Every finding on record at Healing Hands Home Health LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: January 9, 10, 11, 12, 13; 2023 Census: 64 At this Emergency Preparedness survey, Healing Hands Home Care was found to have not been in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 42 CFR 484.102. QR Completed 1/27/2023 A4

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure its Emergency Preparedness communication plan included contact information for all patients’ advanced medical providers, which had the potential to affect all agency patients. Findings include: Policy #1007 titled “Communication Plan during an Emergency/Disaster,” revised 01/09/2020, indicated “… The Clinical Manager shall maintain a list of all current patients with their contact information including demographics, emergency contacts, and physician and physician’s contact information ….” The agency’s complete Emergency Preparedness communication plan was reviewed on 01/09/2023. The plan failed to evidence contact information for the patients’ advanced medical providers. During an interview on 1/11/23 at 3:27 PM, the Administrator confirmed the Emergency Preparedness communication plan did not include contact information for the patients’ advanced medical providers. The Administrator stated if there was an emergency and a patient's advanced medical provider needed to be contacted, the staff would look up the contact information on their cell phone.

This visit was for a Federal Recertification and State Re-licensure survey of a Provider. The survey was announced as fully extended on 01/12/2023 at 03:20 PM. Survey Dates: January 9, 10, 11, 12, and 13, 2023 Census: 64 This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to follow their own policy and failed to include all required information on the plan of care for 5 of 8 patient Plans of Care reviewed (Patient #1, 2 , 3, 4, 8.) 5. The clinical record for Patient #2, SOC 01/21/2019, included a POC for recertification period 01/04/2023 – 03/04/2023. The plan of care indicated the patient’s rehabilitation potential was both “fair” and “good.” The POC also indicated patient goals included but were not limited to “Patient needs will be met with the [home health aide, HHA] providing assistance per care plan. To be completed in 9 weeks … Patient will experience less exposure to infections: HHA will encourage proper infection control measures with daily reminders of hand washing, use hand sanitizes [sic], and limiting exposure to contagious persons. To be completed in 9 weeks … Patient’s daily nutritional requirements will be met with HHA providing assistance with meal preparation, meal set up assist. To be completed in 9 weeks …,” which failed to be measurable. The Discharge Plan section of the POC indicated “no discharge planned as long as [the patient’s] living situation remains unchanged.” The POC failed to evidence discharge planning and education. 6. The clinical record for Patient #3, SOC 08/30/2022, included a POC for the recertification period 12/28/2022 – 02/25/2023. The POC indicated the patient’s medications included but were not limited to atorvastatin (given to treat high cholesterol), Colace, and MiraLax (both given to treat constipation). The record included a recertification comprehensive assessment completed on 12/27/2022 by RN #1. The comprehensive assessment indicated Patient #3 had constipation, indigestion and a history of breast cancer. The POC failed to evidence patient diagnoses specific to the above medications and conditions. During a home visit with Patient #3 on 01/10/2023 at 12:30 PM, the patient reported they were taking several medications for their diagnoses of Post Traumatic Stress Disorder (PTSD) and insomnia. The POC failed to evidence these diagnoses as well. The Discharge Plan section of the POC indicated “no discharge planned as long as [the patient’s] living situation remains unchanged.” The POC failed to evidence discharge planning and education. The POC indicated patient goals included but were not limited to “Patient will verbalize/demonstrate home safety in 9 weeks. Patient will be compliant with medication regimen for the duration of home care episode, 9 weeks. Patient needs will be met with the HHA providing assistance per care plan for the duration of home care episode …,” which failed to be measurable. Findings include: 1. Policy #10022 titled “Medication Patient Information and Reconciliation,” revised 5/15/2020, indicated “… A medication is any product designated by the Food and Drug Administration (FDA) as a drug, as well as any prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, over-the-counter drugs… The list of current medications shall be incorporated into the Plan of Care…” 2. Policy #8001 titled “Care Planning,” dated 5/01/2018, indicated “… The Plan of Care shall include at least the following information… All pertinent diagnoses… Medications, including dose, frequency, and route… Instructions for timely discharge… Measurable objective outcomes and goals identified by the HHA [home health agency] and patient…” 3. Policy #10300 titled “Discharge/ Transfer Policy,” dated 5/01/2018 indicated “… Discharge planning is initiated for every home care client at the time of the client’s admission for home care… Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes… “ 4. The clinical record for Patient #1, SOC (start of care) 07/20/2020, included a POC (Plan of Care) for certification period 01/06/2023 – 03/06/2023. During a home visit observation on 01/10/2023 beginning at 10:00 AM, omeprazole (a medication used to treat certain conditions where there is too much stomach acid) 20 milligram capsules were observed alongside the patient’s scheduled medications. During the home visit observation, LPN #1 indicated Patient #1 is administered the medication daily. The Plan of Care failed to include omeprazole in its medication list. The Discharge Plan section of the POC indicated “No discharge plans as long as living situation remains unchanged.” The POC failed to include instructions for discharge. 7. The clinical record for Patient #4, SOC 01/25/2022, included a POC for certification period 11/21/2022 – 01/19/2023. The POC indicated “… Nystatin (a medication used to treat some types of fungus infections of the skin) 100,000 unit/g (gram) topical powder 1 g LIGHT DUSTING DAILY TO AFFECTED AREAS…” The POC failed to include specific instructions for where to apply the medication. The Discharge Plan section of the POC indicated “No discharge plans as long as living situation remains unchanged.” The POC failed to include instructions for discharge. 8. The clinical record for Patient #8, SOC 09/16/2022, included a POC for certification period 11/15/2022 – 01/13/2023. During a home visit observation on 01/10/2023 beginning at 1:31 PM, observed a bottle of apple cider vinegar gummies an OTC (over-the-counter) supplement and a bottle of Vitamin K2/D3 an OTC vitamin supplement in the bag Patient #8 indicated they kept their scheduled medications. During the home visit, Patient #8 indicated they had been taking those OTC supplements. 10. During an interview on 01/10/2023 at 04:02 PM, the Administrator indicated all the patient’s medications, including OTC, should be listed. 11. During an interview on 01/12/2023 at 03:40 PM, the Administrator indicated the instructions for Patient #1’s Nystatin should have been more specific. The Administrator also indicated the POC should have included all pertinent diagnoses and that all goals should have been measurable. When asked how discharge planning was conducted, the Administrator indicated most of the agency’s patients were chronic and did not need discharge planning and if they were Medicare patients then discharge planning was done. 410 IAC 17-13-1(a)(1)(C) 410 IAC 17-13-1(a)(1)(D)(v, ix, and xi)

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 home health agency failed to ensure the patient’s advanced medical provider was notified of a change in patient condition for 2 of 2 records reviewed which evidenced a change in patient condition (Patients #5, 9). Findings include: 1. Policy #10103 titled “Change in Patient Condition,” dated 05/01/2018, indicated “… Procedure: The patient’s primary care physician’s office shall be called as soon as the nurse identifies a significant change in the patient’s condition … Examples of ‘significant changes’ that should be reported to the physician include, but are not limited to: … Change in patient’s urinary habits to include incontinence, burning, urgency, frequency … Change in patient’s skin integrity …” 2. Policy #10119 titled “Wound Care,” dated 05/01/2018, indicated “… Procedure … The clinician will provide wound care per physician orders and continue to implement and evaluate the plan of care based on … identification of obstacles/risk factors interfering with wound healing. The clinician will notify the physician for any changes in the patient’s condition or lack of progress. 3. The clinical record of Patient #5, start of care 12/22/2021, included plans of care for the recertification period 10/18/2022-12/16/2022 and indicated the patient’s diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes, and chronic wound due to radiation treatment. The plan of care included service orders for skilled nursing for 1 visit per week for nursing interventions which included but were not limited to wound care to the patient’s right hip wound. The plan of care indicated Patient #5’s primary care provider (PCP) signed the patient’s home care orders however the agency was also able to obtain orders from several other providers including the patient’s infectious disease provider. The record included a skilled nursing visit conducted on 11/08/2022 by Former RN #3. The visit note indicated Patient #5’s right hip wound had increased in length by 1.0 centimeters, tan drainage, red and sloughing wound bed, and had “deteriorated.” Former RN #3 documented they notified the patient’s PCP of the increase in size however the note also stated Patient #5 had been informed by Former RN #3 to call their infectious disease provider “for several weeks” regarding the deteriorating wound. The record included a skilled nursing visit conducted on 11/22/2022 by Former RN #3. The visit note indicated Patient #5’s right hip wound had tan drainage and a red and sloughing wound bed. Former RN #3 documented again the patient had been “instructed to contact” their infectious disease doctor regarding the wound. The record included a skilled nursing visit conducted on 12/06/2022 by the Former Clinical Manager. The visit note indicated Patient #5 went to visit with their infectious disease provider and was prescribed an antibiotic (Cefuroxime). The visit note indicated the wound bed appeared red and “healthy” and no drainage was noted. During an interview conducted on 1/12/2023 at 3:40 PM, the Administrator/Clinical Manager reported if a wound was noted to be deteriorating, the nurse should notify the advanced medical provider treating the patient’s wound. The Administrator also reported Former RN #3 was let go from the agency in December 2023 for “performance issues” but denied these issues included failure of physician notification for a patient change in condition. 4. The clinical record of Patient #9, start of care 10/26/2021 and discharge date 07/25/2022, included a plan of care for the recertification period 02/23/2022 – 04/23/2022. The plan of care indicated patient diagnoses included but were not limited to COPD and bowel incontinence and included medication orders for Docusate daily and Miralax (both given to treat constipation) twice a day, Morphine twice a day and Oxycodone-acetaminophen (both opioid narcotics given to treat pain, with a known side effect of constipation) every 4-6 hours as needed, and Ferrous sulfate (iron supplement with a known side effect of constipation). The plan of care included service orders for skilled nursing for 1 visit per week. The record included a skilled nursing visit conducted on 04/11/2022 by Former RN #3. The visit note indicated Patient #9’s last bowel movement (BM) was 7 days prior to the visit on 04/04/2022 and was “in pain due to not getting up and not having a true bowel movement for a full week.” The nurse documented the patient’s abdomen was distended and the nurse educated the patient “on how to keep bowels open since [Patient #9] is on multiple opioids; that are constipating ….” The visit note failed to evidence the nurse notified the patient’s physician of the patient’s abdominal pain, abdomen being distended, and the patient’s last bowel movement being 7 days ago. The record included a “Journal Note” dated 04/14/2022 and entered by Former RN #3. The nurse documented they received notification that Patient #9 went to the Emergency Department on 04/13/2022 “for not being able to have a BM for a significant amount of time.” The journal note indicated the patient was treated and released home. The agency’s QAPI (Quality Assurance and Performance Improvement) program binder was reviewed on 01/13/2023 and included a “Clinical Record Audit Tool” completed on Patient #9’s record on 04/13/2022 by the Administrator/Clinical Manager. The record audit failed to evidence the Administrator/Clinical Manager noted the nurse failed to notify the Patient #9’s physician of their abnormal GI symptoms. During an interview conducted on 01/13/2023 at 12:30 PM, the Administrator/Clinical Manager confirmed the nurse should notify the physician if a patient reported they had not had a bowel movement in 7 days. 410 IAC 17-13-1(a)(2)

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the patient home folder included a current plan of care and aide care plan for 2 of 4 home visit observations (Patients #2, 3) Findings include: 1. Policy #10022 titled “Care Planning,” dated 05/01/2018, indicated “Policy … The patient and/or patient’s legal representative (if any) have the right, and shall be encouraged, to participate in the development of the Plan of Care … when changes in the established Plan of care are implemented ….” 2. The clinical record for Patient #2, SOC 01/21/2019, included a POC (plan of care) for recertification period 01/04/2023 – 03/04/2023. The plan of care indicated the patient was to receive home health aide services. During a home visit with Patient #2 on 01/10/2023 at 8:10 AM, the patient’s home folder was reviewed. The folder failed to evidence the patient’s aide care plan. 3. During a home visit with Patient #3 on 01/10/2023 at 12:30 PM, the patient’s home folder was reviewed. The folder failed to evidence a current plan of care. 4. During an interview on 1/10/23 at 4:02 PM, the Administrator/Clinical Manager confirmed the current plan of care and aide care plan should be in the patient’s home.

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, policy review, and interview the home health agency failed to follow accepted standards of practice and their own policies to prevent the transmission of infections and communicable diseases for 3 of 4 patient home visits observed (Patient #1, 2, 3.) Findings include: 1. Policy #5011 “Hand Hygiene – CDC Guidelines,” revised 04/25/2019, but was not limited to “… All staff shall use the hand-hygiene techniques, as set forth in the following procedure… always after removing gloves… Lather well (soap reduces surface tension enabling the removal of bacteria)… Wash hands thoroughly, using rigorous scrubbing action for at least 20 seconds…” 2. Policy #5016 “Nursing Bag Techniques,” dated 02/13/2018, indicated but was not limited to “… Prior to administering care, skin cleanser and paper towels shall be removed, the bag shall be opened, and hands shall be cleansed according to HHA [home health agency] policy and procedure… After hand cleansing, all the clean supplies and equipment needed for the visit shall be removed from the bag and placed on a barrier…” 3. During a home visit with Patient #1 on 01/10/2023 beginning at 10:00 AM, LPN #1 failed to perform hand hygiene 3 times after removing gloves and putting on new gloves. During the home visit an interview was conducted at 10:49 AM in which LPN #1 indicated hands should be sanitized before putting on gloves and after removing them. 6. During an interview on 01/10/2023 at 04:02 PM, the Administrator indicated staff should wash their hands for at least 20 seconds, staff should not scrub their hands under running water, and staff should perform hand hygiene after removing gloves. 7. During an interview on 01/12/2023 at 03:40 PM, the Administrator indicated staff should not enter the nursing bag with dirty hands. 4. During a home visit with Patient #2 on 01/10/2023 at 8:10 AM, Home Health Aide (HHA) #1 was observed failing to perform hand hygiene prior to entering their supply bag. HHA #1 was also observed washing their hands by scrubbing their hands with soap under running water for 18 seconds. HHA #1 was interviewed during the home visit at 8:27 AM and reported when washing hands, the hands should be scrubbed with soap for 20-25 seconds. 5. During a home visit with Patient #3 on 01/10/2023 at 12:30 PM, Registered Nurse (RN) #1 was observed filing the patient’s medication set. After completing the medication setup and assessment, the nurse removed their gloves but failed to perform hand hygiene prior to gathering up their nursing bag and supplies.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the Registered Nurse (RN) failed to assess a patient’s heart tones and failed to conduct an assessment for the presence or absence of urinary tract infection symptoms when a patient reported abnormal urinary symptoms, for 1 of 1 home visit observations of a RN visit (RN #1). Findings include: Policy #10011 titled “Interdisciplinary Patient Assessments and Reassessments,” dated 05/01/2018, indicated “… Procedure: The [Home Health Agency] strives to meet patient needs for care, treatment and/or services by providing the following services under the direction of a physician. Skilled Nursing: … Monitors patient’s clinical status ….” The clinical record of Patient #3, start of care 08/30/2022, included a plan of care for the recertification period 12/28/2022 – 02/25/2023. The plan of care indicated patient diagnoses included but were not limited to high blood pressure and urinary incontinence and the patient’s home health services included skilled nursing visits. The plan of care also indicated skilled nursing interventions included but were not limited to “observe and assess all body systems.” During a home visit with Patient #3 on 01/10/2023 at 12:30 PM, Registered Nurse #1 was observed performing an assessment of the patient. During the assessment, Patient #3 reported they were experiencing worsening urinary incontinence, urinary frequency, and increased urine output, especially at night, for the past 4 days. The patient stated their urine output was “like a waterfall.” RN #1 failed to conduct any further assessment of the patient’s urinary symptoms, including asking the patient if they were experiencing urinary odor or urgency, blood in the urine, pain or burning with urination, and/or abdominal, back, or side pain. The nurse also failed to assess the patient’s heart tones. RN #1 was interviewed at the end of the visit at 2:37 PM. During the interview the nurse reported they assessed Patient #3’s heart tones "every 2" visits. An interview was conducted on 01/11/2023 at 12:29 PM with Patient #3. During the interview, the patient reported their urine was “really stinky” and had been “dark” when her symptoms first began, but cleared up after increasing water consumption. During an interview conducted on 1/10/2023 at 4:02 PM, the Administrator/Clinical Manager confirmed the nurse should assess patient heart tones at each visit and should inquire about the presence or absence of urinary tract infection symptoms when a patient reported urinary frequency. 410 IAC 17-12-2(g)

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 observation, record review, and interview, the home health agency failed to ensure the home health aide care plan was patient-specific for 1 of 2 home visits of a home health aide visit (Patient #3). Findings include: Policy #4042 titled “Home Health Aide Assignments and Duties,” dated 05/01/2018, indicated “… Policy: … Home Health Aides/[Certified Nurse Assistants] must follow written Patient Care Instructions as prepared by the [Registered Nurse] or other appropriate skilled professional ….” During a home visit with Patient #2 on 01/10/2023 at 8:10 AM, the patient reported they preferred to only shower on Mondays, Wednesdays, and Fridays, and to do a partial bath on all other days. HHA #1 was interviewed during the home visit at 8:27 AM and reported Patient #2 had decreased the frequency she wanted to shower “when the weather got cold.” The aide confirmed they assisted the patient with a partial bath on the days the patient declined to shower. A follow up interview with HHA #1 was conducted on 01/11/2023 at 3:01 PM. During the interview, the aide reported they informed the Administrator/Clinical Manager of Patient #2’s change in shower frequency about “a month or so” ago. The clinical record for Patient #2, SOC 01/21/2019, included a POC for recertification period 01/04/2023 – 03/04/2023. The plan of care indicated the patient was to receive home health aide services 5 hours per day, 7 days per week “to assist with [basic self-care tasks] per HHA care plan ….” The record included a home health aide care plan, reviewed and signed by Registered Nurse (RN) #1 on 01/03/2023, which indicated Patient #2’s aide tasks included showering daily and failed to evidence the task of partial bath. The aide care plan failed to evidence the patient’s preference on type of bathing and frequency. During an interview was conducted on 1/10/23 at 4:02 PM, the Administrator/Clinical Manager confirmed the aide care plan should be patient-specific and they were not aware Patient #3 was only wanting showers 3 times a week.