Every finding on record at Heal at Home LLC

Indianapolis, Indiana · CCN 15K130

40 findings across 6 surveys, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of October 30, 2024

4 findings

G0000

This visit was for a Federal and State complaint survey of a Home Health provider. Survey Dates: 10-29-2024 and 10-30-2024 Complaint: IN00110578 with related deficiencies cited. 12-Month Unduplicated Skilled Admissions: 74 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State form for additional findings. QR by A4 on 11/07/2024

G0768

G0958

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview the Director of Nursing failed to maintain oversight of the agency's contracted Clinical Educator, for 1 of 1 contracted Clinical Educator reviewed. Findings include: 1.A review of an agency policy revised 10-01-2024, titled 'AGENCY SUPERVISION' stated, "… The Governing Body shall designate a full-time Clinical Manager/Director of Nursing to supervise the HHA's performance in providing home health services … Supervision shall be provided in accordance with State and Federal rules and regulations … The Clinical Manager/Director of Nursing shall be responsible to ensure quality care and services are delivered by qualified staff … shall be responsible for the administration and coordination of all services …" 2. On 10-30-2024 at 2:52 PM, in an interview with Person A and the Administrator, when queried as to which aides had taken the first Feeding Tube training conducted in July, the Administrator indicated there was paperwork which the aides had, Person A likely signed off on these, and then the HHAs left the premises with that paperwork in hand. Person A was queried as if there was a roster/sign-in sheet for this training, indicated there was none. Administrator indicated was unaware of this and instructed Person A going forward there would need to be class rosters completed, and in this way, these individuals could be tracked. On 10-30-2024 at 3:30 PM, when discussing the lack of a complete list of home health aides who had completed feeding tube training, and the concern that HHA 7 was not remembered and was not documented by the Clinical Educator, the DON and Administrator could not provide names, and both acknowledged these concerns were indeed an issue. 410 IAC 17-14-1(a)(1)(K) 2.On 10-30-2024 at 9:05 AM, the Director of Nursing (DON) indicated that they were not aware of which aides had taken the Feeding Tube training and that it was the Administrators area to manage. On 10-30-2024 at 10:01 AM, HHA 7 indicated that they had completed the in person Feeding Tube training with the agency's contracted Clinical Educator, and were waiting to hear back from Heal at Home on how to take the final exam. On 10-30-2024 at 11:30 AM the Administrator indicated that several of their HHAs are family members of the patient receiving tube feeds. He indicated that due to the current restriction on services being provided by HHA's, training HHAs to provide tube feeding would allow the HHAs to work a full shift instead of having to split shifts to manage the tube feed.

G0978

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on record review and interview, Heal at Home failed to ensure contracted staffing was provided by a registered staffing company and failed to ensure contracts identify Heal at Home as the entity responsible for maintaining all patient records. Findings include: 1. An agency policy dated 08-15-2024, titled 'CONTRACTED SERVICES #7020' stated, "… Heal at Home retains responsibility, accountability and authority for the care, treatment and/or services provided by contracted staff/entities …" 2. Review of an agency contract dated 08-15-2024, titled 'Home Health Staffing and Administrative Services Agreement' signed by the Administrator and Person G, with Entity F, indicated: a. "… B. [Entity F] will maintain appropriate client records … staffing will be delivered in accordance with the orders of the Agency's client's attending physician … C. [Entity F] agrees that client records will be treated as confidential to the full extent required by law. To the extent permitted by applicable laws, the Agency will be entitled, upon request, to review [Entity F] patient records pertinent to services provided by [Entity F] to Agency's clients … ". b. “… E. [Entity F] represents that (i) has obtained and will maintain all applicable state and federal licenses, certificates and permits, as are applicable to it's business …" A review of the Secretary of State website failed to identify Entity F, a management holding company (who’s owner is the same as Heal at Home) as a registered company who provides staffing. A review of the Indiana Department of Health website failed to identify Entity F had registered under the Temporary Health Care Services Agency Registry. A review of the Employee list revealed Heal at Home had contracted 247 Home Health Aides from [Entity F]. On 10-29-2024 at 1:39 PM, when queried for individual contracts of the Home Health Aides personnel files being reviewed, the Administrator referred to a single contract titled, Home Health Staffing and Administrative Services Agreement, and indicated all of the agency's Home Health Aides were now, 'employees through the staffing department but we contract with [Entity F] to provide them'. 410 IAC 17-12-2 (e)

Survey of August 14, 2024

17 findings

G0000

This visit was for a Federal/State Complaint survey of a Home Health Provider. Survey Dates: 08-09-2024, 08-12-2024, 08-13-2024, and 08-14-2024 Complaint: IN00108886 Non-compliant, with related and unrelated findings 12-month Unduplicated Skilled Admission: 41 Survey was fully extended on 08-12-2024 and announced to the Administrator at 2:36 PM During this Federal/State Complaint Survey, Heal at Home, LLC. was found to be out of compliance with the Conditions of Participation 42 CFR 484.50 Patient Rights, 484.58 Discharge Planning, 484.105 Organization and Administration of Services, as related to this complaint and 484.80 Home Health Aide Services, unrelated to this complaint. Based on the Condition-level deficiencies during the 08-14-2024 survey, your Home Health agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 08-12-2024. 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 for a period of two years beginning 08-14-2024 and continuing through 08-13-2026. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR completed by Area 3 on 8-21-2024.

G0406

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure patients or their representatives were notified and consented to any changes in the care and documentation of such changes in their clinical record (G434) and failed to ensure patients were discharged for cause (G452). The cumulative effect of this systemic problem resulted in the home health agency's inability to ensure the provision of protecting patient rights for the Condition of Participation of 42 CFR 484.50 which could result in the agency not providing quality health care for all 274 patients. .

G0434

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure patients or their representatives were notified and consented to any changes in the care and documentation of such changes in 6 of 6 discharged clinical records. (Patients #1, 2, 3, 4, 5, and 6) Findings include: A review of the clinical record for Patient #2 evidenced the patient was discharged on 04/02/2024. The record failed to evidence documentation of notifying the patient or family of pending discharge. A review of the clinical record for Patient #5 evidenced the patient was discharged on 04/04/2024. The record failed to evidence documentation of notifying the patient or family of pending discharge. On 08-09-2024 at 9:27 AM, in a telephone interview with Person P, caregiver and POA for Patient #5, indicated had been called by the agency regarding discharging the patient, could not recall who had called or when, but was upset by this news, and was told this was standard procedure. When Person P asked for a reason, was told ‘insurance-wise, Medicaid’. Person P indicated, ‘we did not ask for any change’ and had queried the agency as to how Patient #5 had been ‘picked’, indicated was then told some patients needed to change over because ‘something was closing’. On 08-14-2024 at 12:07 PM in a telephone interview with Patient #2, when queried about discharging from Heal at Home, the patient indicated they had said ‘yes’ when the agency asked if the patient would be agreeable to transferring, and indicated was aware the agency had ‘switched’ them to a new agency [Entity Q]. Indicated it was all still the same staff providing care, ‘don’t know why the switch’. On 08-14-2024 at 12:07 PM in a telephone interview with Patient #2, when queried about discharging from Heal at Home, the patient indicated they had said ‘yes’ when the agency asked if the patient would be agreeable to transferring, and indicated was aware the agency had ‘switched’ them to a new agency [Entity Q]. Indicated it was all still the same staff providing care, ‘don’t know why the switch’. 17-12-3(b)(2)(D)(i)(BB) 1. A review of an agency's policy titled 'NOTICE OF RIGHTS 3-385' revealed, "... The HHA shall involve the patient's family in care ... and or service decisions ... permitted by the patient ... Documentation within the patient's medical record shall reflect that the patient and/or legal representative participates ... services provided ..." 2. A review of an agency's policy titled 'DISCHARGE/TRANSFER PROCESS 3-500' revealed, "... To avoid charges of "abandonment" at the time of discharge agency documentation will include the following: The appropriate notice was given prior to discharge ...and will be documented in the client record ... The client, family, and physician(s) participated in the decision to discharge client from the agency ..." 3. A review of the clinical record for Patient #1 evidenced the patient was discharged on 04/10/2024. The record failed to evidence documentation of notifying the patient or family of pending discharge. 4. A review of the clinical record for Patient #3 evidenced the patient was discharged on 11/03/2023. The record failed to evidence documentation of notifying the patient or family of pending discharge. 5. A review of the clinical record for Patient #4 evidenced the patient was discharged on 03/29/2024. The record failed to evidence documentation of notifying the patient or family of pending discharge. 6. A review of the clinical record for Patient #6 evidenced the patient was discharged on 03/26/2024. The record failed to evidence documentation of notifying the patient or family of pending discharge. 7. On 08/12/2024 at 9:14 AM during an interview, Person B, a family member of Patient #1, who was the Power of Attorney (POA) indicated they hadn't heard from the agency about a discharge from the agency. 8. On 08/09/2024 at 3:14 PM, the acting Administrator indicated they thought all patients/family members had been notified and should had been documented in the patient's journal notes of the discharges from the agency, and agreed there was no communication in the clinical records of intent to discharge Patients 1, 2, 3, 4, 5, and 6. The Administrator further indicated a letter of intent to discharge should be mailed, preferably certified, and a copy of the letter uploaded to the patient's record. 9. On 08/12/2024 at 10 AM RN 3 indicated Person T, former Clinical Manager/Director of Nursing had made the calls to all the discharged patients and/or representatives. 10. On 08/12/2024 at 12:10, Person T returned this surveyors' call, indicated they had spoken with Patients 1, 2, 3, 4, 5, and 6, families, and their representatives about the discharges and if they were agreeable. When queried if they contacted the POA for Patient #1, Person T indicated since Patient #1 lived at Entity U, a group home, they had spoken with Person V, the house manger about the discharge. When queried where the documentation of those conversations were located, they indicated they had not documented the conversations.

G0452

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on record review and interviews the agency failed to ensure 6 of 6 discharge patients were discharged for cause. (Patients #1, 2, 3, 4, 5, and 6) Findings include: A review of the clinical record for Patient #2 evidenced the patient was discharged on 04/02/2024. The clinical record for Patient #1 evidenced a document titled 'Discharge Order' dated 04/02/2024 signed by RN 3, indicated the patient was to transfer to Entity Q, an affiliated start-up home health agency. The record failed to evidence documentation of discharge for cause. A review of the clinical record for Patient #5 evidenced the patient was discharged on 04/04/2024. The clinical record for Patient #3 evidenced a document titled 'Discharge Order' dated 04/04/2024 and signed by RN 3, indicated was a verbal order from Doctor O, the ordering physician, to discharge the patient from the agency. The record failed to evidence documentation of discharge for cause. On 08-09-2024 at 12:15 PM in a telephone interview Person L, a registered nurse with Doctor M, indicated they were unaware Patient #2 had been discharged from the agency, and after reviewing internal records, indicated there were no calls on record from the agency in regard to discharging Patient #2 from home health services. On 08-14-2024 at 12:07 PM in a telephone interview with Patient #2, when queried about discharging from Heal at Home, the patient indicated they had said ‘yes’ when the agency asked if the patient would be agreeable to transferring, and indicated was aware the agency had ‘switched’ them to a new agency [Entity Q]. Indicated it was all still the same staff providing care, ‘don’t know why the switch’. On 08-09-2024 at 9:27 AM, in a telephone interview with Person P, caregiver and POA for Patient #5, indicated had been called by the agency regarding discharging the patient, could not recall who had called or when, but was upset by this news, and was told this was standard procedure. When Person P asked for a reason, was told ‘insurance-wise, Medicaid’. Person P indicated, ‘we did not ask for any change’ and had queried the agency as to how Patient #5 had been ‘picked’, indicated was then told some patients needed to change over because ‘something was closing’. Indicated Patient #5 was currently on service with a new agency, Entity Q, and the patient continued to have the same aide, everything was the same, no changes. On 08-12-2024 at 11:30 AM in a telephone interview with Person N of Doctor O’s office, indicated they did not know who was currently providing Home Health care to Patient #5. Person N indicated “no verbal order was given”. Person N indicated their office had not received a telephone call from the agency. and was unaware the patient had been discharged from the agency. A review of an agency's undated policy titled 'DISCHARGE/TRANSFER PROCESS 3-500' revealed, "... The agency may only transfer or discharge the patient from the agency if: 1. The transfer or discharge is necessary for the patient's welfare ... 2, The Patient or payer will no longer pay for the services ... 3, The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the home health agency agree that the measurable outcomes and goals set forth in the plan of care have been achieved ... 4. The patient refuses services ... 5. The home health agency determines ... the patient's (or other persons in the patient's home) behavior is disruptive ... to the extent that deliver of care to the patient or the ability of the agency is seriously impaired ... 6. The patient dies or 7. The home health agency ceases to operate ...". A review of the clinical record for Patient #1 evidenced the patient was discharged on 04/10/2024. The clinical record for Patient #1 evidenced a document titled 'Discharge Order' dated 04/10/2024 signed by RN 3 indicated it was a verbal order from Person A, the attending physician to discharge the patient from the agency. The record failed to evidence documentation of discharge for cause. A review of the clinical record for Patient #3 evidenced the patient was discharged on 03/21/2024. The clinical record for Patient #3 evidenced a document titled "Discharge Order' dated 03/21/2024 and signed by RN 3 indicated the patient was to transfer to Q, an affiliated start-up home health agency. The record failed to evidence documentation of discharge for cause. A review of the clinical record for Patient #4 evidenced the patient was discharged on 03/29/2024. The clinical record for Patient #4 evidenced a document titled "Discharge Order' dated 03/29/2024 and signed by RN 3 indicated the patient was to transfer to Q, an affiliated start-up home health agency. The record failed to evidence documentation of discharge for cause. A review of the clinical record for Patient #6 evidenced the patient was discharged on 03/26/2024. The clinical record for Patient #6 evidenced a document titled "Discharge Order' dated 03/26/2024 and signed by RN 3 read: "Per [Person D], the attending physician for Patient #6, discharge the patient from the agency. Family and new Home Health company to assume care." The record failed to evidence documentation of discharge for cause. On 08/09/2024 at 12:57 PM, Person W, an RN at Entity K indicated they received an order for Patient #4 to transfer to Entity Q on 03/21/2024, that the agency had not placed any phone calls to Entity K and further indicated they didn't know why the patient was transferring to the other agency. On 08/09/2024 at 5:34, Person V the house manager for Entity U indicated the home care agency notified them the Agency would discharge Patient #1 but didn't know why and were not given a 15- day notice of discharge letter. On 08/12/2024 at 9:14 AM, Person B, a family member and Power of Attorney for Patient #1 indicated they were not aware of the discharge, they had not received a call from the agency. On 08/12/2024 at 12:57 PM Person X the office manager at Entity F indicated there was no communication from the agency about transferring Patient #4 to another agency. On 08-12-2024 at 11:25, Person Z, a family member of Patient #6 indicated the Agency had phoned about the discharge and was fine with the transfer to Entity R, as long as it didn’t interfere with the care, but did not receive a 15-day notice of discharge letter. On 08/12/2024 at 11:57 the acting Administrator indicated they could not recall all reasons for discharge for cause but listed not able to staff, goals met, or death. The acting Administrator indicated to discharge a patient to use for a start-up for a new agency is not a reason.

G0560

Discharge Planning CFR(s): 484.58 Condition of Participation: Discharge planning. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure patients were appropriately discharged from Home Health services and failed to ensure the discharges were for cause (an accepted reason). The agency failed to follow their discharge planning process. (see G0562). The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients were appropriately discharged from services which could result in the agency not providing quality health care for all 274 patients. *

G0562

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure patients were discharged and/or transferred appropriately in 6 of 6 discharged records reviewed. (Patients #1, #2, #3, #4, #5, and #6) Findings include: 7. Review of the closed clinical record for Patient #1 with a discharge date of 04/10/2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 8. Review of the closed clinical record for Patient #3 with a discharge date of 11/03/2023, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 9. Review of the closed clinical record for Patient #4 with a discharge date of 03/29/2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 10. Review of the closed clinical record for Patient #6 with a discharge date of 03/26/2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 1. Review of an agency policy updated 12/2017, titled ‘Discharge/Transfer Process 3-500’ indicated, “… Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. The client/family will participate in this process ... Client and their representatives (if any) are told in a timely manner (at a minimum, 15 days prior) of the need to plan for for discharge ... Clients and their representatives are informed of the reason for discharge … agency documentation will include the following: The appropriate notice was given prior to discharge (at a minimum, 15-days) and will be documented in the client record … evidence the decision was not made unilaterally … The client, family and physician(s) participated in the decision to discharge client from agency … Documentation of all communication with the client, including the rationale for discharge, will be kept in the client file …” 2. Review of the closed clinical record for Patient #2 with a discharge date of 04-02-2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 3. Review of the closed clinical record for Patient #5 with discharge date of 04-04-2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient or Power of Attorney (POA, a person legally designated to make decisions or act on another’s behalf) was aware of or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 4. On 08-09-2024 at 3:39 PM, the Administrator indicated if it were the agency’s decision to discharge a patient, the patient should be given a 15-day discharge notice, the agency should be notifying the MD and obtaining an order to discharge. 5. On 08-12-2024 10:15 AM, Registered Nurse (RN) 3, when queried as to how Discharges from the agency are performed, indicated discharge visits are not done in person, but are done over the phone, ‘never been a physical visit’. Indicated the patient should also receive a 15-day notice and this would be documented in the clinical record. When further regarding the lack of documentation in the clinical records of Patient's #1 - #6, and why and how the patients had been discharged, indicated had been instructed by Corporate Person 1 to find current Heal at Home patients, who required few hours, were dually insured with both Medicare and Medicaid, and who would be agreeable to go to Entity Q. When queried as to who had directed this activity, indicated Corporate Person 1 (who resigned during the survey) had, and was likely instructed by Corporate Person 3, to obtain patients for Entity Q in this manner. Indicated Person T had been the one to call the patients in question about opening a new agency and if they would like to 'move over', indicated it was his/her understanding that the patients were given the option to accept or not. 6. On 08-12-2024 at 11:55 AM the Administrator indicated starting up another Home Health agency would not be a reason to discharge current patients from Heal at Home. 1. Review of an agency policy updated 12/2017, titled ‘Discharge/Transfer Process 3-500’ indicated, “… Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. The client/family will participate in this process ... Client and their representatives (if any) are told in a timely manner (at a minimum, 15 days prior) of the need to plan for for discharge ... Clients and their representatives are informed of the reason for discharge … agency documentation will include the following: The appropriate notice was given prior to discharge (at a minimum, 15-days) and will be documented in the client record … evidence the decision was not made unilaterally … The client, family and physician(s) participated in the decision to discharge client from agency … Documentation of all communication with the client, including the rationale for discharge, will be kept in the client file …” 2. Review of the closed clinical record for Patient #1 with a discharge date of 04/10/2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 3. Review of the closed clinical record for Patient #2 with a discharge date of 04-02-2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. Transferred Patient #2 for the express purpose of starting up an affiliated home health agency, Entity Q. 4. Review of the closed clinical record for Patient #3 with a discharge date of 11/03/2023, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 5. Review of the closed clinical record for Patient #4 with a discharge date of 03/29/2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 6. Review of the closed clinical record for Patient #5 with a discharge date of 04-04-2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient or Power of Attorney (POA, a person legally designated to make decisions or act on another’s behalf) was aware of or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 7. Review of the closed clinical record for Patient #6 with a discharge date of 03/26/2024, failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 8. On 08-09-2024 at 3:39 PM, the Administrator indicated if it were the agency’s decision to discharge a patient, the patient should be given a 15-day discharge notice, the agency should be notifying the MD and obtaining an order to discharge. 9. This is not clear. On 08-12-2024 10:15 AM, Registered Nurse (RN) 3, when queried as to how Discharges from the agency are performed, indicated discharge visits are not done in person, but are done over the phone, ‘never been a physical visit’. Indicated the patient should also receive a 15-day notice and this would be documented in the clinical record. When queried further regarding the lack of documentation in the clinical records of Patient's #1 - #6, and why and how the patients had been discharged, indicated had been instructed by Corporate Person 1 to find current Heal at Home patients, who required few hours, were dually insured with both Medicare and Medicaid, and who would be agreeable to go to Entity Q. When queried as to who had directed this activity, indicated Corporate Person 1 (who resigned during the survey) had, and was likely instructed by Corporate Person 3, to obtain patients for Entity Q in this manner. Indicated Person T had been the one to call the patients in question about opening a new agency and if they would like to 'move over', indicated it was his/her understanding that the patients were given the option to accept or not. 10. On 08-12-2024 at 11:55 AM the Administrator indicated starting up another Home Health agency would not be a reason to discharge current patients from Heal at Home.

G0574

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 safety measures to protect against injury and necessary interventions to address the underlying risk factors were on the individualized plan of care for 1 of 4 active clinical records reviewed. (Patient #9) Findings include: 1. A review of an undated policy titled 'CARE PLANS 3-660' revealed, "... The Care Plan shall include ... A list of specific interventions with plans for implementation ...". 2. A review of the clinical record for Patient #9 revealed a document titled 'HOME HEALTH CERTIFICATION AND PLAN OF CARE' with a start of care date of 07/12/2023 for the certification period of 07/06/2024 through 09/03/2024 signed by RN 1 on 07/01/2024. The Plan of Care for Patient #9 evidenced the following diagnoses but not limited to DiGeorge syndrome (DGS), 'also known as 22q11.2 deletion syndrome' (a congenital disorder) that can cause a range of lifelong problems but not limited to seizures. Patient #9 was to receive Skilled Nursing services 5 days a week for 7-8 hours per day. SN interventions were documented as but not limited to: Assess for signs/symptoms and frequency of seizure activity. Chart seizure activity in the nurse's notes/seizure record. Document seizure activity to include: date, time, length precipitating factors, description of seizure and behavior following seizure. 3. On 08/13/2024 at 11:04 AM, RN 1 indicated they weren't aware of recent seizure activity with Patient #9, when queried if Patient #9 was on seizure medications, RN 1 indicated Patient #9 was on seizure medications, and didn't realize seizure interventions should be on the plan of care. When queried if they knew what some of the interventions were they indicated they would lower them to the floor, turn on side, keep objects clear, and give rescue medications if indicated. 4. On 08/13/2024 at 12:06 the acting Administrator indicated seizure precautions should list what should be done in the event of a seizure on the Home Health Plan of Care. 410 IAC 17-13-1(a)(1)(B)

G0584

G0598

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure revisions to patients discharge plans had an appropriate cause/reason and were communicated and agreed upon with the patient, caregiver and ordering provider in, 6 of 6 discharged clinical records reviewed. (Patients #1, #2, #3, #4, #5, and #6) Findings include: 8. Review of the closed clinical record for Patient #1 failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the POA was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 9. Review of the closed clinical record for Patient #3 failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 10. Review of the closed clinical record for Patient #4 failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 11. Review of the closed clinical record for Patient #6 failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 12. On 08/12/2024 at 9:14 AM during an interview, Person B, a family member of Patient #1, who was the Power of Attorney (POA) indicated they hadn't spoken with the agency about a discharge. 13. On 08/09/2024 at 12:57 PM, Person W, an RN at Entity K indicated they received an order for Patient #4 to transfer to Entity Q on 03/21/2024, that the agency had not placed any phone calls to Entity K and further indicated they didn't know why the patient was transferring to the other agency. 14. On 08/12/2024 at 12:10, Person T returned this surveyors' call, indicated they had spoken with Patients 1, 2, 3, 4, 5, and 6, families, and their representatives about the discharges and if they were agreeable. When queried if they contacted the POA for Patient #1, Person T indicated since Patient #1 lived at Entity U, a group home, they had spoken with Person V, the house manager about the discharge. When queried where the documentation of those conversations were located, they indicated they had not documented the conversations. 1. Review of an agency policy titled ‘Discharge/Transfer Process 3-500’ indicated, “… Clients and their representatives are informed of the reason for discharge … agency documentation will include the following: The appropriate notice was given prior to discharge (at a minimum, 15-days) and will be documented in the client record … evidence the decision was not made unilaterally … The client, family and physician(s) participated in the decision to discharge client from agency … Documentation of all communication with the client, including the rationale for discharge, will be kept in the client file …” 2. Review of an agency policy titled ‘Notice of Rights 3-385’ indicated, “… [Entity Q] supports and maintains documentation of compliance with the following Patients Rights and Responsibilities … Right to receive written notice … in advance of reduction or termination of on-going care …" 3. Review of an agency policy titled ‘Clinical Documentation 3-680’ indicated, “… Telephone or other communication with clients, physicians, families, or other members of the health care team will be documented …” 4. Review of the closed clinical record for Patient #2 failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient was aware or in agreement with discharge, and failed to evidence the discharge had been discussed with the ordering provider. 5. Review of the closed clinical record for Patient #5 failed to evidence documentation a discharge was expected or planned, failed to evidence documentation of the need/reason for discharge, failed to evidence documentation the patient or Power of Attorney (POA, a person legally designated to make decisions or act on another’s behalf) was aware of, or in agreement with discharge and failed to evidence the discharge had been discussed with and verbal orders had been properly obtained from the ordering provider. 6. On 08-09-2024 at 3:39 PM, the Administrator indicated if it were the agency’s decision to discharge a patient, the patient should be given a 15-day discharge notice, the agency should be notifying the MD and obtaining an order to discharge. 7. On 08-12-2024 at 11:55 AM the Administrator indicated starting up another Home Health agency would not be a reason to discharge current patients from Heal at Home.

G0682

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 members followed appropriate infection control practices while providing hands-on care for patients in 2 of 3 home visits observed. (Home Health Aide (HHA) 10 and Licensed Practical Nurse (LPN) 1 ) Findings include: Review of an agency policy revised 12-27-2022 titled 'STANDARD PRECAUTIONS #5010' indicated, "... Gloves: To be worn when touching ... bodily fluids, secretions, excretions, mucus membrane ... and other contaminated items, i.e., equipment. Gloves do NOT take the place of hand hygiene. Hand hygiene is to be performed prior to putting on and after removing gloves. Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms ..." 7. On 08-13-2024 at 11:05 AM, Licensed Practical Nurse (LPN) 1 was observed providing care to Patient #8. The patient required intermittent suctioning to remove secretions from the mouth due to an inability to clear mucus or saliva on their own related to an impaired ability to swallow. The patient was in the living room, sitting upright in a motorized wheelchair and was pleasantly conversant. When it became apparent oral secretions were accumulating and affecting the patient's ability to continue speaking clearly, LPN 1 offered to provide suctioning and the patient agreed it was a good time. The nurse proceeded to a back room where a portable suction machine was kept, returned with the machine, turned it on, and placed a Yankauer (an oral suctioning tool, typically a firm plastic suction tip with a large opening surrounded by a bulbous head, designed to allow effective suction without damaging surrounding tissue) in the patient's mouth to suction away the accumulated secretions, to the patient's satisfaction. The nurse then returned the machine to the backroom, then returned to the living room and sat down. Hand hygiene was not performed and gloves were not worn, before, during, or after the procedure. After the visit, the nurse was queried as to the proper procedure for suctioning patients and the nurse indicated should wash or sanitize hands, indicated usually keeps sanitizer in her pocket but it was located in the bag on this day, apply gloves, get the catheter, allow patient to spit, take off cap, suction, replace cap, then dispose of gloves. 8. On 08-13-2024 at 3:?? PM (in Joey's office, after we ask Lana for the ENTIRE contents), discussing the home visit for Patient #8 and the infection control breach observed, the Administrator indicated the LPN should have gloves on when suctioning, change tips, and perhaps have mask and eye protection on depending on the situation, should have hand sanitizer available, and should have gloves available. 410 IAC 17-12-1(m) A review of a policy titled 'HAND HYGIENE-CDC GUIDELINES REFERENCE #5011' dated 2/13/18 revised 12/27/22 revealed, "... Gloves shall be worn when contact with blood, bodily fluids, mucous membranes ... Change gloves and discard after each patient contact ... Change gloves when moving from a contaminated body site to a clean body site on the same patient Change gloves when handling contaminated/dirty items in the patient's home ... all staff shall use the hand-hygiene techniques ... antimicrobial soap and water or an alcohol- based rub ... before each patient encounter ...after coming in contact with patient's intact skin, i.e., take a patient's blood pressure, pulse, lifting/moving the patient, after working on a contaminated body site then moving to a clean body site ... after coming in contact with bodily fluids ... after contact with medical equipment/supplies .. always after removing gloves ... PROCEDURE ... wash hand thoroughly ... dry hands with clean paper towel, turn off faucets with used paper towel and discard ..." On 08/13/2024 at 9 AM during a home visit to observe HHA 10 provide care to Patient #11, HHA 10 assisted Patient #11 to the bathroom, Patient #11 sat on toilet, HHA #11 assisted with undressing, assisted Patient #11 into the bathtub. HHA 10 doffed gloves and donned a clean pair of gloves. HHA 10 began rinsing Patient #11, washed and rinsed their hair, then washed and rinsed their entire body. HHA 10 went to the sink, doffed gloves, turned the water on, washed their hands, turned the water off with their right hand, and dried their hands on the towel hanging next to the sink, and donned a clean pair of gloves. Assisted Patient #11 out of the tub onto the toilet lid covered with a towel. Assisted with drying and dressing Patient #11, doffed and donned gloves, assisted Patient #11 with brushing their teeth. After Patient #11 was finished HHA 10 cleaned the toothbrush off, put toothbrush up, and changed gloves. Assisted with putting socks and shoes on. This surveyor exited the bathroom at that time and ended the visit. On 08/13/2024 at 2:50 PM during an interview with the acting Administrator indicated they should always use hand hygiene between changing gloves, should never use a cloth towel in the home, and always use a paper towel to turn the water off. On 08/14/2024 at 9:48 AM during an interview with HHA 10 when queried if they always use the cloth towel in Patient #11's bathroom, they indicated yes because there's no room for paper towels. When queried if they use alcohol hand sanitizer they indicated the office was too far to drive to get a small bottle of hand sanitizer. When queried if they were to use hand sanitizer or wash their hands between glove changes, they indicated they don't usually perform hand hygiene between glove changes.

G0750

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure home health aide in-service hours were completed and documented (778); failed to ensure the Registered Nurse (RN) failed to identify seizure precautions on the aide care plan (798); and failed to ensure a home health aide followed a patient's plan of care to provide ordered hands-on personal care and failed to be aware the aide was performing unauthorized tasks (G0800). The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate services which could result in the agency not providing quality health care, thus resulting in con-compliance with Condition of Participation CFR 484.80 Home Health Aide Services which could result with the Agency not providing quality health care for all 274 patients. Findings include; *

G0778

Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure in-service hours were completed and documented with 4 of 12 home health aide (HHA) employee records reviewed. (HHA 6, 7, 9, and 10) Findings include: 1. A review of an undated policy titled 'IN-SERVICE EDUCATION/STAFF DEVELOPMENT 4-320' revealed "In-service training or continuing education programs will be provided and documented for employees ... records on in-service education programs will be maintained and attendance will be documented ... Heal At Home will comply with in-service education requirements for home health aides ... The Home Health Aide must complete twelve (12) hours per year ..." 2. On 08/14/2024 a review of HHA 6 employee record failed to evidence in-service hours for the year of 2023. 3. On 08/14/2024 a review of HHA 7 employee record failed to evidence in-service hours for the year of 2023. 4. On 08/14/2024 a review of HHA 9 employee record failed to evidence in-service hours for the year of 2023. 5. On 08/14/2024 a review of HHA 10 employee record failed to evidence in-service hours for the year of 2023. 6. On 08/14/2024 at 3 PM, Corporate Staff 2, Director of HR with Entity R indicated HHA's are not required to have completed 2024 in-services until October 2024, and they could not locate in-service hours for HHA 6, 7, 9, and 10 for the year of 2023. 410 IAC 17-14-1(k)

G0798

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Registered Nurse (RN) failed to identify seizure precautions on the aide care plan in 1 of 3 active records reviewed. (Patient #7) Findings include; 1. A review of an undated policy titled 'CARE PLANS 3-660' revealed, "... The Care Plan shall include ... A list of specific interventions with plans for implementation ...". 2. A review of the clinical record for Patient #7 revealed a document titled 'HOME HEALTH CERTIFICATION AND PLAN OF CARE' with a start of care date of 05/31/2018 for the certification period of 06/28/2024 through 08/26/2024 signed by RN 2 on 06/25/2024. The Plan of Care for Patient #7 evidenced the following diagnoses but not limited to Epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures). Patient #7 was to receive Home Health Aide services 5 days a week for 9 hours per day. Skilled Nursing Interventions were but not limited to: Ease the patient to the floor if standing and keep them free from injury or objects during seizure activity. Note the type and length of activity. If the seizure lasted greater than 2-3 minutes call 911. After seizing, log roll the patient onto their side in a recovery position to prevent aspiration and promote breathing. Stay with the Patient until Emergency Medical Services arrive. Notify the nurse supervisor for any seizure activity. 3. A review of a document titled Aide Care Plan undated and unsigned for Patient #7 failed to identify what seizure precautions the home health aide to take in the event of seizure activity. 4. On 08/13/2024 at 9 AM during a home visit, when queried what HHA 10 would do for Patient #7 in the event of a seizure, HHA 10 indicated they would try to get Patient #7 to the floor as safely as possible, try to keep the area free of objects, and protect their head. When queried how they learned those precautions, HHA #10 indicated Person Y, a family member taught them eveything they needed to know to care for Patient #7. 5. On 08/13/2024 at 12:17 PM, RN 2 indicated seizure precautions should be on the Home Health Aide Plan of Care for Patient #7. 6. On 08/13/2024 at 12:06 the acting Administrator indicated seizure precautions should list what should be done in the event of a seizure on the Home Health Aide Plan of Care. 410 IAC 17-13-2(a)

G0800

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 a home health aide followed a patient's plan of care to provide ordered hands-on personal care and within their scope of practice, in 1 of 2 home health aide visits. (Home Health Aide (HHA) 1) Findings include: 1. Review of an agency policy dated 05-01-2018, titled 'HOME HEALTH AIDE ASSIGNMENTS AND DUTIES #4042' indicated, "... Home Health Aides/CNAs (Certified Nursing Assistants) must follow written Patient Care Instructions as prepared by the RN (Registered Nurse) or other appropriate skilled professional ... The HHA's (Home Health Agency's) Home Health Aides/CNAs shall provide services that are ordered by the physician ... included in the plan of care ... Permitted to be performed under state law ... consistent with home health aide training ... The duties of the HHA's Home Health Aide/CNAs shall include: The provision of hands on personal care ... The performance of simple procedures as an extension of therapy or nursing services ..." 2. Review of an undated agency policy titled '3-751 HOME HEALTH AIDE CARE PLAN' indicated, "... All home health aide staff will follow the identified plan ..." 3. Review of the clinical record for Patient #10 with a Start of Care date of 09-26-2022 for the recertification period of 07-17-2024 to 09-14-2024 indicated the patient had diagnoses which included, but were not limited to: quadriplegia (having no use of extremities: hands, arms, legs, or feet). The record also indicated the patient was dependent for all Activities of Daily Living (or ADLs, the basic tasks that people perform every day to live independently in a household: bathing, dressing, toileting, transferring, eating, and continence) and Instrumental Activities of Daily Living (or IADLs, more complex sets of skills needed in order to live independently: using the telephone, shopping, preparing meals, housekeeping, using transportation, taking medication(s), and managing finances) and possessed a urostomy (surgically created opening in the abdominal wall through which urine passes) and colostomy (surgically created opening in the abdomen in which a piece of the colon (large intestine) is brought outside the abdominal wall to create a stoma through which digested food passes into an external pouching system), the record indicated the urostomy and colostomy were managed by Person S, family member/main caregiver. 4. On 08-13-2024 at 12:35 PM, during a home observation with Home Health Aide (HHA) 9 was interviewed regarding Patient #10, indicated had worked with the patient for approximately four years total, first with another home health agency and now this agency. When queried regarding tasks done for the patient, indicated they do not perform the 'shower' listed on the aide care nor shampooing, indicated Person S, the patient's family member/main caregiver, performs all this, as it was the patient's preference, but does sometimes help. HHA 9 indicated, they emptied the patient's urostomy bag and sometimes changed both the urostomy bag and colostomy bag for the patient. When queried as to who instructed them to do so, indicated Person S, had instructed them. When queried if a nurse from the agency had ever instructed the aide to perform this activity, indicated no, not from this agency, but had received instruction from a nurse with the old agency. 5. On 08-13-2024 at 3:09 PM, when informed regarding HHA 9 changing Patient #10's urostomy and colostomy bags, the acting Administrator indicated was not aware any aide was changing such bags, indicated he believed this was not a task to be delegated to an aide to perform. Would be speaking with aide and ensuring this is rectified. 6. On 08-14-2024 at 10:40 AM, the acting Administrator indicated had verified HHA 9 had cared for no other patients, only Patient #10. 7. On 08-14-2024 at 11:18 AM, Person S, main caregiver for Patient #10, indicated has had HHA 9 with them for approximately 4 years. When queried as to what HHA 9 does for the patient, Person S indicated feeds, does laundry, picks up, and shaves the patient. When queried about showering, indicated the patient did not like to be showered by others, "I do the shower" three times per week, after work while the aide was still there, while the aide helped with changing bedding and preparing clean clothes. Person S indicated also does the shampooing. When queried as to changing the patient's urostomy and colostomy bags, indicated they do this themselves approximately three times a week or when needed and indicated affirmatively HHA 9 does this also, "[HHA 9] knows how to do it". Indicated sometimes, "[HHA 9] has to do it, I can't get home in time, if I'm at work". 8. On 08-14-2024 at 2:28 PM, Registered Nurse (RN) 2, the nurse case manager for Patient #10 was not aware HHA 9 had been changing urostomy or colostomy bags and indicated 'thought aides were not supposed to do that'. Indicated was not aware the aide was not providing showering or shampooing.

G0940

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 organize, manage, and administer its resources to achieve and maintain a high level of performance in the provision of Home Health care services to ensure personnel was current with their license/certificates, current with in-services, client intakes, and scheduling: the agency failed to ensure administrative and supervisory functions are not delegated to another agency or organization(G0940), the Agency failed to ensure the Governing Body hired an Administrator for the Agency (G0942), and the Agency failed to ensure the acting Administrator was involved in discharge for cause, oversight of human resources, and scheduling (G)948) The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate services which resulted in the agency not providing quality health care for the Condition of Participation of 42 CFR 484.105 for all 274 patients. 1. On 08/13/2024 at 1:15 PM, when queried the acting Administrator indicated Corporate Staff 2, HR Director is not an employee of the Agency but works for Entity R. The acting Administrator indicated the Agency had a contract with Entity R, a healthcare management company, and further indicated Entity R provided human resources for the Agency. 2. On 08/13/2024 at 1:22 PM, the acting Administrator provided a 'Management Agreement' between the Agency and Entity R, indicating Entity R would provide the following: Executive leadership/management, marketing, scheduling, client intake, human resources, payroll, and accounting services. 3. On 08/14/2024 at 12:55, Corporate Staff 2, Human Resource Director indicated they were an employee of Entity R. 4. 08/14/2024 at 12:35 PM, when queried what services the Agency would be able to contract, the acting Administrator indicated they did not know and would have to look it up. 410 IAC 17-12-1(a)(1)(2)

G0942

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the Governing Body failed to hire an Administrator for the Agency and failed to ensure the management and operation of the Agency was effective in 1 of 1 agency. Findings include: 1. A review of the Agency's Governing Body meeting minutes on 05/26/2024 evidenced the Governing Body approved to hire the current acting Administrator pending their acceptance of the position. 2. A review of the employee record for the Administrator evidenced a letter from Entity R a healthcare management company, Heal at Home, dated 05/07/2024 revealed, an offer of employment for the role of the Administrator with a start date of 05/28/2024, with the acting Administrator signing electronically on 05/08/2024. 3. Further review of the employee record for the acting Administrator evidenced a signed Administrator job description on 05/28/2024 but failed to evidence which Agency the Administrator was to be employed by. 4. On 08/14/2024 at 12:32, when queried of the letter from Entity R dated 05/07/2024, the acting Administrator indicated "it makes me look like I'm an employee of [Entity R]". 410 IAC 17-12-1(b)

G0948

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 agency failed to ensure the acting Administrator was involved in discharge for cause, oversight of human resources, and scheduling of home health aides in 1 of 1 agency. Findings include: 1. A review of the employee record for the acting Administrator evidenced a document titled 'Job Description: Administrator revised 2023' signed by the Administrator on 05/28/204 revealed, "ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES: 1. Planning, directing, and evaluating operations ... 5. Recruiting, employing, and retaining qualified personnel ... 9. Ensuring staff development including orientation, in-service education, continuing education, and evaluation of staff ...". 2. A review of a document titled 'Management Agreement' dated 01/01/2021, signed by CC, the owner of Entity R, and DD, the former Director of Nursing revealed Entity R, a healthcare management company "shall provide executive leadership/management, marketing, scheduling, client intake, human resources, payroll and accounting services ... TERMS The term of this agreement shall commence on January 1, 2021 and shall renew annually unless otherwise advised by either party in writing ...". 3. The acting Administrator failed to ensure discharged patients were discharged for cause, failed to document the communication with patient's, their families, the patient's physicians about the pending discharges, failed to ensure all employees had signed job descriptions along with job-specific orientation, failed to ensure all employees with certificates were current and in good standing, failed to ensure in-service hours were completed by all home health aides, failed to ensure all patients home health aide plan of care had the necessary information for the home health aide to perform their job adequately, failed to ensure all home health aide perform job duties within their scope of practice. 4. On 08/12/2024 at 11:59 AM, the acting Administrator indicated they realized that documentation had been very poor when speaking of the discharged patients, but when queried if they knew why a patient could be discharged they indicated they didn't know all the reasons and would have to look it up. On 08/14/2024 at 12:32 PM, the acting Administrator indicated Entity R performs all interviews and hires home health aides, receives their training through Entity R, and were by scheduled Entity R. The acting Administrator further indicated Entity R tracks all renewables and yearly in-services. 410 IAC 17-12-1(c)(1)

Survey of June 10, 2024

7 findings

E0000

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 06/05/24, 06/06/24, 06/07/24, and 06/10/24. Active Census: 149 At this Emergency Preparedness survey, Heal at Home, LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers 42 CFR 484.102. QR completed by Area 3 on 6-12-2024.

G0000

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider in conjunction with one (1) complaint, conducted by the Indiana Department of Health. Survey Dates: 06-05-2024, 06-06-2024, 06-07-2024, and 6-10-2024 Complaint: # 107373 with related and unrelated deficiencies cited. 12-month unduplicated census: 154 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR completed by Area 3 on 6-12-2024.

G0536

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 record review and interview the agency failed to ensure a review of all current medications was conducted to identify any potential adverse effects, drug reactions, including ineffective drug therapy, side effects, duplicate therapy, and/or noncompliance with medication regimen, in 1 of 8 active clinical records reviewed. (Patient #2) Findings include: 1. Review of an undated agency document titled ‘3-700 MEDICATION PROFILE’ indicated, “… PURPOSE To provide a complete list of ALL medications the client is taking … identify discrepancies between client profile and the physician and/or agency … The Medication Profile shall be reviewed by a Registered Nurse every sixty (60) days and updated whenever there is a change or discontinuation of medication …” Review of an undated agency document titled ‘3-709 MEDICATION RECONCILIATION’ indicated, "POLICY Heal at Home will reconcile all medications taken by the client during admission to home care, at recertification, after inpatient facility stays, at time of discharge, and whenever needed … Medications will be reviewed with the client on each home visit to determine if other prescriptions or non-prescription drugs are being taken …” 2. Review of the clinical record for Patient #2 evidence a Plan of Care with a start of care date of 11-12-2021 for the certification period of 04-30-2024 through 06-28-2024, was completed and signed by Registered Nurse (RN) 1 on 04-25-2024, and contained diagnoses which included, but were not to limited to: unspecified chronic respiratory disease (disease of the airways and other structures of the lung), tracheostomy (surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing) status, gastrostomy (surgical procedure used to insert a tube, often referred to as a "G-tube", through the abdomen and into the stomach used to provide a route for tube feeding, and/or to vent the stomach for air or drainage) status, and contained a medication list, which included but was not limited to the following: Advair (medication which treats two of the main causes of asthma symptoms: airway constriction and airway inflammation, to help prevent symptoms in the first place) twice daily, Flonase (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms: stuffy/runny nose, itching, and sneezing) daily, Sodium Chloride 3% inhalation solution (treats conditions that cause thick mucus in the lungs, works by thinning and loosening mucus, making it easier to clear from the lungs, may also be used to help deliver other medications to the lungs) four times daily, Supplemental water 30 mls over 30 mins 5 x day an hour after feeding infuses 10 am – 1 pm- 4 pm- 7 pm – 10 pm, Triamcinolone 0.1% topical cream (works by activating natural substances in the skin to reduce swelling, redness, and itching) apply twice daily to tissue around the g-tube. 3. On 06-06-2024 at 11:00 AM during a home visit interview for Patient #2, License Practical Nurse (LPN) 1, who was also a primary caregiver, was shown the most recent Plan of Care dated 04-25-2024 and completed by Registered Nurse (RN) 1. LPN 1 was queried as to each medication and the corresponding directions for each medication on the list. LPN 1 indicated the only medication the patient currently was taking was Advair, Flonase was not ‘daily’, was only used seasonally, Sodium Chloride was only used when given with Albuterol (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease) PRN (as needed), Supplemental water was no longer being given, ‘I give Pedialyte 10 AM and 2 PM’, and indicated further the Triamcinolone cream was no longer being used, but a clear barrier cream was used instead. 4. On 06-06-2024 at 2:30 PM, in a telephone interview, LPN 1, who was also a primary caregiver for Patient #2, indicated Flonase had never been given as ‘Daily’. Indicated ‘Supplemental Water’ had been replaced and indicated Pedialyte was given instead ‘for the last six months, or the 1st of the year’. Indicated was not using the Triamcinolone Cream which had been prescribed by a Nurse Practitioner and then was subsequently discontinued by the doctor and the family was then instructed to use a barrier cream instead, they had been using Critic-Aid Clear AF, and indicated they were able to purchase this cream from Amazon and had been using this for years. When queried as to how the Registered Nurse (RN) reviews medications for Patient #2 during the recertification visits, LPN 1 indicated the RN ‘just asks questions’, ‘just asks me questions’. When queried about whether Sodium chloride was still being given, LPN 1 indicated it was only used when given with Albuterol. And further indicated the Albuterol had not been needed or administered since approximately January of 2023 and was aware Albuterol was not currently on the list. Reiterated Advair was only needed in AM and PM, and was the only medication the patient was currently taking. 5. On 06-06-2024 at 2:44 PM in a telephone interview, Registered Nurse (RN) 1, when queried as to how medications are reviewed and reconciled the nurse indicated they were 'new to doing this'. Indicated being familiar with Patient #2, had performed last comprehensive assessment as the case managing nurse had been unavailable, indicated had talked with LPN 1 and other family members/caregivers, asked if there are new medications, if meds needed clarification would call the doctor, if not, would call the pharmacist. Indicated he/she prints out a Plan of Care and verifies medications with this document. When queried as to whether Patient #2 still used Albuterol, indicated the patient still needed this as the patient can get ‘gunky’. Indicated awareness that the Albuterol was not on the medication list and indicated ‘may have confused this with the Advair’. 6. On 06-06-2024 at 2:58 PM in a telephone interview, Registered Nurse (RN) 2, who is the case managing nurse for Patient #2, when queried as to when and how medications are reviewed and reconciled the nurse indicated performs medication reviews with recert, indicated will talk to LPN 1 who is also a primary caregiver, ‘I go through the list, I ask if any changes, I don’t ask to see each med, each time’. When queried about Sodium Chloride on the list, indicated ‘they’ve slowed down this’. When informed Albuterol was not on the list, RN 2 indicated this should be on the medication list. When queried as to the Triamcinolone cream indicated ‘I guess I did not ask about the cream’. When queried as to Supplemental water being switched out for Pedialyte indicated, ‘I did know about the Pedialyte, I documented it, didn’t change it in the med list’. Indicated would be calling the patient’s doctor and rectifying the matter. 7. On 06-06-2024 at 4:03 PM the Director of Nursing indicated during medication review the nurses should be 'going down the list'. 410 IAC 17-14-1(a)(1)(B)

G0572

G0590

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the clinical staff notified the attending physician with a medication error in 1 of 6 active records reviewed. (Patient #3) Findings include: 1. A review of an undated policy titled 'MEDICATION ADMINISTRATION ERROR' revealed, "... The client's physician is notified of medication errors ... a complete narrative description is documented by the responsible staff member and reviewed by the supervisor ... Appropriate action for follow-up with personnel is instituted ... the incident, actions taken, and client response will be documented in the clinical record ...". 2. A record review of Patient #3 revealed a Plan of Care dated 05/03/2024 and signed by Registered Nurse (RN) 3 for the certification period of 05/08/2024 through 07/06/2024 which evidenced diagnoses but not limited to Epileptic spasms (a sudden flexion, extension or mixed flexion-extension of proximal and truncal muscles, lasting 1-2 seconds), Patient #3 was to receive Enteral (the administration of food or drug into the human gastrointestinal tract) feedings through a gastrostomy tube (this is surgically placed to deliver liquid nutrition or medications through a flexible tube that goes directly into your stomach) and was to receive Ketogenic Enteral feedings 685 milliliters Ketocal 4:1 (formulated, beneficial supplement to ketogenic diets, high-fat, low-carb diet helps seizure control) plus 420 ml water (total daily volume 1105) 230 milliliters 1 feed at 9 PM via gastrostomy via pump at 285-380 milliliters per hour as tolerated, and 685 milliliters Ketocal 4:1 plus 420 ml waster (total daily volume 1105) 220 milliliters give 4 feeds at 9 AM, 12 PM, 3 PM, and 6 PM via gastrostomy (G-tube) via pump at 285-380 milliliter per hour as tolerated. A visit note dated 05/24/2024 for Patient #3, signed by LPN 2 evidenced a Ketogenic formula 220 milliliters was administered via the pump through the G-tube from 12:05 PM to 12:46 PM and 2:58 PM to 3:51 PM and indicated the patient had tolerated both feedings well. The record failed to evidence physician notifications from 05/24/2024 through 06/03/2024. 3. During a phone interview on 06/07/2024 at 1:08 PM with Person A, the family member of Patient #3 indicated on 05/24/2024 when preparing for the tube feeding at 6 PM, they noticed the color was different in the bag than what it should have been. Person A called LPN 2 and asked about the feedings LPN 2 had given. Person A and LPN 2 decided LPN 2 must have grabbed the wrong feeding to give to Patient #3. Person A indicated they did notify Person D, the attending physician of the wrong tube feedings and Patient #3 had 7 seizures on 05/25/2024, was better on 05/26/24, and was back at baseline on 05/27/2024 which is 1-2 seizures per day. During a phone interview on 06/07/2024 at 1:37 PM LPN 2 indicated they did receive a call on 05/24/2024 in the evening from Person A, and it was thought LPN 2 had given the wrong formula to the patient, LPN 2 indicated there were 2 different types of formula in the cabinet and they must have grabbed the wrong one. LPN 2 indicated they should have notified the Registered Nurse Case Manager, the agency, and called the physician as well. On 06/10/2024 at 9:16 AM, the Director of Nursing indicated with medication errors there would be immediate education for all staff, education with the family to label shelves as needed, discipline staff if appropriate, file a medication error report, and contact the physician. This writer attempted to phone Person D the attending physician for Patient #3, on 06/07/2024 at 3 PM, left a voice message, and on 06/10/2024 at 8:46 AM with no return calls. 410 IAC 17-13-1(a)

G0612

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received written instructions for their plan of care, medications, and schedules in 3 of 4 home visits. (Patients 2, 3, and 4) Findings include: 8. On 06-06-2024 at 2:00 PM during a home visit with Patient #2, LPN 1 who is also a caregiver for the patient, offered two agency folders for review, neither contained a Plan of Care. When queried as to whether the agency ensured an updated Plan of Care gets placed in the folder, the nurse indicated, ''No". Person E, a family member and caregiver of Patient #2 was shown a copy of the Plan of Care, and was then queried as to whether they had their own copy of the patient's Plan of Care elsewhere, or had ever received a Plan of Care from the agency which contained the frequency of services, treatments, and medication list, Person E indicated had 'never' received such documents from the agency. 9. On 06-06-2024 at 4:03 PM the Director of Nursing indicated knowing the Plan of Care 'should go back out to the patient'. 1. A review of a policy dated 12/2017 titled 'HOME CARE BILL OF RIGHTS 3-380' revealed, "... Rights of the patient ... 4. ... b. The care to be furnished, including disciplines and frequency of visits ...". 2. On 06/06/2024 at 7:45 AM, the review of Patient #3's home folder failed to evidence their Plan of Care, a Medication list, and schedule. When queried RN 4 indicated that Person A, a family member probably had placed those items somewhere. 3. On 06/06/2024 at 3:20, the review of Patient #4 home folder failed to evidence their Plan of Care, Medication list, and schedule. 4. During an interview on 06/06/2024 at 3:20 RN 5, a family member to Patient #4 indicated there not a Plan of Care, Medication list or schedule, and couldn't recall if there had ever been one. 5. During an interview on 0607/2024 at 1:08 PM, Person A indicated they do not have a Plan of Care or a Medication list from the Agency. 6. During an interview on 06/06/2024 at 12:40 RN 3, a Registered Nurse Case Manager indicated they were unaware they were to put a Plan of Care or a Medication list in the patient's home folders. 7. During an interview on 06/07/2024 at 12:10 the Administrator indicated they had not realized the Plan of Care, Medication Lists, and schedules were not being placed in the patient's homes.

G0682

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 record review, observation, and interview the agency failed to ensure staff utilized appropriate infection control, personnel protective equipment, and hand hygiene practices while providing care in 1 of 4 home visits observed. (Home Health Aide (HHA) 1) Findings include: 1. Review of an agency document 'EFFECTIVE: 1/31/18' titled 'PERSONAL PROTECTIVE EQUIPMENT (PPE) - REFERENCE #5017' stated, "PROCEDURE: The appropriate PPE shall be worn when: ... Whenever there is danger of contamination from blood, body fluids (including secretions and excretions except sweat), or other potentially infectious materials ... All PPE shall be removed prior to leaving a work area ... Protective clothing (gowns and aprons) shall be worn according to isolation guidelines, policy or necessity ... shoe covers shall be worn as needed ..." Review of an agency document 'EFFECTIVE: 1/31/18' titled 'HAND HYGIENE - CDC GUIDELINES - REFERENCE #5011' stated, "PURPOSE: To provide guidelines for effective hand hygiene in order to prevent the transmission of bacteria, germs, and infections ... All staff shall use hand-hygiene techniques, as set forth in the following procedure ... When hands are soiled ... Before each patient encounter ... After coming in contact with patient's intact skin ... i.e. ... lifting/moving the patient ... After contact with medical equipment/supplies in patient areas ... Always after removing gloves ... " 2. On 06-07-2024 at 8:30 AM during a home visit for Patient #8, Home Health Aide (HHA) 1 was observed wearing a knee-length skirt and flip-flops. Entering the roll-in shower, HHA 1 with gloves donned, proceeded to assist the patient who was seated in a rolling shower chair, to complete their shower. During the shower the aide utilized a detachable shower head to rinse the patient's hair and body, the aide's exposed feet were also inadvertently sprayed with water. After the shower, the aide dried off the patient with a bath towel, then transported the patient to their bedroom area and assisted with transferring from the chair to the bed, covered the patient for comfort and privacy, and allowed the patient to rest before dressing. The aide returned to the roll-in shower and proceeded to rinse and ring out a sponge used during the shower. The aide then doffed their gloves, washed their hands with soap and water, dried their hands with disposable paper towels, and shut off the faucet with paper towel. A bath towel used during the shower remained on the floor, using their sandaled feet to scoot the towel around on the floor, the aide attempted to ‘mop’ up any water droplets that remained on the floor after transporting the patient from the shower to the bed. When this was completed the aide slipped out of their flip-flops and stepped onto the towel itself and dried off their feet. The aide put on a different pair of white, lacy-appearing, closed-toed shoes, then returned to pick up the flip-flops and carried them to another area of the room. The aide then proceeded to the patient’s bedside, donned a new pair of gloves and began assisting the patient with applying lotion to their body. Hand Hygiene was not performed during changes in tasks. Hand hygiene was not performed after handling the flip flops with bare hands, and not before donning gloves to apply lotion to the patient’s body. 3. On 06-06-2024 at 9:10 AM, when queried regarding wearing sandals during shower HHA 1 indicated understanding of probable contamination and offered nothing further. When queried regarding handling the sandals barehanded and then proceeding to don gloves and apply lotion to the patient, and whether hands should have been sanitized in between, smiled and nodded their head affirmatively, but offered nothing further. On 06-06-2024 at 11:55 AM when findings at the visit for Patient #2 were discussed the Administrator and Clinical Manager indicated there should have been more hand hygiene performed during the visit, ‘can’t wear sandals’, and discussed the possibility of rain boots, indicated would be handling situation which may include the strategic placement of hand sanitizer in the home. 410 IAC 17-12-1(m)

Survey of January 3, 2024

3 findings

G0644

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 Governing Body failed to ensure the frequency of data collection for the Quality Assessment Performance Improvement (QAPI) Plan was approved by the Governing Body, for 1 of 1 agency QAPI program. Findings include: 1. A review of agency policy #9001, "Organizational Quality Assessment and Performance Improvement (QAPI) Plan," last revised 12/11/23, indicated, "The Governing Body shall have a responsibility to evaluate the effectiveness of the QAPI activities performed ... "Page 15 of the policy evidenced a blank signature page which indicated the date the QAPI plan was reviewed. The policy failed to evidence the frequency of data collection in the QAPI plan was approved by the Governing Body. 2. A review of the undated agency QAPI plan evidenced a 10-page document which included, but was not limited to, priority focus areas, performance measures, benchmarks/goals, and frequency of data collection. 3. On 01/02/24 at 10:17 AM, the Administrator indicated the Governing Body had not met since the previous survey and wasn't scheduled to meet until the end of January, so there were no Governing Body Minutes available for review since the previous survey. 4. On 01/02/24 at 3:11 PM, the Administrator indicated the new QAPI plan was not yet implemented but would be implemented after the Governing Body met to review Q4 at the end of January 2024. When asked if the Governing Body met and discussed the QAPI plan, the Administrator, also a member of the Governing Body, indicated she talked to Person 2, the other Governing Body member, intermittently as the plan was written. When asked for documentation of Governing Body approval of the QAPI plan, the Administrator indicated she wasn't sure where it was, but she would look for it. 5. On 01/03/24 at 2:31 PM, the Director of Clinical Services submitted a document titled "Governing Body Minutes, December 1, 2023." The document evidenced a call to order with the Administrator and Person 2 and indicated the topics of discussion and follow-up actions were "Policy Revision: Comprehensive Assessment policy #3-145, Performance Improvement policy, QAPI Policy, Assessment form, and Certified Home Health Aide Competency Evaluation Program." The document evidenced no further information and was signed by both Governing body members. IAC 42 CFR 17-12-2(a)

G0658

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 observation, record review, and interview, the agency failed to evidence the documentation of the initiation of the performance improvement plan (PIP) activity of obtaining physician orders at the start of care, recertification, patient strengths, and care preferences for 1 of 1 Quality Assessment and Performance Improvement (QAPI) programs. Findings include: 1. A review of a revised 12-11-2023, agency policy, titled, "Organizational Quality Assessment and Performance Improvement (QAPI) Program" indicated but was not limited to, " ... Performance Improvement Projects shall be conducted and documented ... The findings of the outcomes of quality assessment and performance and results of actions taken shall be documented and reported ... " 2. On 01-02-2023 at 10:49 AM, during the Entrance Conference, the Administrator indicated they had completed a PIP as a result of their last survey. 3. A review of an agency binder evidenced the following; undated agency documents titled, Quality Assessment and Performance Improvement (QAPI) Monitoring and Evaluation Plan," agency revised 12-11-2023 policy titled "Organizational Quality Assessment and Performance Improvement (QAPI) Program. The binder failed to evidence a PIP had been initiated. 4. On 01-02-2023 at 4:50 PM, observed the clinical manager with a stack of documents, and the top of the documents contained numbers and percentages. When queried about the survey PIP, the Clinical Manager indicated the documents in front of them represented 156 chart audits, and 8 charts were done correctly resulting in a 5% accuracy. The results and associated PIP were not provided on any document. 5. On 01-05-2023 at 1:45 PM, the Clinical Manager and Administrator, when queried how the agency documents PIPs undertaken and what progress was evidenced, they indicated slow growth would be evident. The Clinical Manager further indicated out of 156 charts audited for physician orders for recertification orders for the plan of care, patient strengths, weaknesses, and care preferences 8 were correct which they had corrected with the nurse. No documents were provided representing the PIP. 6. These findings were reviewed with the Administrator and Clinical Manager on 01-03-2024 from 3:00 PM to 3:06 PM, at which time they had no further documentation to provide.

G0660

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure an ongoing Quality Assessment Performance Improvement program which established clear expectations for patient safety and quality of care was implemented according to the agency's plan of correction date of 12/08/23, and was maintained and evaluated for effectiveness for 1 of 1 Governing Body. Findings include: 1. A review of agency policy #9001, "Organizational Quality Assessment and Performance Improvement (QAPI) Program," last revised 12/11/23, indicated "The HHA's [Home Health Agency's] ... (QAPI) program shall be designed to: Delineate expectations and plan and manager processes to measure, assess and improve ... governance, management, clinical and support activities ... promote positive patient outcomes ... identify ... areas for improvement in the quality of care, treatment and services ... Evaluate, monitor, improve and resolve areas of concern ... The Administration ... shall ... support a planned, systematic and data-driven organization wide [sic] QAPI plan ... The HHA's Governing Body has ultimate responsibility to ensure the QAPI program reflects the complexity of its organization and services ... and shall ... include all services ... The HHA shall maintain documentation of its QAPI program and related activities ... The Administrator will collect data monthly ... Process design ... Supports a culture of safety and quality ... Utilizes reports generated from OASIS [Outcome and Assessment Information Set] data ... Utilizes collected data to monitor the effectiveness and safety of services and quality of care ... The frequency and detail of the data collection as approved by the Governing Body ... Utilizes the results of quality assessment and performance improvement, patient safety and risk reduction activities ... QAPI activities must track adverse patient events, analyze their courses and implement preventative actions ... shall include monitoring of administrative/operational activities (i.e., inservice hours, performance evaluations, billing audits). Page 15 of the policy evidenced a signature page titled "Organizational Quality Assessment and Performance Improvement (QAPI) Plan Approval" which was blank and indicated "see signed copy in QAPI binder." 2. A review of the undated "Quality Assessment and Performance Improvement (QAPI) Monitoring and Evaluation Plan" evidenced a 10-page document which included information for the scope, the responsible individuals, the priority focus area, performance measures/outcomes to be used, related functions, benchmark and goal percentage to achieve, data collection methodology, and integration and collaboration sections on each page. Performance measures/outcomes included categories such as management of the patient with congestive heart failure, areas to assess, benchmark goals of 90-100%, frequency of data collection and review, and individuals involved. The QAPI plan failed to evidence dates, data, aggregated information, or benchmark results for all categories and failed to evidence it was actively implemented. 3. On 01/02/24 AT 3:11 PM, the Administrator and Director of Clinical Services indicated the QAPI plan was developed as part of the recent plan of correction. The Administrator indicated the QAPI program would not be implemented until the end of January 2024 when the data for Q4 was available. 4. On 01/03/24 at 1:53 PM, the Administrator was asked how they QAPI plan shows outcomes for safety and indicated the audit information obtained shows areas in which staff education is needed and indicated safety was not an issue for the agency. When asked to review the current quality indicators, the Administrator indicated the new QAPI plan was not currently implemented and she was trying to finish 2023 now after finding a folder from the prior Administrator that contained various audit information that went to August 2023, and she which she was attempting to sort out the information. The Director of Clinical Services indicated she'd completed 156 clinical record audits and provided the results verbally by percent. The Director of Clinical Services indicated she would not provide the audits for review and indicated there was no documentation to provide for the audit results.

Survey of November 9, 2023

7 findings

G0000

This visit was for a Federal and State complaint survey of a Home Health Provider. On 11/11/08/23 at 3:02 PM, the Alternate Administrator was notified the survey was extended. Survey Dates: 11/02/23, 11/03/23, 11/06/23, 11/08/23, 11/09/23 Complaint: #101435 - Federal and State deficiencies were cited. Unduplicated skilled Admissions (for last 12 months): 18 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. During this extended complaint survey, Heal at Home was found to be out of compliance with Conditions of Participations 42 CoP 484.65 Quality Assessment Performance Improvement. Based on the Condition-level deficiencies during the 11/09/23 survey, your Home Health Agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 11/06/23 at 3:50 PM. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning 11/06/23 and continuing through 11/05/25. QR completed by Area 3 on 12-5-2023.

G0530

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's comprehensive assessment included the patient or patient representative's strengths, goals, and care preferences for 4 of 5 active clinical records reviewed. (Patients #1, 3, 4, 5) Findings include: 1 An undated agency policy 3-145, titled "Comprehensive Assessment," indicated " ... The assessment identifies facilitating factors and possible barriers to client reaching his or her goals including presenting problems. The policy failed to evidence the comprehensive assessment should include the patient's strengths, goals, and care preferences. 2. A review of the comprehensive assessment for Patient #1, dated 09/01/23, evidenced a primary diagnosis of Type 1 Diabetes (a condition where the pancreas fails to produce insulin) with stage IV chronic kidney disease (a condition where the kidneys are close to failing or have totally failed), adjustment disorder with mixed anxiety and depression (a mixed disturbance of emotions and conduct), legal blindness, chronic obstructive pulmonary disease (COPD - scarring of the lungs causing difficulty breathing and poor oxygenation), seizures (abnormal misfiring of electrical impulses in the brain resulting in uncontrolled muscle twitching and jerking), chronic pain, bilateral lower extremity amputation, absence of an eye, presence of an ileostomy (an artificial opening through the abdomen and into the part of the bowel called the ileum), renal dialysis (treatment used for chronic kidney failure where blood is removed via a dialysis pump, impurities are filtered out, and "clean" blood is returned to the patient). The assessment failed to evidence patient strengths, failed to evidence patient desired goals were discussed, and failed to evidence specific care preferences were discussed, such as preferences related to care of the ileostomy, care preferences related to accommodating the patient's visual impairment, or care preferences to minimize anxiety and depression. 3. A review of the comprehensive assessment for Patient #3, dated 10/23/23, evidenced the patient was a pediatric patient with a primary diagnosis of tracheostomy (an artificial opening through the external neck/throat area and into the airway, or trachea to allow for breathing) status and secondary diagnoses of cleft palate (a congenital, or present at birth, split in the roof of the mouth), congenital malformation, unspecified (record does not indicate the area of malformation), gastrostomy (GT - an artificial opening from the outside of the stomach/abdomen into the stomach to allow for feedings/fluids), unspecified lack of expected normal physiological development in childhood, bilateral sensorineural hearing loss, mild protein-calorie malnutrition (poor nutrition due to lack of protein), dermatitis (irritation or inflammation of the skin), and bowel/bladder incontinence. The comprehensive assessment failed to evidenced patient/caregiver specific goals were discussed, failed to evidence care preferences such as methods of comfort, use of a pacifier or comfort toy, and methods of communicating due to hearing impairment, and failed to evidence any patient/caregiver strengths. 4. A review of the comprehensive assessment for Patient #4, dated 08/23/23, evidenced a primary diagnosis of COPD and secondary diagnoses including but not limited to shortness of breath, lumbago (back pain), hypertension (high blood pressure), emphysema (scarring of the lungs), anxiety, and stage 2 chronic kidney disease. The assessment failed to evidence patient strengths, failed to evidence the patient's desired goals were discussed, and failed to evidence specific care preferences were discussed, such as preferences to prevent anxiety or minimize and manage back pain during care. 5. A review of the comprehensive assessment for Patient #5, dated 09/01/23, evidenced a primary diagnosis of unspecified polyarthritis and secondary diagnoses of age-related physical debility, primary adrenocortical insufficiency (a condition where the kidneys don't produce enough of the hormones called cortisol and aldosterone), stress incontinence, and recurrent/moderate major depressive disorder. The assessment failed to evidence the patient's strengths were discussed and failed to evidence the patient's desired goals. 6. On 11/09/23 at 3 PM, the comprehensive assessments for Patients #1, 3, 4, and 5 were reviewed with the Alternate Administrator who indicated they did not include the patients' desired goals, care preferences, and/or strengths.

G0584

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal physician's orders were received verbally from the physician or qualified physician's representative, documented at the time they were received and then read back and verified for accuracy then sent to the physician to be signed, for 5 of 6 active clinical records reviewed. (Patients #1, 3, 4, 5,) Findings include: 1. A review of agency policy 3-635 "Physician Orders," effective 08/02/15 indicated "HHA (Home Health Agency) staff accept telephone/verbal/facsimile and/or written orders ... Heal at Home ensures the accuracy of telephone/verbal orders ... Orders are obtained from the physician or other authorized individual ... prior to providing care, treatment and/or services ... Each telephone/verbal order shall be written down or entered into the computer and then read-back to the individual delivering the order ... The staff member shall verify the order by reading back the order to the individual providing it ... The following statement will appear on electronic verbal orders ... before the electronic signature: "By checking this box, you will be applying your digital signature indicating you have verified and read back the Change Order ...The staff member who accepts the order: Reduces the order to writing, ensures the appropriateness, accuracy and completeness of the order, signs and dates the order ... " 2. A review of a recertification comprehensive assessment for Patient #1, dated 09/01/23, evidenced "The physician, patient/caregiver, and nurse have collaborated in the development of the plan of care to include the stated services, frequencies, and duration of services as listed." A review of order RC-112624 for Patient #1 indicated "V.O.(Verbal Order) - Re-certify patient for 60 day home health care episode. Detailed plan of care to follow." The order failed to evidence patient care orders which were spoken to RN 2 by the patient's physician/representative, documented by RN 2 at the time they were given by the physician/representative, read back for verification, then sent to the physician for review and signature. On 11/8/23 at 2:18 PM, RN 2 indicated she contacted the patient's physician while still in the patient's home to request an order to recertify the patient for 60 more days of home health aide services, then sent a verbal order for the physician's signature. The office nurses completed quality review on the comprehensive assessment and developed the plan of care which they later sent to the physician/representative for review and signature. When asked if RN 2 reviewed current findings and plan of care information with the physician/representative prior to establishing the new plan of care document RN 2 indicated she only sends the verbal order for recertification because it includes the information that a detailed plan of care will follow. 3. A review of a recertification comprehensive assessment for Patient #3, dated 10/23/23, failed to evidence the physician/representative was contacted after the assessment to review findings and obtain verbal or written orders to establish the continuing care plan for the certification period of 10/25/23 - 12/23/23. A review of order #113451, dated 10/23/23, indicated "VO (Verbal Order)": Re-certify patient for another 60 day home health care episode. Detailed to follow." [sic] The document failed to evidence verbal orders for medications, interventions, services, and treatments were received, documented and read back for verification prior to establishing the plan of care. 4. A review of the clinical record for Patient #4 evidenced a comprehensive assessment dated 08/23/23, for the certification period of 08/25/23 - 10/23/23, and failed to evidence the physician/representative was contacted to review findings, obtain continuing care orders, and update the plan of care. A review of order RC-112391 "Recert Order", dated 08/23/23, indicated "V.O. Re-certify patient for 60 day home health care episode. Detailed POC to follow." The document failed to evidence verbal orders for medications, interventions, services, and treatments were received, documented and read back for verification prior to establishing the plan of care. 5. A review of the comprehensive assessment for Patient #5, dated 09/01/23, indicated "rec(d V.O. [sic] from MD to recertify patient. Patient remains appropriate for home care for HHA (home health aide) assistance with ADLs-IADLs to include services and frequencies identified. Patient, HHA, and RNCM hace [sic] cllaborated [sic] in POC development-review. No changes needed at this time. All in agreeeent [sic]. Care conference with DON completed." The comprehensive assessment failed to evidence the physician/representative was contacted to review findings from the comprehensive assessment, obtain verbal or written orders for care and services, and to update the plan of care orders. A review of the clinical record for Patient #5 failed to evidence further documentation indicating the physician was contacted to review findings and obtain verbal orders for the plan of care for certification period 09/04/23 - 11/02/23. 6. On 11/9/23 at 2 PM, the Alternate Administrator was interviewed concerning the agency's process for obtaining continuing orders after a recertification assessment was completed. The Alternate Administrator indicated most of the information on a recertification plan of care doesn't change and they do not contact the physician's office because no one has time to speak to them about all the comprehensive assessment findings and what they put on the plan of care. The field clinician completes the recertification comprehensive assessment and submits it to the quality review queue for review by the Alternate Administrator or RN 1. After reviewing the comprehensive assessment, the Alternate Administrator or RN 1 create a finished plan of care and fax it to the physician for signature. The Alternate Administrator was asked to clarify at what point the physician/physician representative discusses the assessment findings with the RN and gives the RN the verbal orders that were documented on the plan of care. The Alternate Administrator indicated the plan of care is the verbal order. When asked to indicated in the record when the clinician spoke with the physician/representative and received those verbal orders, the Alternate Administrator stated, "We don't speak to the physician before we make and send the plan of care. We send a verbal order to recertify for the next 60-days with a statement that says a detailed plan of care will follow." 410 IAC 17-14-1(a)(H)

G0640

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to develop, implement, document, and maintain an effective, ongoing, agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) program that reflected the complexity of the organization and its services; failed to evidence a QAPI program that demonstrated tracking, measurement, analysis, and performance improvement of high-risk, high-volume, problem-prone areas including the use of emergent care services, hospital admissions/re-admissions, Outcome and Assessment Information Set (OASIS) indicators, adverse events, and other aspects of care, services, and operations; failed to evidence a QAPI program which monitored the effectiveness and safety of services and quality of care and identified opportunities for improvement; and failed to demonstrate the agency's governing body ensured an ongoing program for quality improvement and patient safety was defined, implemented, and maintained; and failed to demonstrate performance improvement efforts were implemented, sustained, and evaluated quality of care and patient safety. The cumulative effect of this systemic problem resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.65 Quality Assessment Performance Improvement. 1. A review of an agency policy titled "Performance Improvement Projects," effective 01/13/18, indicated " ... Heal at Home HHA [Home Health Agency] shall conduct performance improvement projects as part of its organization-wide Quality Assessment and Performance Improvement (QAPI) program. Performance improvement project(s) shall be conducted at least annually. Performance improvement projects shall be documented and maintained ... Performance improvement projects shall be selected based on indicators related to improved patient safety and quality outcomes (See Organizational Quality Assessment and Performance Improvement (QAPI) Program Policy) ... The number and scope of distinct improvement projects conducted annually shall be based upon the HHA's scope, complexity, past performance of services and operations ..." 2, On 11/08/23 at 3:15 PM, the Alternate Administrator was asked for the agency's Quality Assessment Performance Improvement (QAPI) program and all QAPI documents, including but not limited to any QAPI binders, audits, meeting minutes, performance improvement plans (PIP), aggregated numbers/tracking information, recent resolved PIPS, etc. The Alternate Administrator provided a 5-page document titled "QAPI Indicators 2023" which evidenced indicators tracked between January 2023 - present and included 82 indicators such as goals met, incident reports, bed bugs, falls, resumptions of care, and wounds. The document failed to evidence which indicators were part of the agency's QAPI program and/or were being monitored under a PIP and failed to evidence a program which measured, analyzed, improved, and followed-up on the indicators listed. 3. On 11/09/23, the Alternate Administrator provided QAPI meeting minutes dated 05/04/23 and 08/22/23. The minutes failed to evidence the agency's QAPI program was discussed; failed to reflect the QAPI meeting reflected review of tracking, measurement, analysis, and performance improvement of high-risk, high-volume, problem-prone areas including the use of emergent care services, hospital admissions/re-admissions, Outcome and Assessment Information Set (OASIS) indicators, adverse events, and other aspects of care, services, and operations; and failed to evidence discussion of active PIPs or implementation of new PIPs. The Alternate Administrator indicated she was not aware of any further QAPI program information and indicated she was not aware of any active PIPs or indicators showing a need for a PIP. 410 IAC 17-12-2(a)

G0754

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure it employed qualified home health aides (HHAs) who successfully completed an HHA training and competency program or evidenced prior equivalent training and completed the agency's HHA competency program consisting of successful completion of a written test and demonstration of skills with a live or pseudo-patient, for 8 of 8 active home health aide records reviewed. (HHA 1, 2, 3, 4, 5, 6, 7, 8) Findings include: 1. A review of the agency's current home health aide (HHA) job description, last revised 12/2017, evidenced qualifications for a home health aide included, but were not limited to, a certificate of completion from an approved home health aide or certified nurse aide training program, certification as a certified nurse aide by the State of Indiana, or completion of the first year of clinical studies at a school of nursing. 2. A review of the personnel file for HHA 1, date of hire 10/02/19, failed to evidence a certificate of completion from an approved home health aide or certified nurse aide training program, failed to evidence nurse aide certification in the State of Indiana, and failed to evidence HHA 1 completed the first year of clinical studies at a school of nursing. On 11/09/23 at 10:15 AM, HHA 1 indicated no previous HHA training or experience prior to employment with Heal at Home. HHA 1 indicated Heal at Home trained her in all areas of written and skills competency at orientation. 3. A review of the personnel file for HHA 2, date of hire 06/23/21, failed to evidence a certificate of completion from an approved home health aide or certified nurse aide training program, failed to evidence nurse aide certification in the State of Indiana, and failed to evidence HHA 2 completed the first year of clinical studies at a school of nursing. On 11/08/23 at 2:10 PM, HHA 2 indicated she had no previous patient care experience as an HHA or certified nursing assistant prior to employment with Heal at Home and stated she received training from Heal at Home during orientation. HHA 2 indicated she had no formal experience or training on bed baths and learned on a mannequin during competency testing. HHA 2 also recalled being taught to use a Hoyer lift (a mechanical lift for transferring non-weight bearing individuals), a walker, a gait belt, and provide catheter care, which were skills she'd had no previous training or experience performing. 4. A review of the personnel file for HHA 3, date of hire 04/28/21, failed to evidence a certificate of completion from an approved home health aide or certified nurse aide training program, failed to evidence nurse aide certification in the State of Indiana, and failed to evidence HHA 3 completed the first year of clinical studies at a school of nursing. On 11/08/23 at 2:15 PM, HHA 3 indicated she had no previous experience or training as an HHA and received all HHA training from Heal at Home. HHA 3 indicated she watched a video on bathing and the agency instructor walked her through how to do a bed bath during the competency training, but she never demonstrated bathing on a live patient or pseudo-patient. 5. A review of the personnel file for HHA 4, date of hire 08/22/18, failed to evidence a certificate of completion from an approved home health aide or certified nurse aide training program, failed to evidence nurse aide certification in the State of Indiana, and failed to evidence HHA 4 completed the first year of clinical studies at a school of nursing. On 11/08/23 at 2 PM, HHA 4 indicated she had previous experience helping with family and had been a certified nursing assistant but allowed the certification to lapse "years ago." 6. A review of the personnel file for HHA 5, date of hire 06/16/21, failed to evidence a certificate of completion from an approved home health aide or certified nurse aide training program, failed to evidence nurse aide certification in the State of Indiana, and failed to evidence HHA 5 completed the first year of clinical studies at a school of nursing. On 11/08/23 at 1:30 PM, HHA 5 indicated she had previous experience caring for a parent but had never received formal HHA or certified nursing assistant training prior to employment with Heal at Home. 7. A review of the personnel file for HHA 6, date of hire 11/14/22, failed to evidence a certificate of completion from an approved home health aide or certified nurse aide training program, failed to evidence nurse aide certification in the State of Indiana, and failed to evidence HHA 4 completed the first year of clinical studies at a school of nursing. On 11/08/23 at 2 PM, HHA 6 indicated she had previously worked in a nursing home where she received some training but was not a certified nursing assistant and had never completed formal HHA training. HHA 6 indicated training with Heal at Home consisted of having the procedures explained and she did not actually demonstrate any skills on a live patient or pseudo-patient. 8. A review of the personnel file for HHA 7, date of hire 03/13/19, failed to evidence a certificate of completion from an approved home health aide or certified nurse aide training program, failed to evidence nurse aide certification in the State of Indiana, and failed to evidence HHA 7 completed the first year of clinical studies at a school of nursing. On 11/08/23 at 1:45 PM, HHA 7 indicated she had previous experience as an HHA and as a certified nursing assistant. 9. A review of the personnel file for HHA 8, date of hire 10/30/20, failed to evidence a certificate of completion from an approved home health aide or certified nurse aide training program, failed to evidence nurse aide certification in the State of Indiana, and failed to evidence HHA 8 completed the first year of clinical studies at a school of nursing. On 11/08/23 at 1:53 PM, HHA 8 indicated her certified nursing assistant certification expired in 2015 and was never renewed. HHA 8 indicated she received HHA training from Heal at Home upon employment but could not remember competency testing. 10. On 11/08/23 at 2:30 PM, the Alternate Administrator, RN 1, and Person 7, the Director of Human Resources were questioned concerning the qualifications for a Home Health Aide applicant and indicated an HHA applicant was required to have previous experience, pass a written competency test, and complete an HHA skills evaluation which included hands-on care of a live patient or pseudo-patient for all tasks marked with an asterisk. When questioned whether a qualified HHA was required to complete formal training through an HHA or certified nurse aide training program the Alternate Administrator indicated the agency did not have an HHA training program and did not provide HHA training and/or competency testing to individuals without previous HHA experience. Person 7 indicated they do not require an HHA applicant to have 75 hours of classroom and practical training combined but they required previous experience and successful written and skills competency testing in lieu of 75 hours of training. 410 IAC 17-14-1(I)(1)(A)

G0768

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all home health aides successfully completed a competency testing program that included written competency testing and skills competency testing of the aide performing specific tasks on a live patient or pseudo-patient, including but not limited to communication skills, the ability to read, write, and verbally report information, the ability to read and record vital signs, bed, sponge, tub, and shower bathing and shampoo, nail and skin care, oral hygiene, toileting and elimination, safe transfer and ambulation, and normal range of motion and positioning, for 8 of 8 active Home Health Aide (HHA) personnel files reviewed. (HHA 1, 3, 2, 4, 5, 6, 7, 8) Findings include: 1. A review of the agency's current home health aide (HHA) job description, last revised 12/2017, evidenced qualifications for a home health aide included, but were not limited to, the ability to pass a competency skills check-off, the ability to pass a written competency test, and six month's documented experience in patient care. 2. A review of the agency's competency testing material evidenced the written test score was set at 80% unless modified by agency policy and competency areas denoted with an asterisk must be observed on a patient or pseudo-patient regardless of written test scores in the same areas. 3. A review of the personnel file for HHA 1, date of hire 10/02/19, evidenced a written competency test dated 10/02/19, with a score of 138/160. Ac signature page indicated " ... the skills with *ASTERICKS have been conducted on a live patient." A review of the written test evidenced incorrectly graded questions which resulted in an actual score of 133/160. A review of the competency checklist evidenced HHA 1 demonstrated all areas with an asterisk using a live patient or pseudo-patient. On 11/09/23 at 10:15 AM, HHA 1 indicated no previous HHA training or experience prior to employment with Heal at Home. HHA 1 indicated Heal at Home trained her in all areas of written and skills competency at orientation. 4. A review of the personnel file for HHA 2, date of hire 06/23/21, evidenced a written competency test dated 06/23/21, with a score of 148/160. A review of the test evidenced incorrectly graded questions resulting in an actual score of 143/160. A review of the competency checklist evidenced HHA 2 failed to demonstrate competency using a live patient/pseudo-patient in all areas with an asterisk. On 11/08/23 at 2:10 PM, HHA 2 indicated she had no previous patient care experience as an HHA or certified nursing assistant prior to employment with Heal at Home and stated she received training from Heal at Home during the competency portion of the testing that included viewing various videos. HHA 2 indicated she had no experience or training on bed baths and learned on a mannequin during competency testing. HHA 2 also recalled being taught to use a Hoyer lift (a mechanical lift for transferring non-weight bearing individuals), a walker, a gait belt, and provide catheter care, which were skills she'd had no previous training or experience performing. 5. A review of the personnel file for HHA 3, date of hire 04/28/21, evidenced a written competency test dated 04/20/21, with a score of 143/160. A review of the test evidenced incorrectly graded questions, resulting in an actual score of 141/160. A review of the skills competency checklist evidenced HHA 3 failed to demonstrate all skills with an asterisk on a live patient or pseudo-patient. On 11/08/23 at 2:15 PM, HHA 3 indicated she had no previous experience as an HHA and received all HHA training from Heal at Home. HHA 3 indicated she watched a video on bathing and the agency instructor walked her through how to do a bed bath during the competency training, but she never demonstrated bathing on a live patient or pseudo-patient. 6. A review of the personnel file for HHA 4, date of hire 08/22/18, evidenced a written competency test dated 08/08/18, with a score of 154/160. A review of the test evidenced incorrectly graded question which resulted in an actual score of 156/160. A review of a competency checklist dated 08/22/18 evidenced HHA 4 demonstrated all skills with an asterisk on a live patient or pseudo-patient. On 11/08/23 at 2 PM, HHA 4 indicated she had previous experience helping with family and had been a certified nursing assistant but allowed the certification to lapse "years ago." HHA 4 indicated a live person was available during competency testing. HHA 4 indicated she did not remember much else about the competency testing other than all training for the competency checkoff was provided by Heal at Home. 7. A review of the personnel file for HHA 5, date of hire 06/16/21, evidenced a written competency test dated 06/11/23, with a score of 143/160. A review of the test evidenced incorrectly graded questions which resulted in an actual score of 138/160. A review of the competency checklist dated 06/06/23 evidenced HHA 5 failed to demonstrate hands-on competency on a live patient or pseudo-patient for all required skills identified with an asterisk. On 11/08/23 at 1:30 PM, HHA 5 indicated she had previous experience caring for a parent but had never received formal HHA or certified nursing assistant training prior to employment with Heal at Home. HHA 5 indicated she watched videos for the first 2 days of orientation, was never trained in providing bed baths, and confirmed she did not complete a skills competency demonstration on a live patient or pseudo-patient. 8. A review of the personnel file for HHA 6, date of hire 11/14/22, evidenced a written competency test dated 07/12/22, with a score of 133/160. A review of the test evidenced incorrectly graded questions resulting in an actual score of 130/160. A review of the competency checklist dated 07/12/22, evidenced HHA 6 completed all skills listed on the checklist via demonstration. On 11/08/23 at 2 PM, HHA 6 indicated she had previously worked in a nursing home where she received some training but was not a certified nursing assistant. HHA 6 indicated training with Heal at Home consisted of having the procedures explained and she did not actually demonstrate any skills on a live patient or pseudo-patient. 9. A review of the personnel file for HHA 7, date of hire 03/13/19, evidenced a written competency test dated 03/08/18, with a score of 145/160. A review of the competency test evidenced incorrectly graded answers resulting in an actual score of 143/160. A review of the competency checklist evidenced a date of 03/13/19, noted to be over a year later than the date of hire. The competency checklist evidenced HHA 7 demonstrated all skills with an asterisk on a live patient or pseudo-patient. On 11/08/23 at 1:45 PM, HHA 7 indicated she had previous experience as an HHA and as a certified nursing assistant. HHA 7 indicated she completed each skill on the checklist and was tested using a live patient or pseudo-patient. 10. A review of the personnel for HHA 8, date of hire 10/30/20, evidenced a written competency test dated 10/01/20, with a score of 140/160. A review of the test evidenced incorrectly graded questions, resulting in an actual score of 120/160. A review of the competency checklist dated 10/14/20, evidenced HHA 8 demonstrated all skills listed were performed using a live patient or pseudo-patient. On 11/08/23 at 1:53 PM, HHA 8 indicated her certified nursing assistant certification expired in 2015 and was never renewed. HHA 8 indicated she provided care for family members and remembered receiving HHA training from Heal at Home upon employment but could not remember competency testing. 11. On 11/08/23 at 2:30 PM, the Alternate Administrator, RN 1, and Administrator 2, the Director of Human Resources were questioned together concerning the personnel files and the qualifications for a Home Health Aide applicant and indicated an HHA applicant was required to have previous experience, pass a written competency test, and complete an HHA skills evaluation which included hands-on care of a live patient or pseudo-patient for all tasks marked with an asterisk. The Alternate Administrator indicated the agency did not have an HHA training program. Administrator 7 indicated the tests and competencies were graded in the Human Resources Department and the results were not typically reviewed by the Administrator or Clinical Manager. The incorrectly graded written tests were reviewed and they agreed with the identified grading errors but indicated the tests remained in passing range after re-grading. They were unable to indicate whether the written test was graded by section, overall percentage, or a specific number of correct questions and did not know the procedure if an applicant failed a specific section or sections but achieved a passing percentage. 410 IAC 17-14-1(I)(A)

G0804

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA) reported changes in the patient's condition to a Registered Nurse for 1 of 5 active patient records reviewed. (Patient #5) Findings include: 1. A review of agency policy 3-156, titled "Change in Patient's Condition - Reporting to the Physician," effective 01/25/18, indicated examples of "significant changes" that should be reported to a physician included, but were not limited to, " ... upper respiratory congestion, increased shortness of breath ... increased edema ... " 2. A review of undated agency policy 3-155, titled "Reassessment/Update of Comprehensive Assessment (SCIC)" [Significant Change in Condition], indicated " ... Clients are reassessed when significant changes occur in their condition. Clients are reassessed when significant changes occur in their diagnosis ... " 3. A review of a recertification comprehensive assessment for Patient #5, dated 09/01/23, evidenced a primary diagnosis of unspecified polyarthritis (arthritis - a condition characterized by inflammation and degeneration/damage of a joint; polyarthritis - not a specific disease on its own but rather indicates arthritis affects at least five separate joints at the same time) and secondary diagnoses of age-related physical debility, primary adrenocortical insufficiency (a condition where the kidneys don't produce enough of the hormones called cortisol and aldosterone, especially during management of a stress response). A review of a home health aide visit note, dated 11/13/23, evidenced Patient #5 was having a hard time breathing at approximately 10:30 AM, during the aide's visit to assist with personal care. The visit note indicated the patient's skin below their eyes was swollen (a common and potentially significant symptom for multiple conditions, including kidney and cardiac impairment, and which can indicate an abnormal retention of fluid and/or toxins in the body (called edema) due to the body's inability to adequately pump and/or filter the blood) The visit note indicated the patient felt the swelling "never looked this bad." The aide reported concerns to Person E, a facility nurse for Entity F, an assisted living facility. The record failed to evidence the aide reported concerns of difficulty breathing to a Heal at Home nurse to facilitate completion of a comprehensive assessment assess the patient's respiratory status and difficulty breathing. A review of the clinical record for Patient #5 failed to evidence follow-up to the patient's edema and difficulty breathing, including a comprehensive assessment to determine if there was an existing change in condition. On 11/09/23 at 3 PM, the Alternate Administrator and RN 1 were interviewed concerning the agency's process for reporting and assessing changes in patient condition. The Alternate Administrator indicated the aide should have immediately reported the patient's difficulty breathing to a Heal at Home nurse, but it appeared the aide reported to the facility nurse, so Heal at Home could not have known the patient had a change in condition. When asked how often the aide visit notes were reviewed, the Alternate Administrator indicated they were reviewed daily. When asked if Patient #5's visit note for 09/13/23 was reviewed on 09/13/23, or any alternate day, the Alternate Administrator and RN 1 indicated they were unsure if/when the note was reviewed.

Survey of July 21, 2021

2 findings

G0000

This visit was for a Federal Recertification and State Relicensure in conjunction with three complaints. IN00314605 Substantiated with findings IN00288483 Unsubstantiated. Lack of sufficient evidence IN00318994 Substantiated. No deficiencies cited Survey Dates: July 16, 19, 20, and 21, 2021 Facility number 013641 Provider number 15K130 Census: 369 This deficiencies report reflect State findings in accordance with 410 IAC 17. Quality Review Completed on 08/09/2021 by Area 3

G0572

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 ensure they provided home health aide service as ordered per the plan of care for 3 (Patient's #2, 8, 9) of 7 records reviewed of patients who were to receive home health aide services and failed to ensure hours were not reduced due to the agency's inability to staff for care in 2 of 4 active records reviewed of patients receiving home health aide services. (Patients #8, 9) Findings include: 1. A review of agencies policy binder approved by the board in 2020 page 3-115 titled CLINICAL DECISION MAKING , contained the following information under sub-heading "Policy." : "Heal at Home will base decisions regarding acceptance or discharge of clients on identified clients needs and the agency's ability to meet those needs. Furthermore under a sections titled "SPECIAL INSTRUCTIONS" the second line states, "Referrals to the agency will be accepted based on the identified client clinical needs and the agency's ability to respond to those needs." 2. The clinical record of patient #2, start of care (SOC) 01-29-2019, contained a plan of care for the certification period of 3/24/2020 to 5/22/2020 with orders for a home health aide to provide the following cares daily; check for skin break down, clean bathroom daily, fall precautions, incontinent care/assist with each episode, light housekeeping (clean up after personal care), meal preparation, meal set up, moisturize skin, offer oral fluids, oral care, patient bath of choice, personal care (grooming assist) patient is competent to choose bath and direct aide to task, provide glass of water to take medications, shampoo hair, shave (electric only), transfer bed/chair, turn/reposition every 2 hours and prn (as needed). Plan of Care orders for Home Health Aide indicated were for 2 hours in a.m. and 2 hours in p.m. daily, 7 days per week. An interview with patient #2 was conducted on 07-19-2021 at 9:31 a.m. He/she reported that his/her home health aide was a relative of him/her and was employed by Heal at Home(Employee F). Patient #2 has difficulty with verbal communication related to his/her diagnosis and requested that questions be addressed with his/her relative(referring to Employee F). An interview with former employee F was conducted on 07-20-2021 at 1:40 p.m. Employee F confirmed that he/she was often called upon to work his/her day off, since the agency did not have staff to provide care for patient#2. Employee F reported on one particular occasion where he/she scheduled vacation time 6 months in advance, went on vacation, and the agency proceeded to call other relatives to provide care for patient #2 because the agency did not have staff. Employee F reported the agency's inability to cover Sunday shifts was happening with great regularity. He/she reported this concern to the agency's owner and was assured the problem would be resolved. He/she reports it was not and that he/she left the agency and patient #2 left Heal at Home as well. 3. The clinical record of patient #8 start of care 06-10-2016 review of certification period 05-31-21 to 7-13-21 contained physician orders for a HHA( Home Health Aide) 2 hours a day for 7 days for 9 weeks. During the certification period beginning 05-31-21 through 7-13-2021, Heal at Home LLC was unable to provide a home health aide on weekends and handed care over to the group home patient #8 resides as evidenced by the following journal notes: Review of a Journal Note dated 06/03/2021 9:15 a.m. "called and spoke to GH (group home) manager about staffing for the weekend....GH will assume care. Review of a Journal Note dated 06/11/2021 1:34 p.m. "unable to staff 6/12 & 6/15/21 due to staffing availability. GH agreeable to care." Review of a Journal Note dated 06/16/2021 8:39 a.m. "unable to staff 6/19 & 6/20/21 due to staffing availability. GH will assume care" Review of a Journal Note dated 06/21/2021 8:39 a.m. "unable to staff due to staffing availability, GH will assume care." Review of a Journal Note dated 06/25/2021 3:41 p.m. "unable to staff 6/26 & 6/27/21 due to staffing availability, GH will assume care." Review of a Journal Note dated 07/02/2021 3:12 p.m. "unable to staff 7/3 &7/4/21 due to staffing availability, GH will assume care." Review of a Journal Note dated 07/06/2021 3:50 p.m. " unable to staff 7/7/21 due to staffing availability, GH will assume care." The clinical record of patient #8 review of certification period 07-14-2021 through 09-11-2021 Contained Home Health Certification and Plan of care for a HHA 2 hours a day 4 days week 1 and a HHA 2 hours a day for 7 days per week for 8 weeks "assist with adl (activities of daily living)/iadls per HHA care plan. Patients 8's clinical record revealed the agency still not able to staff for the patients plan of care and handing care to the group home as evidence by the following journal notes: Review of a Journal Note dated 07/15/2021 9:21 a.m.. "unable to staff due to staffing availability, Group home assume care...aware agency still seeking permanent staffing solution..." Review of a Journal Note dated 07/16/2021 2:54 p.m. "unable to staff this date, group home assumed care [name of group home manager] is aware." Review of a Journal Note dated 07/16.2021 3:52 p.m. "unable to staff 7/17 & 7/18/21 due to staffing availability, group home will assume care. [Name of Group home Manager] aware" During an interview with Patient #8 on 07-20-2021 at 8:30 a.m. during a home observation, Patient #8 stated, "I have no aide on the weekends." A group home employee present at the time confirmed the agency (Heal at Home) had no staff for patient #8 for the weekends and they assume care. During an interview on 07-21-21 at 10:12 a.m. with patient #8's group home field manager, he/she reported the missed visits had not always been communicated. When queried about how long this has been going on he/she reported "a couple of months." When queried if the agency offered to find another agency to accommodate patient 8, the field manager reported they suggested the patient could change his hours for visits. The field manager explained the patient is used to being able eliminate in the toilet early but the patient said he would try to change his/her schedule so the agency could care for him/her. The field manager further explained that the patient has had the same early schedule for over 15 years but agreed to the change. The field manager confirmed the agency was still not able to staff to meet the plan of care and the group home assumed care for those missed visits. When queried if at any time the agency stated patient 8 needs to transfer to another agency, the field manager stated once because they could not staff at 6 a.m. The field manager stated even though patient 8 changed their time for the agenyc, they still are not able to staff. 4. A clinical record review of patient # 9 contained a fax dated June 1, 2021, 5:13 PM with the heading " Heal at Home LLC " and the agency address is titled "Face-to Face Documentation Physicians Attestation". In this fax the physician authorized the start of care (SOC) for 06-03-2021. A review of patient #9's clinical record contains a physician order for Home Health Certification and Plan of Care for the certification period of 6-3-21 to 8-1-21, with orders for a home health aide 6 hrs (hours) per day, 7 X per week, may be divided into 2 shifts x 9 weeks. A review of a document titled "Episode Calendar" from the agency shows that a nursing assessment - SOC (start of care) was documented by employee I on 06-03-2021. Heal at Home LLC was unable to provide a home health aide on weekends and handed care over to the group home patient #9 resides as evidenced by the following journal notes: No other entries occur until 06-24-21 when a visit occurs for a home health aide for 3 hours in the morning and three hours in the evening. Employee I is on the schedule for a nursing reassessment on this date as well. The following dates contain a note that stated "No clinician missed visit": 06-25-21 a.m. visit , 06-27-21 a.m. visit, 06-28-21 a.m. visit, 06-29-21 a.m. visit, 06-30-21 a.m. visit, 07-03-21, 07-04-21 a.m. visit , 07-05-21 a.m. visit, 07-06-21 a.m. visit, 07-07-21 a.m. visit, 07-08-21 p.m. visit, 07-09-21 a.m. and p.m. visit, No entries for 07-09-2021 through 07-17-2021. A review of documents titled "Journal Notes" from Patient #9's chart has entries with information from the following dates: 06-03-2021 entered by the administrator: "Initial assessment completed...Patient appropriate for home health aide, 6 hrs (hours) per day, 7 days per week for assistance..." Review of a Journal Note dated 06-25-2021 6 a.m.-9 a.m. indicated "unable to staff due to no staff available, GH (group home) will assume." Review of a Journal Note dated 06-26-2021 6 p.m.-9 p.m. indicated "unable to staff due to no staff available, GH will assume." Review of a Journal Note dated 06-27-2021 6 p.m.-9 p.m. indicated "unable to staff due to no staff available, GH will assume." Review of a Journal Note dated 06-27-2021 indicated "change Mon-Fri 6 a.m.- 9 a.m. to 8 a.m.-11 a.m. moving forward." Review of a Journal Note dated 06-27-2021 indicated "change 6 a.m. - a.m. to 9:30a.m. to 12:30 p.m." Review of a Journal Note dated 06-28-2021 indicated the patient was agreeable to reduced visit schedule due to staffing availability, and the PA (prior authorization) was reduced by 4 hours. "Starting 06-28-2021 change Mon-Fri 6 a.m. to 9 a.m. to 8 a.m. to 11 a.m. moving forward." Review of a Journal Note dated 06-29-2021 note entered by agency's scheduler: "Spoke with GH manager and informed...float aide would be there today from 6 p.m.-8 p.m. and she agreed to the shortened shift Also informed ...we did not have coverage for this a.m. GH assuming care." Review of a Journal Note dated 7-4-2021, 07-06-2021, 07-07-2021 "unable to staff due to no staff." Review of a Journal Note dated 07-09-2021 "Spoke with GH manager they would like to put PT (patient) on hold until we can get one CG (caregiver) for all shifts." Review of a Journal Note dated 07-21-2021 "spoke with group home manager they have agreed on 2 or 3 different caregivers to do PT's hours." 410 IAC 17-13-1(a)

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