Every finding on record at Gibson General Hospital Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 08/08/2023 to 08/11/2023 & 08/08/2023 Active Census: 48 At this Emergency Preparedness survey, Deaconess Home Health LLC was not found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to address the use of volunteers in the agency’s emergency preparedness plan for 1 of 1 emergency preparedness plan reviewed. Findings include: 1. A revised policy dated 05/04/2023, titled “Emergency Preparedness Plan for Deaconess Gipson Home Health”, was provided on 08/8/2023 at 1:25 PM by Facility Administrator (FA). No documentation found in policy addressing use of volunteers or other emergency staffing. 2. During an interview on 08/14/2023 at 11:30 AM, The Facility Administrator (FA) revealed the agencies Emergency Preparedness Plan does not address the use of volunteers.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 08/08/2023-08/11/2023 & 08/14/2023 12 Month Unduplicated Skilled Admissions: 249 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR on 8/22/2023 by A4

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 observation, record review and interview the agency failed to notify physician of changes to home visit frequency made after plan of care (POC) was signed by physician on 3 of 7 record reviews. (Patient #4, #5, #7) Findings include: 1. A revised policy dated 05/01/2023, titled “Medical Plan of Care (POC 485/ add Orders / Re-Certification” was provided on 08/8/2023 at 1:25 PM by the Facility Administrator (FA). The policy indicated, but was not limited to, “… The POC and all add orders will be sent to the physician … 3. The physician is consulted to approve additions and modifications to the original plan. 4. Orders for service must include the specific procedures and modalities to be used, including frequency and duration of services …” 2. A revised policy dated 05/01/2023, titled “Communication with Physician” was provided on 08/8/2023 at 1:25 PM by the Facility Administrator (FA). The policy indicated but was not limited to “… 4. All communication will be documented in the medical record …”. 3. The clinical record for Patient #4, with a certification period from 07/24/23 to 09/21/23, was received on 08/08/23 at 1:25 PM, provided by the Facility Administrator (FA). The clinical record included two Physician telephone orders, one for Occupation Therapy (OT) and one for Physical Therapy (PT). The orders were dated 07/27/2023 and indicated OT/PT to start the week of 07/31/2023 two times per week, for four weeks. OT and PT failed to provide services after 08/04/2023 as ordered by the Physician. During an interview on 08/09/2023 at 2:00 PM, Patient #4’s husband indicated PT and OT had been placed on hold the following week. PT/OT was awaiting new instructions for therapy after the next doctor's visit on 08/15/2023. 4. The clinical record for Patient #5, with a certification period from 06/27/2023 to 08/25/2023, was reviewed on 08/08/2023. Skilled nursing was ordered twice a week for the week of 7/16/2023. The record indicated one skilled nursing visit was provided on 07/21/23. The agency failed to provide a second skilled nursing visit that week. During an interview on 08/08/2023 at 2:15 PM with Registered Nurse (RN) 5, The RN indicated he/she was unable to locate a nursing note or a notification by fax to the physician regarding SN visit missed for the week of 07/16/23. During an interview on 08/08/2023 at 4:00 PM with Registered Nurse (RN) 2, He/She indicated if a nursing visit is missed, the physician would be notified, a phone call and/or fax would be sent to the physician and placed in the patient's paper chart. RN 2 revealed one nursing visit had been missed on week of 07/21/23 and no communication with the doctor was provided. 5. During a home visit observation on 08/09/2023 at 10:35 AM, the Occupational Therapist (OT) 1 provided therapy services to Patient #7. At the end of the therapy visit, OT 1 discussed with patient #7 the next scheduled OT visit and showed the calendar in the admission packet of the next day OT services were scheduled. The clinical record for Patient #7, Certification period of 06/26/23 to 08/24/23, was reviewed on 08/08/223. A Physician Telephone Order, found in clinical records, dated 07/03/23 indicated but was not limited to “… OT … 2x/WK x 4 WKS from 7/10/23 through 8/4/23…”, no orders found in clinical records for OT to continue therapy past 08/04/23. 6. During an interview on 08/11/2023 at 10:45 AM, OT 1 indicated that when a change in frequency happens, a progress report is sent to the physician via fax with new orders requesting frequency change, once the physician signs the order, it is placed in the patient’s paper chart. OT 1 explained patient’s therapy service can be placed on hold, the physician would have to be notified of the missed visits while the services are on hold. 410 IAC 17-13-1(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 observation, record review and interview, the agency failed to maintain an updated individualized plan of care (POC) for 7 of 7 clinical records reviewed. (Patient #1, #2, #3, #4, #5, #6, #7) Findings include: 1. A revised policy dated 05/01/2023, titled “Medical Plan of Care (POC 485/add Orders/Re-Certification”, was provided on 08/8/2023 at 1:25 PM by the Facility Administrator (FA). The policy indicated but was not limited to, “… 1. The POC includes, but is not limited to the following: … b. Mental status, c. Types of services, e. Frequency of visits, f. Duration of visits, … m. Medications n. Treatments …” 2. The clinical record for Patient #1, with a certification date of 01/16/23 to 03/18/23, was reviewed on 08/09/23. The patient's medication list indicated Losartan was discontinued on 02/16/2023. The patient's POC failed to indicate the medication has been discontinued. A document titled Team Care Plan indicated the patient received Physical Therapy services from 01/17/23 through 02/16/23. The POC failed to evidence the patient was receiving Physical Therapy services. 3. The clinical record for Patient #2, with a certification date of 01/09/23 to 03/09/23, wa reviewed on 08/11/23. A document titled Team Care Plan indicated orders for Physical Therapy, Occupational Therapy, Speech Therapy, and Home Health Aide services. The POC failed to include these orders and failed to include the complete mental, psychosocial, and cognitive status of the patient. 4. The clinical record for Patient #3, with a certification date of 06/10/2023 to 08/08/2023, was reviewed on 08/11/2023. The POC failed to include the complete mental, psychosocial, and cognitive status of the patient. A document titled Supplemental Order indicated new wound care orders were received on 07/10/23. The updated orders were not included in the POC. 5. The clinical record for Patient #4, with a certification period from 07/24/2023 to 09/21/2023, was reviewed on 08/08/2023 and evidenced the following: A POC for the certification period that included the medications Cephalexin (an antibiotic), Methocarbamol (a muscle relaxer), Acetaminophen-oxycodone (used for pain), and Hibiclens (an antibacterial body wash). A supplemental order dated 08/03/2023 indicated Cephalexin (an antibiotic) and Methocarbamal (a muscle relaxer) were discontinued on 07-25-2023 and 07-27-2023. The POC failed to indicate the medications had been discontinued. A medication list that included normal saline and triad paste. Normal saline and triad paste were not included in the POC. 7/27/2023 dated physician orders for Occupation Therapy (OT) and Physical Therapy (PT). The POC failed to evidence the orders for PT and OT. A document titled Team Care Plan with orders for skilled nursing effective 07/2023 once a week for eight weeks. The plan of care indicated orders for skilled nursing for one visit. During an observation on 08/09/2023 at 2:00 PM, RN 1 provided wound care to Patient #4. The POC failed to evidence orders for wound care. During an interview on 08/09/2023 at 2:00 PM, with Patient #4's caregiver, The caregiver indicated the medication list, provided by RN 1, was correct except for Methocarbamol, which was a one-day order to be taken before surgery day, Patient #4 was no longer taking medication. The caregiver also revealed PT/OT was placed on hold as of 08/04/23, due to patient #4 condition, both therapies were awaiting further instruction, which was expected after the next doctor's visit on 08/15/2023. The clinical record failed to evidence documentation of PT/OT being placed on hold. During an interview on 08/09/2023 at 5:05 PM, The FA indicated the SN frequency was incorrect on the POC. FA continued by revealing this was not uncommon for RN 1 to make mistakes in charting, due to RN 1 getting in a hurry during documentation. 6. The clinical record for Patient #5, with a certification period from 06/27/23 to 08/25/23, was reviewed on 08/08/23. The record included a POC that failed to include the complete mental, psychosocial, and cognitive status of the patient. The POC included orders for Lantus (medication to treat high blood sugar) 7 units at bedtime. During an interview on 08/08/23 at 4:00 PM with Patient #5’s caregiver indicated the Lantus had been changed to 3 units. During an interview on 08/11/23 at 12:00 PM RN 2 revealed he/she would not look at POC for current care being provided. He/She would refer to other documents such as the care plan document and medication list since POC is not up to date. 7. The clinical record for Patient #6 with a certification date of 07/22/2023 to 09/19/23, was reviewed on 08/11/2023. The record included a POC that failed to include the complete mental, psychosocial, and cognitive status of the patient. 8. The clinical records for Patient #7 with Certification period 06/26/23 to 08/24/23, was reviewed on 08/09/2023. The record included a POC that failed to include the complete mental, psychosocial, and cognitive status of the patient. The record indicated orders for PT and OT. The POC failed to include orders for PT or OT. 9. During an interview on 08/09/2023 at 12:10 PM, The Facility Administrator (FA) indicated no other agencies were involved in current patients’ healthcare. She indicated if other agencies were involved they would not be included on the POC. 10. During an interview on 08/09/2023 at 5:05 PM, The Facility Administrator (FA) indicated all therapy services being provided are not located on POC, since therapy does all paper charting, and the therapy evaluation is performed after POC is sent to the doctor, no POC will have therapy frequency or individualized interventions. FA also indicated there was no way for the agency to keep POC up to date with new orders throughout the certification period, due to the computer system only updating on the start of care, resumption of care, and recertification. FA revealed Plan of care (POC) would not be a current document and is not being updated throughout the patient’s certification period. 11. During an interview on 08/011/2023 at 4:15 PM, The Facility Administrator (FA) indicated Physicians would be placed on POC if they are known about at the start of care (SOC) otherwise they would not be included in POC. 410 IAC 17-13-1(a)(1)(B) 410 IAC 17-13-1(a)(1)(D(i-xiii)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, and interview the agency failed to update patients plan of care (POC) with new orders obtained during certification period on 6 of 7 chart reviews. (Patient #2, #3, #4, #5, #6, #7) Findings include: 1. A revised policy dated 05/01/2023, titled “Medical Plan of Care (POC 485/ add Orders / Re-Certification”, was provided on 08/8/2023 at 1:25 PM by the Facility Administrator (FA). The policy revealed, but was not limited to, “… PURPOSE: To ensure current orders for services and provide effective care, treatment, and services for the patient … 3. The physician is consulted to approve additions or modifications to the original plan … 5. Add orders will be obtained during the current certification period (60 days) for any additional orders necessary for the patient …” 2. The clinical records for Patient #2, with a certification date of 01/09/23 to 03/09/23, was reviewed on 08/11/23. A Charts/Clinical Note dated 01/11/23 indicated but was not limited to “Pt saw Dr … yesterday with the following medication changes. SN verifies changes with Dr … office by phone this day. Stop Gabapentin [medication for nerve pain], Protonix [a medication used for reflux], Clonidine patch [a medication used to control blood pressure], lisinopril (sic) [a medication used to control blood pressure], Trazadone [an antipsychotic], and Prozac [an antidepressent]. Make Baclofen [used for muscle spasticity] prn [as needed] and start taking Clonidine [medication used to control blood pressure] 0.1 Mg twice a day in BP [blood pressure] greater than 150/90 prn.” The updated orders were not included in the plan of care. 3. The clinical record for Patient #3, with a certification period from 06/10/23 to 08/08/23, was reviewed on 08/11/23. The record included new wound care orders received on 07/10/23. The plan of care failed to include the updated wound care orders. 4. The clinical record for Patient #4, with a certification period from 07/24/23 to 09/21/23, was reviewed on 08/08/23. A Supplemental Order received on 08/03/23 indicated but was not limited to “… Cephalexin 500 Millgram … antibiotic ended on 07-25-23 …Methocarbamol 750 Milligram … ended on 07-27-23 …”The POC failed to indicate the medications have been discontinued. The record evidenced orders for Occupation Therapy (OT) and Physical Therapy (PT), both dated 07/27/23, and indicated OT/PT to start the week of 07/31/23. The POC failed to include orders for PT or OT. 5. The clinical record for Patient #5, with a certification period from 06/27/23 to 08/25/23, was reviewed on 08/08/23.The record included new orders for wound care orders received on 08/04/23. The plan of care failed to include 6. The clinical records for Patient #6, with a certification date of 07/22/2023 to 09/19/23, was reviewed on 08/11/23. The record included an order dated 7/28/23 for Privigen (an antibody) weekly. The plan of care failed to include the new order. 7. The clinical record for Patient #7 with Certification period 06/26/23 to 08/24/23, was reviewed on 08/09/2023. The record included an order dated 07/03/23 that indicated OT twice a week for 4 weeks. The plan of care failed to include the new order. 8. During an interview on 08/09/2023 at 5:05 PM, The Facility Administrator (FA) indicated there was no way for the agency to keep POC up to date with new orders throughout the certification period, due to the computer system only updating at the start of care, resumption of care and recertification. FA revealed Plan of care (POC) would not be a current document and is not being updated throughout the patient’s certification period.

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 record review the agency failed to use standard precautions to protect patients from infection and communicable disease on 2 of 3 home visits. (Patient #4, #5) Findings include: 1. A revised policy dated 06/14/2023, titled “Guidelines for Hand Hygiene Policy and Procedure”, was provided on 08/8/2023 at 1:25 PM by Facility Administrator (FA). The policy indicated but was not limited to, “… Clean your hands immediately after exposure risk to body fluids (after glove removal) … Gloves …Procedure: … 7. Gloves should be changed between patient contacts and when they become contaminated …11 …Hands shall be washed immediately and thoroughly after gloves have been removed …” 2. During a home visit observation on 08/08/23 at 4:00 PM, Registered Nurse (RN) 2 failed to perform hand hygiene after removing gloves, used to inspect the foley catheter (used to drain urine from the bladder) on Patient #5, and before finishing head to toe assessment. 3. During a home visit observation on 08/08/23 at 4:00 PM, Registered Nurse (RN) 1 failed to perform hand hygiene after entering the nursing bag to retrieve gloves, RN 1 then placed a new dressing over the wound site at the suprapubic catheter and assisted patient # 4 with clothes and blankets before removing gloves and performing hand hygiene. 410 IAC 17-12-1(m)