Every finding on record at Hands at Home LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 9/17/2024-9/20/2024 Active Census: 6 At this Emergency Preparedness survey, Hoosier Home Health was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR Completed on 09/30/2024 by A4.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 9/17/2024-9/20/2024 12-Month Unduplicated Skilled Admissions: 3 This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the ordered frequency and duration of Home Health Aide (HHA) services on the Plan of Care was met for 1 of 4 active patient records reviewed (Patient #5). Findings include: 1. An undated policy titled Plan of Care indicated, but was not limited to, "Policy: An individualized Plan of Care is developed utilizing the comprehensive and initial assessment, as well as, information provided by member of the interdisciplinary team and the physician that:…Procedure:…32. The initial Plan of Care must include at a minimum, these patient specific items:…q. Order for all disciplines including amount, frequency, and duration of visits to be made… " 2. The complete clinical record for patient #5 was reviewed on 9/19/2024 and included a plan of care (POC) for the certification period 7/30/2024 to 9/27/2024. The record evidenced the following: A medical POC dated and completed by the Clinical Supervisor RN on 7/30/2024, listed in the Home Health Aide Orders section an order for Home Health Aide (HHA) visits, with a frequency of 5 hours per day for two days a week, 8-10 hours per day for two days a week, and 15 hours per day for one day a week for nine weeks for a total of 41 to 45 hours five days a week. On the same POC in the Clinical Summary section. An Aide Plan of Care (APOC) with an effective date on 7/30/2024, showed in the frequency/duration section of the APOC an order for HHA five hours per day for 2 days a week, 8-10 hours per day for three days a week, and 15 hours per day for one day a week for nine weeks. This amounted to 49 to 55 hours per week. A review of Home Health Visit Notes Documentation for the certification period evidenced the following: Week 1 07/30/2024 through 08/3/2024 indicated Patient #5 received 45 hours of HHA services. Week 2 08/4/2024 through 08/10/2024 indicated Patient #5 received 43.5 hours of HHA services. Week 3 08/11/2024 through 08/17/2024 indicated Patient #5 received 30 hours of HHA services. Week 4 08/18/2024 through 08/24/2024 indicated Patient #5 received 23.5 hours of HHA services. Week 5 08/25/2024 through 08/31/2024 indicated Patient #5 received 23.5 hours of HHA services. Week 6 09/1/2024 through 09/07/2024 indicated Patient #5 received 22.25 hours of HHA services. Week 7 09/08/2024 through 09/14/2024 indicated Patient #5 received 29.5 hours of HHA services. 3. On 9/20/2024 at 11:42 AM, the Clinical Supervisor indicated there had been many changes to the staff for the waiver company providing hours so the agency had received more hours to provide to the patient which was being met. The Clinical Supervisor indicated that when the new POC was completed and sent to the doctor they were meeting the orders. However, the aide that was providing those increased hours went back to school and was unable to maintain the hours with classes as planned. The Clinical Supervisor and administrator both indicated the physician should have been updated of the current staffing change, the situation discussed with the patient’s guardian, and new orders implemented with the correct visit schedule completed.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider. Survey Dates: August 18, 19, 22, 23, 24, of 2022. Partially Extended survey was announced on 8/22/2022 Fully Extended survey was announced on 8/23/2022 Census: 9 active This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. During this Federal Recertification Survey, Hoosier Home Health was found to be out of compliance with Conditions of Participation 484.60 Care Planning, Coordination, Quality of Care. Based n the Condition-level deficiencies during the 8/24/2022 survey, your HHA was subject to a partial and extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act of 8/23/2022. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning 8/24/2022 and continuing through 8/23/2024. QR Completed 9/7/2022 A4

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure a medication had appropriate labeling and written instructions for use for 1 of 1 patient observation with a catheter. (Patient 1, RNCM 1) Findings include: A revised 11/2019 policy titled Medication Administration was provided by the Administrator on 8/23/2022 at 3:15 p.m. The policy indicated, but was not limited to, “14. If any medication order is incomplete, illegible, or unclear, the clinician will immediately seek to clarify the order with the prescribing physician and document the corrections in the medical record. … 22. All medications will be labeled in accordance with currently accepted professional practice and will include the medication name … appropriate usage, and cautionary instructions … 25. Prior to administration of all medications, the clinician will verify: a. That medication selected matches the medication order and product label, … 28. Clinicians will follow drug manufacturer and pharmacist instructions …” The complete clinical record for patient 1 was reviewed on 8/19/2022 for the certification period 8/16/2022 to 10/14/2022, start of care date 1/4/2019. The record included a plan of care with orders for home health aide services for 5 hours a day 6 days a week for 9 weeks and Skilled nursing services for 1 hour a day two times a week for 9 weeks. The plan of care indicated orders for Gentamicin solution 480 mg/1000 ml NS (normal saline) concentration, instill 60 mls (milliliters) (=28.8 mg dose) warmed solution intravesically 2 x (times)/week, dwell 45 minutes then drain. During a home visit on 8/19/2022 at 10:40 a.m. observed RNCM 1 remove an unopened bottle of Gentamicin solution from the refrigerator. The label indicated Gentamicin 80 mg in Sodium Chloride 2 times a week clamp/plug for 1 (one) hour. The label did not indicate specific instructions on warming the solution prior to administering to the patient. RNCM 1 drew 60 mls of the solution up into a 60 ml syringe, placed the syringe back into the syringe wrapper uncapped, then placed the syringe into the microwave to warm up for 8 seconds. RNCM 1 indicated it should be warmed for 15 seconds in the microwave but only set the microwave for 8 seconds. At that time, reviewed the plan of care that was provided by RNCM 1 prior to the visit. The plan of care did not indicate specific instructions on warming the medication prior to administration nor reflect what was on the label of the Gentamicin solution. RNCM 1 indicated the dwell time for the Gentamicin was 45 minutes instead of 1 hour and acknowledged the pharmacy needed a clarification order / label change. 410 IAC17-14-1(a)(1)(B)

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure the physicians signed and dated the patients plan of care (See tag G572); and failed to ensure the phyicians reviewed the 60-day summary (See tag G588). The cumulative effect of this systemic problem resulted in the agency being out of compliance with the Condition of Participation 484.60 Care planning, Coordination, Quality of Care.

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 record review and interview, the agency failed to follow agency policy to ensure the patient's individualized plans of care were established, reviewed, and signed by the physician in a timely manner for 6 of 7 record reviews. (Patient 1, 2, 4, 5, 6, 7) Findings include: 1. A revised 11/2019 policy titled Plan of Care was provided by the Administrator on 8/23/2022 at 10:20 a.m. The policy indicated, but was not limited to, “16. The signature and date of the review by the responsible physician verifies the interval between plan of care reviews. … 21. All orders, including the Plan of Care and all verbal orders, will be signed by the physician in a timely manner. … a. If the physician delays or fails to sign orders, care cannot be continued. Physician orders are tracked for timely signatures in the agency office. b. Efforts to obtain signature include frequent communication with the physician’s office staff, hand delivery and pick up of orders to the physician office, and senior management intervention, when necessary. … 29. Recertification orders will be sent to the physician along with the Plan of Care for skilled service.” 2. A revised 11/2019 policy titled Physician Plan of Care/Physician Orders was provided by the Administrator on 8/23/2022 10:20 a.m. The policy indicated, but was not limited to, “7. … The order must be documented in the medical record by the staff receiving the order, indicated by orders must be signed and dated with the date of receipt by the nurse … 8. Hoosier Home Health is responsible for physician authentication, i.e., for obtaining a physician signature for verbal/telephone orders received within days. The signature may be written or in electronic form following the requirements of the particular system.” 3. The complete clinical record for patient 1, certification periods 6/17/2022 to 8/15/2022 and 4/18/2022 to 6/16/2022 failed to indicate the physician signed and dated patient 1’s plan of care. 4. The complete clinical record for patient 2, certification periods 7/23/2022 to 9/20/2022 and 5/24/2022 to 7/22/2022 failed to indicate the physician signed and dated patient 2’s plan of care. The plan of care for the certification period 5/24/2022 to 7/22/2022 failed to indicate a nurse signature and date of verbal SOC (start of care). 5. The complete clinical record for patient 4, certification period 6/27/2022 to 8/25/2022 failed to indicate the physician signed and dated patient 4’s plan of care. 6. The complete clinical record for patient 5, certification periods 6/29/2022 to 8/27/2022 and 4/30/2022 to 6/28/2022 failed to indicate the physician signed and dated patient 5’s plan of care. 7. The complete clinical record for patient 6, certification period 6/27/2022 to 8/25/2022 failed to indicate the physician signed and dated patient 6’s plan of care. 8. The complete clinical record for patient 7, certification period 5/22/2022 to 7/20/2022 failed to indicate the physician signed and dated patient 7’s plan of care. 9. During entrance conference interview on 8/18/2022 at 11:10 a.m. the Administrator indicated the timeframe for clinicians to turn in documentation was 72 hours, but the agency pushes for 24 hours. The Administrator indicated the timeframe for documents to be incorporated in the patient record was 72 hours. On 8/23/2022 at 11:05 a.m. the Administrator indicated the agency had a hard time getting physicians to sign and return patient plans of care to the office despite phone calls and hand delivering and pick up efforts. The Administrator indicated 3 physicians the agency had issues with. During an interview on 8/24/2022 at 10:42 a.m. the Administrator indicated contracted personnel 1 advised him/her not to send the plan of care for MD signature if the contents are not correct. At that time, informed the Administrator of an interview conducted with the office manager of the clinic the agency had issues with and stated the clinic would help ensure physicians sign and return all orders to the agency. 410 IAC 17-13-1(a)

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the 60-day summary was reviewed by the physician for 3 of 5 active record reviews. (Patients 1, 2, 5) Findings include: 1. A revised 11/2019 policy titled Plan of Care was provided by the Administrator on 8/23/2022 at 10:20 a.m. The policy indicated, but was not limited to, “12. … Plan of Care that is established by the primary care physician, the agency staff and the patient. … It is then reviewed and revised as frequently as the patient’s condition or needs require, but no less than every 60 days from the start of care date. …16. The signature and date of the review by the responsible physician verifies the interval between plan of care reviews. … 21. All orders, including the Plan of Care and all verbal orders, will be signed by the physician in a timely manner. … a. If the physician delays or fails to sign orders, care cannot be continued. Physician orders are tracked for timely signatures in the agency office. b. Efforts to obtain signature include frequent communication with the physician’s office staff, hand delivery and pick up of orders to the physician office, and senior management intervention, when necessary. … 29. Recertification orders will be sent to the physician along with the Plan of Care for skilled service.” 2. A revised 11/2019 policy titled Physician Plan of Care/Physician Orders was provided by the Administrator on 8/23/2022 10:20 a.m. The policy indicated, but was not limited to, “7. … The order must be documented in the medical record by the staff receiving the order, indicated by orders must be signed and dated with the date of receipt by the nurse … 8. Hoosier Home Health is responsible for physician authentication, i.e., for obtaining a physician signature for verbal/telephone orders received within days. The signature may be written or in electronic form following the requirements of the particular system.” 3. The complete clinical record for patient 1, certification periods 6/17/2022 to 8/15/2022 and 4/18/2022 to 6/16/2022 failed to indicate the physician reviewed, signed, and dated patient 1’s plan of care that included a 60-day summary. 4. The complete clinical record for patient 2, certification periods 7/23/2022 to 9/20/2022 and 5/24/2022 to 7/22/2022 failed to indicate the physician reviewed, signed, and dated patient 2’s plan of care that included a 60-day summary. The plan of care for the certification period 5/24/2022 to 7/22/2022 failed to indicate a nurse signature and date of verbal SOC (start of care). 5. The complete clinical record for patient 5, certification periods 6/29/2022 to 8/27/2022 and 4/30/2022 to 6/28/2022 failed to indicate the physician reviewed, signed, and dated patient 5’s plan of care that included a 60-day summary. 6. During entrance conference interview on 8/18/2022 at 11:10 a.m. the Administrator indicated the timeframe for clinicians to turn in documentation was 72 hours, but the agency pushes for 24 hours. The Administrator indicated the timeframe for documents to be incorporated in the patient record was 72 hours. On 8/23/2022 at 11:05 a.m. the Administrator indicated the agency had a hard time getting physicians to sign and return patient plans of care to the office despite phone calls and hand delivering and pick up efforts. The Administrator indicated 3 physicians the agency had issues with. During an interview on 8/24/2022 at 10:42 a.m. the Administrator indicated contracted personnel 1 advised him/her not to send the plan of care for MD signature if the contents are not correct. At that time, informed the Administrator of an interview conducted with the office manager of the clinic the agency had issues with and stated the clinic would help ensure physicians sign and return all orders to the agency. 410 IAC 17-13-1(a)(2)

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 agency failed to ensure staff were following acceptable standards of practice regarding a bed bath, perineal care, and drainage bag care for 2 of 3 patient care observations. (RNCM 1, HHA 5) Findings include: 1. A 08/2019 policy titled Hand Hygiene was provided by the Administrator on 8/23/2022 at 10:20 a.m. The policy indicated, but was not limited to, “… Hand Hygiene is to occur: a. Before and after direct patient contact b. Before donning gloves to administer care to the patient. c. After removing and disposing of gloves and other protective equipment. … f. After contact with blood, body fluids, mucous membranes, non-intact skin … g. When moving from contaminated patient body site to clean site during patient care h. After contact with the patient or objects in the immediate vicinity of the patient … n. After each episode of removing gloves, including in between all glove changes …” 2. A procedure titled Bed Bath/Perineal Care date 5/11/21 signed by HHA 5 was provided by the Administrator on 8/24/2022 at 12:00 p.m. The procedure indicated, but was not limited to, “… 8. Wet washcloth and apply soap, if requested. Wash, rinse and pat dry face, neck, ears and behind ears. 9. Remove resident’s gown. 10. Place towel under far arm. 11. Wash, rinse and pat dry hand, arm, shoulders and underarm. 12. Repeat steps with other arm. 13. Place towel over chest and abdomen. Lower bath blanket to waist. Lift towel over chest and abdomen. Lower bath blanket to waist. 14. Lift towel and wash, rinse and pat dry chest and abdomen. 15. Pull up bath blanket and remove towel. 16. Uncover and place towel under far leg. 17. Wash, rinse and pat dry leg and foot. Be sure to wash, rinse and dry well between toes. 18. Repeat with other leg and foot. 19. Change bath water and gloves, wash hands and use clean gloves and towel. 20. Assist resident to spread legs and lift knees, if possible. 21. Wet and soap folded washcloth. … Perineal Care: 23. Wipe from front to back and from center of perineum to thighs … B. Continue washing down the penis to the scrotum and inner thighs. Rinse off soap and dry. … 24. Change water in basin. Wash hands and change gloves. With a clean washcloth, rinse area thoroughly in the same direction as when washing. 25. Gently pat area dry with towel in same direction as when washing. … 28. Clean anal area from front to back. Rinse and pat dry thoroughly. 29. Change bath water and gloves. Use clean washcloth and towel. 30. Wash, rinse and pat dry from neck to buttocks …” 3. A 11/5/2015 article titled Catheter – Associated Urinary Tract Infections (CAUTI) from the CDC (Centers of Disease Control and Prevention at https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html indicated, but was not limited to “…Keep the collecting bag below the level of the bladder at all times …” 4. During a home visit on 8/19/2022 at 10:40 a.m. observed RNCM 1 remove the suprapubic (catheter inserted through the abdomen and directly into the bladder) tubing from the top bedrail and place the tubing and attaching the drainage bag to the bed frame of patient 1. RNCM 1 informed HHA 5 the drainage tubing/bag need to hang lower than the patient to prevent backflow of the urine into the bladder. Observed RNCM 1 disconnect the suprapubic tubing/bag from the catheter to empty the urine into the toilet. Once the drainage bag was empty RNCM 1 failed to clean the tip of the drainage valve with an alcohol wipe. 5. During a home visit on 8/19/2022 at 12:00 p.m. observed HHA 5 perform a bed bath on patient 1. HHA 5 filled two bath basins from the bathroom sink. HHA 5 used a soapy washcloth to wash patient 1’s face, scalp, neck, right upper and lower arm, axilla, and hands. HHA 5 then walked to the other side of patient 1’s bed and used the same soapy washcloth to wash patient 1’s left side of head, face, posterior neck, left upper and lower arm, hands, and axilla. HHA 5 returned to the basin to retrieve one wash cloth from the rinse basin and proceeded to rinse patient 1’s right upper/lower arm, fingers, axilla, then to right side of face and neck. HHA 5 used the same rinse cloth to rinse off patient 1’s head, back of neck, left upper/lower arm, fingers, and axilla. HHA 5 failed to dry the patient off after rinsing. HHA 5 used a soapy washcloth to wash patient 1’s right lower leg, feet, and toes then proceeded to wash the left lower leg, feet, and toes. HHA 5 went to kitchen to obtain a dry towel to dry off bilateral lower legs and feet but failed to dry in between the toes. HHA 5 failed to wash patient 1’s bilateral upper legs and bilateral abdominal folds. While still gloved, HHA 5 proceeded to get the mechanical lift, and attach the blue sling already under patient 1 to the lift and raised patient 1 up from the bed. HHA 5 failed to remove gloves and perform hand hygiene after providing patient care and before touching the mechanical lift. HHA 5 placed the suprapubic tubing and bag on top of patient 5’s abdomen. HHA 5 took a soapy washcloth from the same basin to wash patient 1’s groin area, buttocks, and then lower back. HHA 5 then used the same rinse cloth from the same rinse basin to rinse the groin area, buttocks, and then lower back. HHA 5 failed to change out wash/rinse clothes and failed to change out water during the bath. At the end of the bath, observed HHA 5 place patient 1’s suprapubic tubing/bag over top of the bedrail instead of attaching the bag to the bed frame. HHA 5 failed to follow RNCM 1 instructions regarding suprapubic tubing and bag placement after completing the bath and failed to follow agency bath procedure. 6. During an interview on 8/23/2022 at 3:15 p.m. the Administrator was informed of the steps HHA 5 took to perform a bed bath on patient 1 and drainage bag care. The Administrator agreed the observation findings do not meet the expectations of the agency regarding bathing and drainage bag care. 410 IAC 17-12-1(m)

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review and interview, the agency staff failed to assume responsibility for ensuring patient plans of care were signed and dated by a physician; and failed to ensure home health aide documentation was incorporated into the electronic medical record for 6 of 7 record reviews. (Patient 1, 2, 4, 5, 6, 7) Findings include: 1. A 01/12/2013 revised Director of Nursing job description was provided by the Administrator on 8/24/2022 at 1:42 p.m. The job description indicated, but was not limited to, “1. Assure compliance with company policy and all federal, state, and local regulatory bodies. 2. Supervise all clinical activities and staff related to nursing …” 2. The complete clinical record for patient 1, certification periods 6/17/2022 to 8/15/2022 and 4/18/2022 to 6/16/2022 failed to indicate the physician signed and dated patient 1’s plan of care. 3. The complete clinical record for patient 2, certification periods 7/23/2022 to 9/20/2022 and 5/24/2022 to 7/22/2022 failed to indicate the physician signed and dated patient 2’s plan of care. The plan of care for the certification period 5/24/2022 to 7/22/2022 failed to indicate a nurse signature and date of verbal SOC (start of care). 4. The complete clinical record for patient 4, certification period 6/27/2022 to 8/25/2022 failed to indicated the physician signed and dated patient 4’s plan of care; and failed to indicate HHA documentation was incorporated into the medical record for the following dates: 7/1/22, 7/4/22, 7/5/22, 7/6/22, 7/7/22, 7/8/22, 7/11/22, 7/12/22, 7/13/22, 7/14/22, 7/15/22, 7/18/22, 7/19/22, 7/20/22, 7/21/22, 7/25/22, 7/26/22, 7/27/22, 7/28/22, and 7/29/22 indicated the visits were not started. 5. The complete clinical record for patient 5, certification periods 6/29/2022 to 8/27/2022 and 4/30/2022 to 6/28/2022 failed to indicate the physician signed and dated patient 5’s plan of care. 6. The complete clinical record for patient 6, certification period 6/27/2022 to 8/25/2022 failed to indicate the physician signed and dated patient 6’s plan of care. 7. The complete clinical record for patient 7, certification period 5/22/2022 to 7/20/2022 failed to indicate the physician signed and dated patient 7’s plan of care. 8. During entrance conference interview on 8/18/2022 at 11:10 a.m. the Administrator indicated the timeframe for clinicians to turn in documentation was 72 hours, but the agency pushes for 24 hours. The Administrator indicated the timeframe for documents to be incorporated in the patient record was 72 hours. On 8/23/2022 at 11:05 a.m. the Administrator indicated the agency had a hard time getting physicians to sign and return patient plans of care to the office despite phone calls and hand delivering and pick up efforts. The Administrator indicated 3 physicians the agency had issues with. During an interview on 8/24/2022 at 10:42 a.m. the Administrator indicated contracted personnel 1 advised him/her not to send the plan of care for MD signature if the contents are not correct. At that time, informed the Administrator of an interview conducted with the office manager of the clinic the agency had issues with and stated the clinic would help ensure physicians sign and return all orders to the agency.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure assessment documentation and dressing changes for a PICC-line (peripherally inserted central catheter) were ordered and documented for 1 of 1 record review of a patient with a PICC-line. (Patient 6); failed to ensure the physician was notified of low blood sugar readings for 1 of 2 closed record reviews. (Patient 6); and failed to submit documentation for 1 of 3 record reviews with home health aide visits. (Patient 1, HHA 5) Findings include: 1. A revised 6/6/2019 Registered Nurse job description was provided by the Administrator on 8/24/2022 at 11:50 a.m. The policy indicated, but was not limited, “2. Evaluate patients’ needs, review all medications. Perform ordered procedures and communicate with other disciplines as appropriate. … 7. Observe and report signs, symptoms, and progress of patient to physician. 8. Coordinate services, informing physician …” 2. An undated policy based on Lippincott documentation guidelines was provided by the Administrator on 8/24/2022 at 3:20 p.m. The policy indicated, but was not limited to, “Peripheral Inserted Central Catheter: Insertion Guidelines … Nursing Considerations … watch for signs/symptoms of mechanical phlebitis (inflammation of the vein), including edema (swelling), red streaks, from the insertion site and cording, and intense and continuous pain in the arm of insertion …” 3. A Certified Home Health Aide job description dated 4/12/21 signed by HHA 5 indicated, but was not limited to, “Document client care as required by the Agency … Complete and submit all required forms on a shift basis as required by the agency …” 4. The complete clinical record for patient 1 was reviewed on 8/19/2022 for the certification period 8/16/2022 to 10/14/2022, start of care date 1/4/2019. The record included a plan of care with orders for home health aide services for 5 hours a day 6 days a week for 9 weeks. Review of the electronic medical record failed to indicate HHA 5 documented and uploaded home health aide visit notes for 7/2/22, 7/9/22, and 7/16/22. 5. During entrance conference interview on 8/18/2022 at 11:10 a.m. the Administrator indicated the timeframe for clinicians to turn in documentation was 72 hours, but the agency pushes for 24 hours. The Administrator indicated the timeframe for documents to be incorporated in the patient record was 72 hours. On 8/24/2022 at 4:30 p.m. office personnel 3 indicated HHA 5 clocked in and out for the home visits with patient 1. At that time, the Administrator was unaware of the missing documentation in the electronic medical record and was unsure why HHA 5 did not document patient care for the visits. 6. The complete clinical record for patient 6 was reviewed on 8/23/2022 for the certification period 7/11/2020 to 9/18/2020, start of care date 3/13/2020. The record included a plan of care with orders for skilled nursing services 1 hour a day times 3 days a week. The plan of care indicated orders to notify the physician of a fasting blood greater than 350 or less than 70 and orders for Lantus (diabetic medication) 40 units injection every bedtime and Novolin (diabetic medication) sliding scale (dose based on blood sugar reading). The plan of care did not include orders for PICC-line dressing change. Review of a ROC (resumption of care) note dated 7/22/2020 indicated patient 6 came back from the hospital with a PICC-line (flexible catheter inserted into a vein in the upper arm to deliver medications) and orders for an IV antibiotic push. The ROC indicated the PICC-line was placed and secured with a dressing on 7/20/2020. Review of the RN-Skilled Nursing Visit notes dated 7/22/2020, 7/23/2020, 7/24/2020, 7/25/2020, 7/26/2020, 7/27/2020, 7/28/2020, and 7/29/2020 failed to indicate the nurse assessed the PICC-line site for redness, swelling, pain, or leakage/dislodgement in the skin section or narrative note for each visit. The agency failed to document if a PICC-line dressing change occurred or not for patient 6. RN-Skilled Visit note dated 7/24/2020 indicated patient 6’s blood sugar was 51 prior to nursing visit. The RN note indicated the patient ate a small cherry pie and drank orange juice prior to nurse visit. Patient 6’s blood sugar was 111 at the end of the nursing visit. The agency failed to notify the physician of a blood sugar reading of less than 70 and if the physician wanted to review / change diabetic medications or monitor patient 6. 7. During an interview on 8/24/2022 at 3:00 p.m. the Administrator indicated he/she reviewed patient 6’s electronic medical record and agreed there should be a dressing change order and documentation on assessing the PICC-line site each visit. At that time, RNCM 1 indicated there should be assessment documentation in the nurses visit that would include if there were pain, redness, swelling, or leaking around the PICC-line site in the integumentary (skin) section or narrative note on each visit. RNCM 1 indicated the dressing to the PICC-line site should be changed weekly and documented. 410 IAC 17-14-1(a)(1)(E)

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 agency failed to ensure services provided by a home health aide was consistent with home health aide training regarding a bed bath, perineal care, hand hygiene, and drainage bag care for 1 of 1 home health aide observation. (HHA 5) Findings include: 1. A 08/2019 policy titled Hand Hygiene was provided by the Administrator on 8/23/2022 at 10:20 a.m. The policy indicated, but was not limited to, “… a. Before and after direct patient contact b. Before donning gloves to administer care to the patient. c. After removing and disposing of gloves and other protective equipment. … f. After contact with blood, body fluids, mucous membranes, non-intact skin … g. When moving from contaminated patient body site to clean site during patient care h. After contact with the patient or objects in the immediate vicinity of the patient … n. After each episode of removing gloves, including in between all glove changes …” 2. A procedure titled Bed Bath/Perineal Care date 5/11/21 signed by HHA 5 was provided by the Administrator on 8/24/2022 at 12:00 p.m. The procedure indicated, but was not limited to, “… 8. Wet washcloth and apply soap, if requested. Wash, rinse and pat dry face, neck, ears and behind ears. 9. Remove resident’s gown. 10. Place towel under far arm. 11. Wash, rinse and pat dry hand, arm, shoulders and underarm. 12. Repeat steps with other arm. 13. Place towel over chest and abdomen. Lower bath blanket to waist. Lift towel over chest and abdomen. Lower bath blanket to waist. 14. Lift towel and wash, rinse and pat dry chest and abdomen. 15. Pull up bath blanket and remove towel. 16. Uncover and place towel under far leg. 17. Wash, rinse and pat dry leg and foot. Be sure to wash, rinse and dry well between toes. 18. Repeat with other leg and foot. 19. Change bath water and gloves, wash hands and use clean gloves and towel. 20. Assist resident to spread legs and lift knees, if possible. 21. Wet and soap folded washcloth. … Perineal Care: 23. Wipe from front to back and from center of perineum to thighs … B. Continue washing down the penis to the scrotum and inner thighs. Rinse off soap and dry. … 24. Change water in basin. Wash hands and change gloves. With a clean washcloth, rinse area thoroughly in the same direction as when washing. 25. Gentle pat area dry with towel in same direction as when washing. … 28. Clean anal area from front to back. Rinse and pat dry thoroughly. 29. Change bath water and gloves. Use clean washcloth and towel. 30. Wash, rinse and pat dry from neck to buttocks …” 3. A 11/5/2015 article titled Catheter – Associated Urinary Tract Infections (CAUTI) from the CDC (Centers of Disease Control and Prevention at https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html indicated, but was not limited to “…Keep the collecting bag below the level of the bladder at all times …” 4. During a home visit on 8/19/2022 at 12:00 p.m. observed HHA 5 perform a bed bath on patient 1. HHA 5 filled two bath basins from the bathroom sink. HHA 5 used a soapy washcloth to wash patient 1’s face, scalp, neck, right upper and lower arm, axilla, and hands. HHA 5 then walked to the other side of patient 1’s bed and used the same soapy washcloth to wash patient 1’s left side of head, face, posterior neck, left upper and lower arm, hands, and axilla. HHA 5 returned to the basin to retrieve one wash cloth from the rinse basin and proceeded to rinse patient 1’s right upper/lower arm, fingers, axilla, then to right side of face and neck. HHA 5 used the same rinse cloth to rinse off patient 1’s head, back of neck, left upper/lower arm, fingers, and axilla. HHA 5 failed to dry the patient off after rinsing. HHA 5 used a soapy washcloth to wash patient 1’s right lower leg, feet, and toes then proceeded to wash the left lower leg, feet, and toes. HHA 5 went to kitchen to obtain a dry towel to dry off bilateral lower legs and feet but failed to dry in between the toes. HHA 5 failed to wash patient 1’s bilateral upper legs and bilateral abdominal folds. While still gloved, HHA 5 proceeded to get the mechanical lift, and attach the blue sling already under patient 1 to the lift and raised patient 1 up from the bed. HHA 5 failed to remove gloves and perform hand hygiene after providing patient care and before touching the mechanical lift. HHA 5 placed the suprapubic tubing and bag on top of patient 5’s abdomen. HHA 5 took a soapy washcloth from the same basin to wash patient 1’s groin area, buttocks, and then lower back. HHA 5 then used the same rinse cloth from the same rinse basin to rinse the groin area, buttocks, and then lower back. HHA 5 failed to change out wash/rinse clothes and failed to change out water during the bath. At the end of the bath, observed HHA 5 place patient 1’s suprapubic tubing/bag over top of the bedrail instead of attaching the bag to the bed frame. HHA 5 failed to follow RNCM 1 instructions regarding suprapubic tubing and bag placement after completing the bath and failed to follow agency bath procedure. 5. During an interview on 8/23/2022 at 3:15 p.m. the Administrator was informed of the steps HHA 5 took to perform a bed bath on patient 1 and drainage bag care. The Administrator agreed the observation findings do not meet the expectations of the agency regarding bathing and drainage bag care.

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 provide overall direction and leadership of agency services and failed to ensure the agency met all rules and regulations for recertification for 1 of 1 home health agency. Findings include: 1. A revised 01/12/2013 policy titled Administrator/Alternate Administrator job description indicated but was not limited to "Job Summary: Act as liaison between the Owners/Officers, the staff and the community. Responsible for the daily operations and quality of the home health agency. Maintain a leadership role ... 9. Monitor the record system and statistical reporting system for proper documentation, planning and evaluation. 12. Oversee care delivery and patient outcomes to ensure that care meets the patients’ needs. … b. Compliance with applicable Federal, State and Local laws and professional standards are maintained. c. Compliance with established policies and procedures. d. Compliance with the patient’s plan of care.” 2. The administrator failed to ensure the physician signed and dated the patient’s plan of care. (See tag G572) 3. The administrator failed to ensure staff followed acceptable standards of practice regarding a bed bath, perineal care, and drainage bag care. (See tag G682) 4. The administrator failed to ensure agency staff assumed responsibility and followed agency policy regarding the patient’s plan of care were reviewed and signed by the physician (See tag G704) 5. The administrator failed to ensure assessment documentation and dressing changes for a PICC-line were ordered and documented; failed to ensure the physician was notified of low blood sugar reading; and failed to ensure home health aide visit notes were documented and incorporated into the electronic medical record. (See tag G716) 6. The administrator failed to ensure services provided by a home health aide was consistent with home health aide training regarding a bed bath, perineal care, hand hygiene, and drainage bag care. (See tag G800) 7. The administrator failed to ensure the quality of care provided by the home health aide was maintained. (See tag G822) 8. The administrator failed to ensure the home health aide submitted home visit documentation. (See tag G1012) 410 IAC 17-12-1(b)(3) 410 IAC 17-12-1(c)(1)

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health aide failed to submit documentation for 2 of 3 record reviews with home health aide visits. (Patient 1, 4) Finds include: 1. A Certified Home Health Aide job description dated 4/12/21 signed by HHA 5 indicated, but was not limited to, “Document client care as required by the Agency … Complete and submit all required forms on a shift basis as required by the agency …” 2. The complete clinical record for patient 1 was reviewed on 8/19/2022 for the certification period 8/16/2022 to 10/14/2022, start of care date 1/4/2019. The record included a plan of care with orders for home health aide services for 5 hours a day 6 days a week for 9 weeks. Review of the electronic medical record for patient 1 failed to indicate HHA 5 documented and uploaded HHA notes for 7/2/22, 7/9/22, and 7/16/22 home visits. 3. The complete clinical record for patient 4, certification period 6/27/2022 to 8/25/2022 failed to indicate HHA documentation was incorporated into the medical record for the following dates: 7/1/22, 7/4/22, 7/5/22, 7/6/22, 7/7/22, 7/8/22, 7/11/22, 7/12/22, 7/13/22, 7/14/22, 7/15/22, 7/18/22, 7/19/22, 7/20/22, 7/21/22, 7/25/22, 7/26/22, 7/27/22, 7/28/22, and 7/29/22. The electronic medical record indicated the visits were not started. 4. During entrance conference interview on 8/18/2022 at 11:10 a.m. the Administrator indicated the timeframe for clinicians to turn in documentation was 72 hours, but the agency pushes for 24 hours. The Administrator indicated the timeframe for documents to be incorporated in the patient record was 72 hours. On 8/24/2022 at 4:30 p.m. office personnel 3 indicated HHA 5 clocked in and out for the home visits with patient 1. At that time, the Administrator was unaware of the missing documentation in the electronic medical record and was unsure why HHA 5 did not document patient care for the visits. 410 IAC 17-15-1(a)(1)-(7)

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all documentation was complete and appropriately authenticated, dated, and timed in the medical record for 3 of 5 active record reviews. (Patient 1, 2, 5) Findings include: 1. A revised 11/2019 policy titled Physician Plan of Care/Physician Orders was provided by the Administrator on 8/23/2022 at 10:20 a.m. The policy indicated, but was not limited to, "8. Hoosier Home Health is responsible for physician authentication, i.e. for obtaining a physician signature ..." 2. The complete clinical record for patient 1, certification periods 6/17/2022 to 8/15/2022 and 4/18/2022 to 6/16/2022 failed to indicate the physician signed and dated patient 1’s plan of care that included a 60-day summary. 3. The complete clinical record for patient 2, certification periods 7/23/2022 to 9/20/2022 and 5/24/2022 to 7/22/2022 failed to indicate the physician signed and dated patient 2’s plan of care that included a 60-day summary. The plan of care for the certification period 5/24/2022 to 7/22/2022 failed to indicate a nurse signature and date of verbal SOC (start of care). 4. The complete clinical record for patient 5, certification periods 6/29/2022 to 8/27/2022 and 4/30/2022 to 6/28/2022 failed to indicate the physician signed and dated patient 5’s plan of care that included a 60-day summary. 5. On 8/23/2022 at 11:05 a.m. the Administrator indicated the agency had a hard time getting physicians to sign and return patient plans of care to the office despite phone calls and hand delivering and pick up efforts. 410 IAC17-15-1(a)(7)

This visit was for a Federal Complaint Survey. Complaint 29876 - substantiated with findings Survey Dates: 8/23 - 8/25/2021 Facility Number: 013308 QR completed 9/10/2021 A4

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to cancel visits during hospitalizations for 1 of 4 (Patient #1) records reviewed. Findings include: 1. A policy titled Patient Care Policy was taken from the Team Member manual provided by the Administrator on 8/24/2021 at 11:15 a.m. The policy indicated, but was not limited to, "Hoosier Home Health provides compassionate, individualized home health care services by qualified team members…Team member assignments are made by qualifies supervisors…Patient Telephones The patients’ phones are to be used only for the following purposes, and only if the patient has granted permission in advance of usage: 1. Clock-in for shift, 2. Clock-out for shift, 3. Check in with your supervisor, 4. Check out with your supervisor, 5. Report emergencies, 6. Assist patient in making phone calls..." 2. The complete clinical record for patient #1, start of care date 4/30/21, was reviewed on 8/23/2021, and included a plan of care for the certification period 6/29/2021 to 8/27/2021 with orders for skilled nursing (1d/w X 9w) and home health aide (11h/d X 7d/w X 9w) services. Patient #1's diagnoses were Spastic Quadriplegia Cerebral Palsy, with localized symptomatic epilepsy, legally blind, ototoxic bilateral hearing loss and dysphagia. The record evidenced a home health aide visit scheduled on 4/12/2021 that began at 8:00 a.m. and ended at 7:00 p.m. HHA D was shown to document completing the home health aide care plan interventions as ordered for patient 1 clocking in at 8:00 a.m. and clocking out at 7:02 p.m. Patient #1 was shown to be in the hospital at this time admitted on 4/10/21 and discharged on 4/13/21. A communication note from 4/10/21 completed by Former Employee (FE) RN J indicated HHA I had notified the on-call nurse patient #1 had a seizure for greater than six minutes and was instructed to call 911. Emergency services was called and patient #1 was taken to the hospital at 12:33 p.m. A physician order from 4/13/21 that indicated patient #1 was discharged to home from the hospital and for Hoosier Home Health services to restart care with no change in frequency or duration of prior services. 3. An interview was conducted with the Administrator (Admin) on 8/24/21 at 12:20 p.m. The Admin stated there should be no documentation for a visit on 4/12/21 because the patient was in the hospital. 4. An interview was conducted with HHA D on 8/25/21 at 1:34 p.m. HHA D indicated no visits were completed during the patient’s hospitalization. HHA D stated there should have been no clock-ins or outs or documentation completed during the patient’s hospitalization as no visits were completed by HHA D. HHA D indicated the login and pin for clock in and out times was known by other home health aides who helped to set up the account and Former Employee (FE) CM/DON F set up HHA D’s electronic medical record login and password. Both system logins were stated to HHA D weren’t to be changed. 17-12-1(m)