Every finding on record at Foster Home Care Services Inc

A complaint investigation survey was conducted at Foster Home Care Services. Complaint # IN00336526 - substantiated with findings Survey Date: 1/29/2021 Facility ID: 013729 Skilled Unduplicated Census: 29 Active Census: 18 Discharged Census: 29 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Quality Review completed 02/19/2021 Area 1

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients were advised of the state toll free home health telephone hotline number in 1 of 1 patient interview. (#1) The findings include: 1. An agency policy number C:2-002.1, titled "Admission Documents" revised May 2009, stated "To ensure organizational compliance with the Patient Bill of Rights and regulatory requirements ... Policy ... Foster Home Care Services, Inc will provide written admission documents prior to or at initiation of home care services including: ... 8. Information addressing the availability, purpose, and appropriate use of State, Medicare and [entity A, accreditation agency] hotline numbers ... " 2. An agency admission folder was received on 1/29/2021, at 11:20 AM, by employee A, administrator, who indicated the folder was ready for patient use. Page 8 of the admission folder stated "1. To contact the state regulatory Agency in writing or via the state home health agency hotline in order to seek information on agencies in the state and or file a complaint. The patient also has the right to use the hotline to lodge complaints concerning the implementation of advanced directives requirements the state agency operates 24 hours a day, seven days a week. ISDH [Indiana State Department of Health] Toll-free complaint report line: 1-800-246- or email complaints@isdh.in.gov ... " An agency document in the admission folder, titled "Home Health Toll Free Hotline" stated "The purpose of the toll free hotline is to receive complaints or inquiries about home health agencies that are Medicare certified and operate in Indiana. Also to use this hotline to lodge complaints concerning the implementation of the advance directive requirements. The hotline maybe contracted [sic] as follows: ... Indiana State Department of Health (ISDH) toll-free complaint report line: 1-800-246- or email complaints@ISDH.in.gov ... " Record review of the admission folder failed to evidence the complete phone number for the Indiana state toll-free hotline. On 1/29/2021 at 3:08 PM, the administrator was unable to read back the Indiana Home Health Hotline number by looking at the admission folder provided to patients of the agency. 3. During an interview on 1/29/2021, at 1:15 PM, Patient #1, an active patient of the agency, explained that a skilled nurse comes to the home and draws blood to determine therapeutic levels of Coumadin [blood thinning medication] and would report the result to their physician. The patient indicated their services with the agency were set up by entity C, a healthcare system, and was asked to always call them first. When queried if the skilled nurse coming from the agency left an admission folder with agency information, the patient indicated no. This patient failed to know how to report a complaint to the Indiana Department of Health. 410 IAC 17-12-3(b)(2)(C)

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 ensure the QAPI [Quality Assurance Performance Improvement] data was collected and monitored to assess the effectiveness and safety of services and quality of care. The findings include: An agency policy number C:4-001.1, titled "Organizational Planning" revised May 2009, stated "Purpose ... To define a process for the development and monitoring of an organizational/strategic plan that is consistent with the organizations mission and patient needs ... Procedure ... 3. The planning process will be monitored by leadership through a quarterly review of: ... D. Quality Assessment Performance Improvement results ... " Record review on 1/29/2021, evidenced a document titled "Quarterly QAPI Minutes of Meeting" dated 4/9/2020, in the agency's QAPI binder. Record review failed to evidence a QAPI meeting was held to monitor the effectiveness of the agency's Performance Improvement Plan (PIP), quality of care, or opportunities for improvement. Record review on 1/29/2021, evidenced an agency document titled "PDSA [Plan Do Study Act] Worksheet" which was identified as a current PIP for the agency by RN (Registered Nurse) B. The PIP had a cycle start date of 8/27/2019, and a cycle end date of January 2020. This document stated "Plan ... Teams on different projects will work on following (high risk hospitalization patients, out come measure, process measure, 485 and other audit sheets) for this purpose our dedicated team headed by our DON [director of nursing] and administrator [Person B] who will work on patients charts with their teams which is already started from 10/10/2019 and will be finalized January 1st 2020 ... " Record review failed to evidence the PIP was monitored for accuracy. Record review failed to evidence the correct name of the current administrator on the PIP. Record review evidenced the PIP had expired in January 2020. During an interview on 1/29/2021, at 3:03 PM, RN B stated "QAPI meetings are held quarterly." RN B indicated a QAPI meeting was overdue. 410 IAC 17-12-2(a)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the administrator failed to ensure performance improvement projects (PIP) were in development, on-going, or completed annually. The findings include: An agency policy number C:2-038.1, titled "Patient Focused Performance Improvement" revised May 2009, stated "Policy ... The organization's performance improvement process says will focus on the quality of patient in program outcomes. In addition, the assessment, planning, implementation of care in services, and evaluation of goal attainment will be individualized to the specific patient ... Procedure ... Patient Specific Outcomes ... 2. Time frames will be established for goal attainment. Organization-wide outcomes ... As part of the organization-wide performance improvement process, opportunities for improvement related to patient outcomes will be identified through continuous measurement of patient satisfaction survey results, clinical service record review, monitoring of incidents an infection control reports and Adverse Event Outcomes Reports. 2. Program, or process related performance improvement activities will focus on opportunities to improve overall organizational performance ... " Record review of the QAPI [Quality Assurance Performance Improvement] binder on 1/29/2021, evidenced an agency document titled "PDSA [Plan Do Study Act] Worksheet" which was identified as a current PIP for the agency, by RN (Registered Nurse) B. The PIP had a cycle start date of 8/27/2019, and a cycle end date of January 2020. This document stated "Plan ... Teams on different projects will work on following (high risk hospitalization patients, out come measure, process measure, 485 and other audit sheets) for this purpose our dedicated team headed by our DON [director of nursing] and administrator [Person B] who will work on patients charts with their teams which is already started from 10/10/2019 and will be finalized January 1st 2020 ... " Record review evidenced a document titled "QAPI Canvas" which identified to be the outline of the PIP by RN B. This document stated "Problem: ... High blood pressure monitoring ... " Record review evidenced a document titled "Blood Pressure Audit Report" which was separated into columns to document data including, but not limited to, patient's name, date of visit, and patient's blood pressure reading. The dates where data was recorded ranged from 1/30/2020 to 8/11/2020. The bottom of this document stated "Final Report Will Be Established in the Month of December with Action Taken.... " Record review failed to evidence a current PIP or additional PIPs. Record review failed to evidence the PIP was ongoing or completed.

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 administrator failed to ensure responsibility for the day-to-day operations of the home health agency. (employee A) The findings include: 1. An undated policy #A-4, titled "Administrator" stated "Purpose ... To ensure compliance with all federal and state regulations and define the responsibilities of the Administrator ... Policy Statement ... The administrator shall have the following responsibilities: 1. Organize and direct the agencies on going functions. 2. Ensure that the agency meets all rules and regulations for licensure. 3. Maintain an up-to-date knowledge of all applicable federal state and local regulations and ensure agency compliance ... 7. Maintain a current organizational chart to show lines of authority down to the patient level ... 10. Maintain appropriate personnel records, administrative records, and all policies and procedures of the agency. 11. Designate in writing a qualified individual to act in the absence of the Administrator. 12. Report in writing all changes in ownership or management to the ISDH and any accrediting body. 13. Ensure the accuracy of public information materials and activities. 14. Implement an effective budgeting and accounting system ... " 2. An agency policy number HH:1-006.1, titled "Home Health Administrator" revised May 2009, stated "Purpose... To define the overall responsibilities of the home health administrator position ... Policy ... The home health Executive Director/Administrator position will be responsible for the direction, coordination, and general supervision of all home health services ... The full extent of the home health Executive Director/Administrator responsibilities will be defined in the applicable job description ... Procedure ... 3. Responsibilities of the position will include but not be limited to: A. planning, organizing, directing and evaluating operations to ensure the provision of adequate and appropriate care and services ... B. Complying with applicable law and regulations of operations ... C. Fiscal planning, budgeting, and management ... E. Establishing and maintaining effective channels of communication ... G. Directing and monitoring performance improvement activities ... M. Ensuring the accuracy of public information materials and activities ... N. Appointing a similarly qualified alternate to be available at all times during operating hours in the absence of the Executive Director/Administrator ... " 3. An agency policy number HH:1-001.1, titled "Scope of Services" revised May 2009, stated "Purpose... To describe Foster Home Care Services, Inc. operations including the geographical service area ... Policy ... Foster Home Care Services, Inc will be open from 8:00 a.m. to 5:00 p.m., Monday through Friday ... Foster Home Care Services, Inc will provide care to persons living within the following Counties: Lake ... Porter... LaPorte ... " 4. An agency policy number C:1-006.1, titled "Appointment of Executive Director/Administrator" revised May 2009, stated "Purpose... To define the qualifications and selection process of the Executive Director/Administrator of the organization ... Policy ... The Governing Body will appoint the Executive Director/Administrator through a procedure established by the Governing Body. The Executive Director/Administrator will: 1. Be responsible for the day-to-day operations of the organization ... 4. Be knowledgeable of applicable law and regulation including Medicare Conditions of Participation as applicable, state regulations, licensure requirements, and any other applicable local/state/ or federal regulations ... " 5. An agency policy number C:1-007.1, titled "Designation of Individual in Absence of Executive Director/Administrator" revised May 2009, stated "To facilitate smooth and uninterrupted daily operations of Foster Home Care Services, Inc during time off of administrative personnel ... Policy ... Foster Home Care Services, Inc we'll have an executive director/administrator or designee available at all times ... Procedure ... In the event that the Executive Director/Administrator is absent, the clinical director will assume the operational duties in responsibilities at Foster Home Care Services, Inc ... " 6. Record review of the state form titled "Facility Census - Home Health" had an area that was subtitled "Total [number] of Active Patients" which was filled in by the administrator as "18. "During the entrance conference interview on 1/29/2021 at 10:08 AM, the administrator indicated the current census was 11 patients. The administrator failed to demonstrate accurate knowledge of the home health agency's active patient census. 7. Review of the state form, completed by the administrator on 1/29/2021, titled "Home Health Agencies ... Geographic Area Served" had an area subtitled "Please Check4 [sic] The Counties Served By Your Agency" which indicated Lake and Porter counties were being served. Record review of the agency's policies evidenced Lake, Porter, and LaPorte counties are served. The administrator failed to indicate of all the counties the home health agency served. 8. During the entrance conference interview on 1/29/2021 at 10:08 AM, the administrator indicated the members of the governing body as Person B, Person D, Person E and themselves (the administrator). Record review of the agency's governing body binder, evidenced an agency document titled "Governing Body Members" which stated the following members will hold these positions until 12/21/2022: Person B, Chairman/President, Person F, Vice President/Treasurer, and Person G, secretary. The administrator failed to indicate all the members of the home health agency's governing body. Record review of an agency document titled "Organizational Chart" stated "Governing Body: [Person D] and [Person E] ... " The administrator failed to indicate all of the governing body members. 9. On 1/29/2021, at 10:38 AM, the administrator asked what the facility number and CCN (CMS Certification Number) was for the agency. The administrator failed to evidence knowledge of state and federal license and Medicare funding information. 10. Record review of the administrator's personnel record failed to evidence a signed job description. Record review failed to evidence the administrator's personnel file was kept current. On 1/29/2021 at 2:25 PM, copies of the job descriptions for employee records reviewed were requested. The administrator indicated their own signed job description should have been kept in the personnel file. The agency personnel files failed to be complete and contain a signed job description for all personnel files reviewed. 11. Record review of information provided to the State of Indiana from the agency indicated RN C assumed the role of alternate administrator on 6/5/2019. Record review of RN C's personnel record failed to evidence a job description, training, or orientation for the alternate administrator position. During the entrance conference on 1/29/2021 at 10:08 AM, the administrator indicated the agency does not have an alternate administrator, but RN D, the clinical supervisor, would fill in if needed. The administrator failed to ensure an alternate administrator was established in writing. 12. Record review on 1/29/2021, evidenced an agency document titled "PDSA [Plan Do Study Act] Worksheet" which was identified as a current PIP [performance improvement plan] for the agency by RN (Registered Nurse) B. The PIP had a cycle start date of 8/27/2019, and a cycle end date of January 2020. This document stated "Plan ... Teams on different projects will work on following (high risk hospitalization patients, out come measure, process measure, 485 and other audit sheets) for this purpose our dedicated team headed by our DON [director of nursing] and administrator [Person B] who will work on patients charts with their teams which is already started from 10/10/2019 and will be finalized January 1st 2020 ... " The administrator failed to ensure the PIP was monitored for accuracy to evidence the correct name of the current administrator and that the PIP was completed prior to its expiration in January 2020. 13. Record review of the agency's QAPI [quality assessment performance improvement] binder on 1/29/2021, evidenced the last QAPI meeting was held in April 2020. During an interview on 1/29/2021 at 3:03 PM, the administrator was queried on the frequency of QAPI meetings. RN B answered "QAPI meetings are held quarterly." RN B agreed a QAPI meeting was overdue. The administrator failed to evidence knowledge of the on going details and frequent monitoring of the agency's QAPI program. 410 IAC 17-12-1(b)(3) 410 IAC 17-12-1( c)(1)