, and the Home Health Aide Registry Application signed by HHA 4 and Person 3 on 07/23/2025; HHA 4 received their HHA Certificate on 08/05/2025. The record failed to evidence the classroom and supervised practical training totaled 75 hours. 6. A review of the personnel record of Person 1, a former HHA evidenced an application for employment dated 03/13/2025, a certified HHA/CNA Skills Check list completed on and dated 03/13/2025, signed by Person 3, and by HHA 7, a Certified HHA /CNA test dated 03/13/2025 signed by Person 3, and the Home Health Aide Registry Application signed by Person 1 and Person 3 on 03/13/2025; Person 1 received their HHA Certificate on 03/18/2025. The record failed to evidence the classroom and supervised practical training totaled 75 hours. 7. A review of the personnel record of Person 2, a person who started orientation but did not complete; evidenced an application for employment dated 07/18/2025, a certified HHA/CNA Skills Check list completed on and dated 07/17/2025, signed by Person 3, and a Certified HHA /CNA test dated 07/17/2025 signed by Person 3. The record failed to evidence the classroom and supervised practical training totaled 75 hours. 8. A review of the Professional Licensing Agency of Indiana indicated Person 2 obtained their HHA certificate on 07/22/2025. 9. On 09/18/2025 at 1:43 PM, Person 1, a former HHA, indicated they were at the Agency for 4 hours for their orientation and training but could not remember who conducted the training. 10. On 09/18/2025 at 1:49 PM, HHA 1 indicated they arrived at the agency around 9 AM until 2-3 PM for their orientation and HHA training. 11. On 09/18/2025 at 2:03 PM, HHA 2 indicated they came into the office for orientation, completed paperwork, did not complete any hands-on training, further indicated it was probably because of their healthcare background is why they did not have to go through the typical training for HHA's. 12. On 09/18/2025 at 2:12 PM, Person 2, a person who started orientation but did not complete; indicated they did most of the paperwork and testing online, drove to the office for their tuberculosis test, then decided to go a different direction with employment, and was not aware if they had received their HHA certificate. When queried if they had taken HHA training elsewhere, they indicated what was conducted online. 13. On 09/22/2025 at 9:15 AM, the Administrator and Clinical Director indicated 4-5 hours of orientation and training was enough time to complete HHA training and testing. The Administrator indicated they usually conduct their classes from 9-1 then from 1-5, indicated Person 3 performs competencies with each one. On 09/22/2025 at 1 PM, the Administrator indicated after reading the HHA Services Policy, they needed to revamp their training and competencies procedures.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for Home Health Agencies. Survey Dates: 10/17/2024, 10/18/2024, 10/21/2024 and 10/22/2024 Census: 133 At this Emergency Preparedness Survey, First Horizon Home Health Care was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR completed by Area 3 on 10-25-2024.

This was a Federal complaint survey of a deemed home health provider conducted by the Indiana Department of Health Complaint: IN110577 non-compliant with related deficiencies cited. Survey dates: 10/21/2024 and 10/22/2024 Facility #: 157695 12 Month Unduplicated Skilled Admissions: 12 The survey was announced as fully extended to the Alternate Administrator on 10/21/2024 at 9:16 AM. During this Federal Complaint Survey, First Horizon Home Health Care was in found to be out of compliance with the Conditions of Participation 42 CFR 484.105 Organization and administration of services as related to complaint IN110577. Based on Condition-level deficiencies during the October 22, 2024 survey, your Home Health agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 10/21/2024. Therefore and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency, and/or competency evaluation programs from a period of two years beginning 10/22/2024 and continuing through 10/21/2026. Abbreviations HHA Home Health Aide RN Registered Nurse PSA Personal Service Agency CAN Certified Nurses Aide QR completed by Area 3 on 10-29-2024.

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 ensure an RN performed an initial start of care assessment before a HHA provided care for 1 of 1 active clinical record reviewed where the patient’s services were placed on hold. (Patient #2) Findings Include: 1. An undated policy titled “Comprehensive Client Assessment,” Policy No. C-145, indicated but was not limited to, “ … A thorough, well-organized, comprehensive and accurate assessment, consistent with the client’s immediate needs will be completed for all clients in a timely manner … 1. The Comprehensive Assessment will be completed by a Registered Nurse …” 2. A review of Patient #2’s clinical record evidenced a Plan of Care (POC) with a Start of Care date 09-29-2017 and a certification period from 06-24-2024 to 08-22-2024. The POC indicated the HHA provided service 5 days a week for 6 hours a visit. The "Orders" section evidenced HHA orders dated 08-01-2024 which indicated the patient’s HHA services were placed on hold. The POC included an order dated 10-18-2024 and evidenced the patient’s hold orders were until 08-31-2024. Patient #2’s clinical record failed to evidence a comprehensive assessment was completed before the HHA provided care on 09-02-2024. The last comprehensive assessment completed was 06-20-2024 by RN 2. During an interview with the Alternate Administrator/Director of Nursing (DON) on 10-18-2024 at 9:44 AM, they indicated for Patient #2 there were issues with their insurance and they had to place the patient on hold until the insurance issue was fixed. They evidenced RN 1 for the patient was newer and there was a miscommunication regarding when the insurance covered the services again. The DON confirmed RN 1 had not performed an assessment on the patient before HHA 12 started providing care for the patient again. During an interview with RN 1 on 10-18-2024 at 3:33 PM, they evidenced another nurse had placed the hold order for Patient #2 on 08-01-2024. They indicated they had not been informed the patient’s insurance was corrected and they were cleared to restart services. They evidenced they were unable to remember the last time they saw the patient, but confirmed they saw the patient 10-18-2024 for a SOC assessment. RN 1 indicated if a patient resumed services outside of the certification period, they would readmit the patient. 410 IAC 17-14-1(a)(1)(A)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a plan of care was completed for 1 of 1 active clinical record reviewed where the patient’s services were placed on hold. (Patient #2) Findings Include: 1. An undated policy titled “Care Plans,” Policy No. C-660, indicated but was not limited to, “ … 2. The Care Plan shall be reviewed, evaluated, and revised (minimally every sixty (60) days and as needed) …” 2. A review of Patient #2’s clinical record evidenced a POC with a SOC date 09-29-2017 and a certification period from 06-24-2024 to 08-22-2024. The POC evidenced HHA orders dated 08-01-2024 which indicated the patient’s HHA services were placed on hold. The POC included an order dated 10-18-2024 and evidenced the patient’s hold orders were until 08-31-2024. Patient #2’s clinical record evidenced a POC with a SOC date of 10-18-2024 and a certification period from 10-18-2024 to 12-16-2024. The clinical record failed to evidence a POC with a certification period dated when HHA services resumed on 08-31-2024. During an interview with the Alternate Administrator/Director of Nursing (DON) on 10-18-2024 at 9:44 AM, they indicated for Patient #2 there were issues with their insurance and they had to place the patient on hold until the insurance issue was fixed. They evidenced RN 1 was newer and there was a miscommunication regarding when the insurance covered the services again. The DON indicated there was no current POC for Patient #2 because RN 1 had not gone out to see the patient. During an interview with RN 1 on 10-18-2024 3:33 PM, they evidenced another nurse, Person 15 (a previous employee) had placed the hold order for Patient #2 on 08-01-2024. They evidenced they were unable to remember the last time they saw the patient, but confirmed they saw the patient 10-18-2024 for a SOC assessment and complete the POC. 410 IAC 17-13-1(a)(1)(B)(C)(D)(I, ii, iii, iv, v, vi, vii, viii, ix, x, xi, xii, xiii)

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 record review and interview, the agency failed to ensure physician orders were received before providing care for 1 of 1 active clinical record reviewed where the patient’s services were placed on hold. (Patient #2) Findings Include: 1. An undated policy titled “Physician/Allowed Non-Physician Practitioner (NPP) Orders,” Policy No. C-635, indicated but was not limited to, “ … All medications, treatments and services provided to clients must be ordered by a physician …” 2. A review of Patient #2’s clinical record evidenced a Plan of Care (POC) with a Start of Care date 09-29-2017 and a certification period from 06-24-2024 to 08-22-2024. The POC indicated the HHA provided service 5 days a week for 6 hours a visit. The POC evidenced HHA orders dated 08-01-2024 which indicated the patient’s HHA services were placed on hold. An order on the POC dated 10-18-2024 evidenced the patient’s hold orders were until 08-31-2024. A review of Patient #2’s clinical record evidence HHA visit notes dated from 09-02-2024 to 10-17-2024. The clinical record failed to evidence orders for the HHA to provide services starting 09-02-2024. During an interview with the Alternate Administrator/Director of Nursing (DON) on 10-18-2024 at 9:44 AM, they indicated for Patient #2 there were issues with their insurance and they had to place the patient on hold until the insurance issue was fixed. They evidenced the nurse for the patient was newer and there was a miscommunication regarding when the insurance covered the services again. They indicated they had no orders for the HHA to provide care form 09-02-2024 to 10-17-2024. They indicated they had a nurse call and receive orders for care today, 10-18-2024. During an interview with RN 1 on 10-18-2024 at 3:33 PM, they evidenced another nurse had placed the hold order for Patient #2 on 08-01-2024. They indicated they were not informed the patient’s services were supposed to resume on 08-31-2024. They indicated another nurse, Person 40, had received the orders to resume care for the patient from the physician on 10-18-2024. During an interview with HHA 12 on 10-18-2024 at 3:21 PM, they indicated they stopped providing services for Patient #2 on 08-01-2024. They evidenced HHA 16 informed them to resume services on 09-02-2024. During an interview with HHA 16 on 10-22-2024 at 10:14 AM, they indicated they were a scheduler and an HHA. They indicated Patient #2’s services were stopped from 08-01-2024 to 08-31-2024. They evidenced when they were informed the patient could receive services again, they were told to schedule an HHA to see the patient. They indicated a nurse had informed them to schedule the HHA for the patient, but was unable to recall the name of the nurse. During an interview with a nurse, Person 28, and Patient #2’s primary care provider’s, Person 24, office, Entity 18 on 10-22-2024 at 10:45 AM, the nurse indicated most of what they received from the agency was faxed to them. Person 28 indicated there were no orders received from the agency since 08-14-2024, which was a POC with a certification period from 08-05-2024 to 10-03-2024. They explained the patient’s record did not evidence orders for the agency to hold care and restart care. They evidenced the physician, Person 24, potentially had other documents and orders from the agency which may not been incorporated into the patient’s clinical record. 410 IAC 17-13-1(a)

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 record review and interview, the agency failed to ensure the physician was notified of the need to restart services for 1 of 1 active clinical record reviewed where the patient’s services were placed on hold. (Patient #2) Findings Include: 1. An undated policy titled “Medical Supervision,” Policy No. C645, indicated but was not limited to, “ … 4. Physician … will be contacted when any of the following occur: … e. Any changes in client condition or agency services …” 2. A review of Patient #2’s clinical record evidenced a POC with a SOC date 09-29-2017 and a certification period from 06-24-2024 to 08-22-2024. The POC indicated the HHA provided service 5 days a week for 6 hours a visit. The HHA orders in the POC dated 08-01-2024 evidenced the patient’s HHA services were placed on hold. The POC included an order dated 10-18-2024 and evidenced the patient’s hold orders were until 08-31-2024. Patient #2’s active clinical record failed to evidence communication to the physician regarding the resumption of care. During an interview with the Alternate Administrator/Director of Nursing (DON) on 10-18-2024 at 9:44 AM, they indicated for Patient #2 there were issues with their insurance and they had to place the patient on hold until the insurance issue was fixed. They indicated they had a nurse, Person 41 call and receive orders for care today, 10-18-2024. The DON confirmed there was no prior contact to the physician regarding restarting services since the patient was placed on hold. During an interview with RN 1 on 10-18-2024 3:33 PM, they indicated they were not informed the patient’s services were supposed to resume on 08-31-2024. They evidenced another nurse, Person 41, had received the orders to resume care for the patient from the physician on 10-18-2024, no prior contact to the physician because they were unaware the patient was able to resume care. During an interview with a nurse, Person 28, and Patient #2’s primary care provider’s, Person 24, office, Entity 18 on 10-22-2024 at 10:45 AM, the nurse indicated most of what they received from the agency was faxed to them. Person 28 indicated there were no orders received from the agency since 08-14-2024, which was a POC with a certification period from 08-05-2024 to 10-03-2024. They explained the patient’s record did not evidence orders for the agency to hold care and restart care. They evidenced the physician, Person 24, potentially had other documents and orders from the agency which may not been incorporated into the patient’s clinical record. 410 IAC 17-14-1(a)(1)(F)

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 and interview, the agency failed to ensure infection control practices were upheld for hand hygiene and gloving for 2 of 3 home visits with HHAs (HHA 3 and 7) and 1 of 1 home visits with an RN (Alternate Clinical Supervisor) providing care. Findings Include: 4. On 10-18-2024 at 9:30 AM, during a home visit, HHA 7 was observed providing care for Patient #4. The HHA proceeded to wash their hands in the bathroom sink, turned on the faucet, and used soap and running water to wash their hands for greater than 30 secs, used their left bare hand to shut off each faucet handle and used disposable paper towel to dry their hands. The HHA disposed of the paper towel, but returned to the right of the sink and reached for a white hand towel hanging from a towel rack and dried their hands again, rearranged the towel and returned it to the towel rack. The HHA then went to the left of the sink, opened a drawer by pulling on the drawer's small metal knob with their left bare hand to reveal a box of gloves, then donned gloves from this box. When queried as to touching the faucet handles with bare hands, drying hands on the hand towel, and putting a bare hand to the drawer knob, HHA 7 indicated acknowledged should have done this differently. On 10-18-2024 at 12:20 PM, when discussing the home visit with HHA 7, the Alternate Administrator/Director of Nursing indicated there would be corrective education regarding going from 'area to area in the proper sequencing'. 3. During an observation on 10-18-2024 at 9:00 AM, HHA 3 prepared Patient #3 for a bed bath. With gloved hands HHA 3 removed the external catheter, placed the external catheter in the trash, and shut the storage drawer. HHA 3 removed their gloves, performed hand hygiene, and put on clean gloves. HHA 3 washed the patient's peri area (area between scrotum and anus). Wearing the same gloves, HHA 3 obtained an adult diaper, placed the diaper around the patient's ankles, obtained and put on socks, obtained and put on shoes, assisted the patient to sit on the side of the bed, washed the patient's back with the same washcloth, and assisted the patient with a t-shirt and a flannel button down shirt. HHA 3 removed their gloves, and buttoned the flannel. HHA 3 failed to remove their gloves at appropriate intervals, perform hand hygiene at appropriate intervals, and performed a bath going from a dirty area to a clean area. During an interview with the Alternate Administrator/Director of Nursing on 10-18-2024 at 12:00 PM, they indicated they would remind the HHA "what is the last spot to wash in a bath and when to change gloves and perform hand hygiene". They also indicated they know it can be "a lot of gloves and hand hygiene". 1. An undated policy titled “Infection Prevention/Control,” Policy No. B-403, indicated but was not limited to, “ … Standard Precautions … 2. Hands are washed … immediately after gloves are removed … 3. Gloves are worn when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes, or contaminated items …” An undated policy titled “Nursing Bag,” indicated but was not limited to, “ … The inside of the bag and its contents are considered clean. … Hand washing must occur before entering the bag for any reason …” 2. During an observation on 10-22-2024 at 1:30 PM, the Alternate Clinical Supervisor performed an assessment and set up Patient #6’s medications. The Alternate Clinical Supervisor wore gloves and listened to the patient’s heart and lung sounds. Wearing the same gloves, they reached into their nursing bag and retrieved a black box containing an automatic blood pressure cuff. The automatic blood pressure cuff was not working, and using the same gloves, cleaned the automatic blood pressure cuff and put it back in their bag. They grabbed a bag with the manual blood pressure cuff without changing gloves from their nursing bag, took the patient’s blood pressure, cleaned the manual blood pressure cuff, and placed it back in the nursing bag. Without changing gloves and performing hand hygiene, the Alternate Clinical Supervisor reached into their bag and retrieved a thermometer. The Alternate Clinical Supervisor failed to perform hand hygiene before entering their nursing bag. During an interview with the Alternate Clinical Supervisor on 10-22-2024 at 2:20 PM, they indicated hand hygiene was to be performed before entering their nursing bag.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to evidence the Governing Body assumed responsibility for managing Home Health services by failing to provide services to Medicare-insured patients since 2017, as a participant in the Medicare program. These deficiencies had a potential cumulative effect on all 91 patients and 144 staff. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the Condition of Participation of 42 CFR 484.105, Organization and Administration of Services. Findings include: 1. Review of an undated agency policy titled 'CLIENT ADMISSION PROCESS C-140' stated, "… 1. Admission criteria are standards by which a client can be deemed appropriate for admissions. These standards include: … h. The client receiving Medicare reimbursed services has the need for a minimum of one skilled home care service, which will be provided on an intermittent, part-time, or full-time basis (Medicare requirement) …" 2. Review of the agency's website page found at https://www.firsthorizonhhc.com/faq, titled 'FAQ' contained the following, "… What insurance do you accept? … We are pleased to accept a variety of payment methods. Medicaid A&D Waiver, Prior Authorization, CHOICE program, private pay, long-term care insurances, etc. If your insurance is not listed, please call 317-591-9941 to speak to one of our intake team …" and failed to evidence the agency was Medicare certified, able to service Medicare-insured patients. 3. A review of the agency's Admission folder (documents patients would receive upon admission to the agency for home health services) evidenced a page titled 'ACCEPTANCE OF PATIENTS' which stated, "… In evaluating the appropriateness of the request for home care services, acceptance for services shall be based upon the following admission criteria: … C. Patients must have a means for payment of services whether through Medicare (not currently a Medicare Provider), Medicaid, Insurance, self-pay or other private or government funds …" 4. A review of the agency's Governing Body meeting minutes dated 04-12-2024 stated, "… Payor sources will not include Medicare but First Horizon remains open to Medicare as a payor source in the future …" 5. On 10-17-2024 at 10:49 AM, the Alternate Administrator/Director of Nursing (AA/DON) indicated the agency had not serviced Medicare patients "in years". On 10-18-2024 at 10:15 AM, the ADON indicated the agency did not take Medicare, "we have not chosen to do so". When queried as to whether the agency ever had serviced Medicare patients, indicated the agency had not done so in the 8 years they had been employed there. On 10-18-2024 at 10:31 AM, when queried as to why the agency had not taken on Medicare patients, the AA/DON indicated the agency was willing and able to do so, but had not wanted to take this on, wanting to get this [Medicaid] model down first, then explore Medicare. When queried as to whether Medicare patients had been turned away, indicated the agency evaluated whether care could be provided, and the payor source, as they do not take on patients they cannot provide the care for. When queried as to what occurs when a patient develops a wound while on service, indicated we can do wound care, but if it’s under Medicaid we don’t have the resources, we can talk with the physician and for example find a new outpatient wound clinic to manage the wound for patients who are dually insured [having both Medicare and Medicaid]. On 10-18-2024 at 11:28 AM, RN 3 indicated was a newer employee with the agency, had started in July of 2024, and currently assisted the agency with intake duties. When queried as to what happens with Medicare referrals that may come in, indicated most referrals come from a community resource that provides case management for patients, most referrals were essentially PA [Prior Authorization], Structured Family waiver, or private pay. Indicated had not received any Medicare referrals recently. Indicated if a referral for a Medicare patient comes their way, has been instructed to send it to the AA/DON, indicates this had not yet happened. When queried if the agency accepts Medicare indicated, "don’t accept Medicare" and "all the nurses told me that too" when they started. On 10-18-2024 at 02:49 PM, the AA/DON, also a governing body member, indicated there had been no discussions regarding relinquishing their Medicare certification. On 10-22-2024 at 3:32 PM, the AA/ADON, when considering corrective actions, indicated the agency could 'pull-out' of Medicare and then reapply with a new 855 when the agency was better prepared to take on Medicare. 410 IAC 17-12-1(b)