Every finding on record at Heaven Sent Home Health Care LLC

This visit was for a Federal/State complaint survey of a Home Health Provider. Survey Dates: March 10, 11 and 12, 2025 Complaint: IN113510 with unrelated deficiencies cited. 12 Month Unduplicated Skilled Admissions: 3 Abbreviations CM-Clinical Manager HHA-Home Health Aide RN-Registered Nurse POC-Plan of Care SN-Skilled Nurse SOC-Start of Care QR 3/14/25 A2

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 home health agency failed to ensure the POC included specific medication box set-up orders for 1 of 1 home visit observation with a SN (Patient #1) and failed to ensure the patient received all HHA services as ordered in the plan of care for 1 of 4 records reviewed with HHA services only (Patient #5). Findings include: 1. The agency policy “Care Planning”, last updated 12/11/19, indicated the client will receive the services that are written in an individualized POC; if the HHA misses a visit, then the HHA must notify the responsible physician of such missed visit and the HHA will make an attempt to re-schedule the visit. 2. The agency policy “Medication Set Up”, last revised 6/29/19, indicated the nurse ensures that he/she is filling in the med-planner correctly; the nurse will clearly document what nursing tasks were performed and will document prescriptions refilled and whether the client has all medications available for the set up. 3. Patient #1’s clinical record evidenced a POC for the certification period 2/08/25 to 4/08/25. The POC included orders for SN to complete medication review and weekly set up of ordered medications. The clinical record also evidenced an order for the following medications to be taken three times a day: Pregabalin 200 milligram (mg) capsule and Tizanidine HCl 4 mg tablet. During a home visit observation with Patient #1 and RN 1 on 3/10/25 at 2:43 PM, RN 1 was observed setting up Patient #1’s weekly medications. Patient #1 has had a medication box with two slots for medications since SOC on 12/09/24. RN 1 gave Patient #1 a new pill box during the visit and set up the medications in the new pill box. RN 1 failed to place the Pregabalin and Tizanidine in the pill box. During an interview on 3/10/25 at 4:08 PM, Surveyor asked RN 1 how RN 1 set up the three times a day medications prior to bringing the new pill box on 3/10/25. RN 1 relayed she did not set up the three times a day medications and HHA’s and family reminded Patient #1 to take the mid-day doses of Pregabalin and Tizanidine. During an interview on 3/10/25 at 4:08 PM, RN 1 relayed she only fills the pill box with the morning and evening medications and HHA’s and family are responsible for reminding the patient to take his mid-day dose of Pregabalin and Tizanidine. During an interview on 3/12/25 at 9:44 AM, HHA 2 relayed he was not educated to remind Patient #1 to take the mid-day doses of Pregabalin and Tizanidine. During an interview on 3/12/25 at 12:44 PM, HHA 1 relayed she visits Patient #1 in the evening and was not educated to remind Patient #1 to take the mid-day doses of Pregabalin and Tizanidine. During an interview on 3/12/25 at 2:36 PM, RN 1 verified the POC did not include information on how to fill the medication box and the HHA care plan didn’t include specific instructions to remind the patient to take the mid-day dose of Pregabalin and Tizanidine. 4. Patient #5’s clinical record evidenced a POC for the certification period 1/31/25 to 3/31/25. The POC included orders for HHA visits four hours a day, six days a week. The record failed to evidence HHA visits were completed six days a week for the weeks of 2/16/25, 2/23/25 and 3/02/24. During an interview on 3/12/25 at 10:15 AM, RN 2 relayed she was unaware of Patient #5 not receiving HHA visits as ordered and she verified the clinical record did not include documentation of any missed visits. During an interview on 3/12/25 at 12:40 PM, the CM relayed the patient should have received all visits as ordered in the POC and if a visit was missed, the clinical record should include documentation of the missed visit. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the POC included all medications for 1 of 1 active record reviewed with a HHA home visit observation (Patient #2). Findings include: 1. The agency policy “Care Planning”, last updated 12/11/19, indicated the individualized plan of care must include all medications and treatments, the types of services, supplies and equipment required. 2. Patient #2’s clinical record evidenced a SOC on 4/18/24 and included a POC and medication profile for the certification period 2/12/25 to 4/12/25. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #2’s medications. During a home visit observation conducted with Patient #2 and HHA 1 on 3/11/25 at 2:45 PM, Surveyor comparison of the home health agency’s POC medication list against the medications in the home evidenced the following discrepancies: a) Nystatin (used to treat a fungal or yeast infection) 100 units/gram twice a day was found in the home. This medication was not listed on the POC. 3. During the entrance conference on 3/10/25 at 9:46 AM, the CM relayed medications should be reconciled during every recertification visit and when any new medications are found in the home. 4. During an interview on 3/11/25 at 4:12 PM, Patient #2 relayed she uses the Nystatin cream twice a day. 5. During an interview on 3/12/25 at 10:15 AM, RN 2 relayed she was unaware the Nystatin cream was not listed on the POC. 410 IAC 17-13-1(a)

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 home health agency failed to ensure staff followed agency infection control policies and procedures related to equipment cleaning and hand hygiene for 2 of 2 home visit observations performed (RN 1 and HHA 1). Findings include: 1. The agency policy “Hand Washing/Hand Hygiene”, last updated 2/08/19, indicated hand washing and hand antisepsis should be done before donning gloves and after removing gloves. 2. During a home visit observation conducted with Patient #1 and RN 1 on 3/10/25 at 2:43 PM, RN 1 was observed cleaning the stethoscope after use on Patient #1. RN 1 placed the clean stethoscope partially on a clean barrier. The diaphragm and ear tubes of the clean stethoscope were lying on the kitchen countertop. RN 1 failed to ensure the entire clean stethoscope was placed on a clean barrier. During an interview on 3/12/25 at 12:40 PM, the CM relayed the clean stethoscope should have been placed entirely on a clean barrier to air-dry. During an interview on 3/12/25 at 2:36 PM, RN 1 relayed the clean stethoscope should not have touched the kitchen counter. 3. During a home visit observation conducted with Patient #2 and HHA 1 on 3/11/25 at 2:40 PM, HHA 1 was observed assisting Patient #2 remove their clothes before the shower. HHA 1 removed her gloves and failed to perform hand hygiene prior to putting on new gloves. After the shower, HHA 1 carried Patient #2’s soiled clothing to the garage. HHA 1 then removed her gloves and failed to perform hand hygiene prior to putting on new gloves. Later in the visit, HHA 1 removed her gloves. While still holding the soiled gloves, HHA 1 removed 2 new gloves from the box and walked to the kitchen to throw the soiled gloves away. HHA 1 failed to perform hand hygiene. During an interview on 3/11/25 at 4:15 PM, HHA 1 relayed hand hygiene should have been performed anytime necessary, after touching things, every 30 minutes as often as possible. During an interview on 3/12/25 at 12:40 PM, the CM relayed hand hygiene should be performed when visibly soiled, anytime in contact with a new patient, new care area, before and after gloves. 410 IAC 17-12-1(m)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: October 22, 23, 24, 25, 28, 2024 Active Census: 28 At this Emergency Preparedness survey, Heaven Sent Home Health Care, LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: October 22, 23, 24, 25, 28, 2024 12 Month Unduplicated Skilled Admissions: 2 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR 11/6/24 A2

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to conduct an initial assessment to determine the patient's immediate care and support needs within 48 hours of referral for 1 of 4 active records receiving HHA services only (Patient #6). Findings include: 1. The agency policy “Referrals and Acceptance of Client”, last updated July 2024, indicated the assigned clinical staff member will obtain a physician order to assess individual for home care services and complete this assessment within 48 hours of referral. 2. Patient #6’s clinical record evidenced a referral was received on 8/11/23 and the SOC visit was conducted on 8/14/23. The record failed to evidence the reason for delay in conducting an initial assessment. 3. During an interview on 10/28/24 beginning at 3:05 PM, the Clinical Manager stated the initial assessment should have been within 48 hours of the referral and she was unsure of the delay in SOC. 410 IAC 17-14-1(a)(1)(A)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on observation and interview, the RN failed to conduct a thorough and complete ongoing assessment for 1 of 1 home visit observations with a skilled professional performing the visit (Patient #1). Findings include: 1. During a home visit observation conducted with Patient #1 and RN 1 on 10/23/24 beginning at 9:05 AM, RN 1 was observed while performing a recertification assessment. RN 1 failed to assess Patient #1’s skin. 2. During an interview on 10/24/24 beginning at 12:46 PM, RN 1 stated a skin assessment should be done every visit and she forgot to assess Patient #1’s skin during the home visit observation on 10/23/24. 3. During an interview on 10/25/24 beginning at 10:30 AM, the Clinical Manager stated a skin assessment should be completed at a minimum on every recertification visit. 410 IAC 17-14-1(a)(1)(B)

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 the plan of care was reviewed by the attending practitioner at SOC for 1 of 1 discharge record reviewed who didn’t have a signing practitioner (Patient #9). Findings include: 1. Patient #9’s clinical record evidenced a SOC on 5/13/24 and a POC for the certification period 5/13/24 to 7/12/24. The POC was created and signed by RN 1 on 5/13/24. The clinical record failed to evidence a signed POC was obtained for Patient #9. Patient #9 was discharged from the home health agency on 7/12/24 due to not having a signing doctor. 2. During an interview on 10/28/24 beginning at 2:55 PM, RN 1 reported she contacted Practitioner Q prior to the SOC visit to request an order for the initial assessment and faxed the POC to Practitioner Q after the SOC visit. The home health agency did not receive any signed orders from Practitioner Q after the SOC visit. She reported she contacted Entity P trying to obtain signed orders and was told Practitioner Q was no longer there and Patient #9 had been transferred to Entity S for medical care. 410 IAC 17-13-1(a)

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 physician was notified of the need to alter the POC related to possible discharge for 2 of 2 discharge for non-compliance records reviewed (Patients #7 and 8). Findings include: 1. The agency “Discharge/Transfer Policy”, last updated July 2024, indicated prior to discharge the patient and attending physician shall be notified and a patient conference, with the participation of all appropriate disciplines, will be held to discuss the situation and any appropriate actions which could be taken. 2. Patient #7’s clinical record included a POC for certification period 6/04/24 to 6/27/24. The POC indicated the patient was to receive HHA visits 1 hour a day, 7 days a week for 9 weeks. The record evidenced HHA Visits were not completed on 6/25/24 and 6/26/24. The record failed to include documentation of collaboration with the physician regarding POC frequencies needing to be altered due to possible discharge for non-compliance. During an interview on 10/25/24 beginning at 8:25 AM, Person O, an employee of Physician N, reviewed the medical record for Patient #7 and did not see any documentation from the home health agency regarding possible discharge for non-compliance prior to the 6/27/24 discharge. During an interview on 10/28/24 beginning at 3:05 PM, the Clinical Manager reported the clinical record for Patient #7 did not include any documentation of collaboration with the physician for possible discharge for non-compliance prior to the discharge. 2. Patient #8’s clinical record included a POC for certification period 7/11/24 to 8/21/24. The POC indicated the patient was to receive HHA visits 1-2 hours a day, 5-7 days a week for 9 weeks. The record evidenced a HHA Visit was not completed on 8/21/24 and evidenced documentation Patient #8 had refused personal care from the HHA for multiple visits and the physician was not notified. The record failed to include documentation of collaboration with the physician regarding POC frequencies needing to be altered due to possible discharge for non-compliance. During an interview on 10/28/24 beginning at 9:21 AM, RN 2 stated they thought they collaborated with the physician about possible discharge for non-compliance. The clinical record for Patient #8 failed to evidence any documentation of collaboration with the physician prior to discharge. 410 IAC 17-13-1(a)(2)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure employees followed standards of practice for hand hygiene to reduce the spread of infections for 2 of 3 home visit observations (RN 1 and HHA 1). Findings include: 1. The agency policy “Hand Washing/Hand Hygiene”, last updated February 2019, indicated hand hygiene should be performed before donning gloves and after removing gloves. 2. During a home visit observation conducted with Patient #1 and RN 1 on 10/23/24 beginning at 9:05 AM, RN 1 was observed taking her cell phone out of her pocket to use timer to count Patient #1’s respirations. RN 1 donned gloves and proceeded to assess Patient #1. RN 1 failed to perform hand hygiene prior to donning gloves. During an interview on 10/24/24 beginning at 12:46 PM, RN 1 stated hand hygiene should be performed before and after gloves. 3. During a home visit observation conducted with Patient #2 and HHA 1 on 10/24/24 beginning at 12:57 PM, HHA 1 was observed donning gloves after covering Patient #1 with a blanket. HHA 1 failed to perform hand hygiene prior to donning gloves. Later in the visit, HHA 1 walked to the bathroom to get Patient #2’s deodorant. HHA 1 returned to the bedroom and donned gloves again to perform care. HHA 1 failed to perform hand hygiene prior to donning gloves. During an interview on 10/24/24 beginning at 1:42 PM, HHA 1 stated hand hygiene should be performed anytime hands are dirty, before and after gloves and before and after personal care. 4. During an interview on 10/25/24 beginning at 10:30 AM, the Clinical Manager relayed hand hygiene should have been performed before and after gloves. 410 IAC 17-12-1(m)

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 home health agency failed to ensure the HHA provided services as ordered in the HHA care plan for 1 of 2 HHA home visit observations (Patient #3). Findings include: 1. Patient #3’s clinical record for certification period 9/11/24 to 11/09/24 included a HHA care plan which indicated Patient #3 was to receive HHA visits 3 to 4 times a week. The aide care plan indicated the patient was to receive hair care and oral care every visit. During a home visit observation conducted with Patient #3 and HHA 2 on 10/24/24 beginning at 10:26 AM, observed HHA 2 give Patient #3 a shower. After the shower, HHA 2 dried the patient off, assisted with dressing, walked with the patient back to the bedroom and tucked Patient #3 in bed. HHA 2 failed to perform oral care and failed to comb Patient #3’s hair. The HHA visit note for 10/24/24 indicated HHA 2 performed hair care and oral care during the home visit observation. HHA 2 failed to accurately document the HHA visit and failed to follow the HHA care plan. During an interview on 10/24/24 beginning at 2:20 PM, HHA 2 stated she reviewed the aide care plan daily and confirmed Patient #3’s hair should have been combed after the shower. She also stated mouth care should be performed after meals, in the morning and at night. During an interview on 10/25/24 beginning at 10:30 AM, the Clinical Manager stated the HHA should follow the care plan and should have performed hair care and oral care during the home visit observation.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure the HHA supervisory visits were performed and recorded accurately for 5 of 5 active records reviewed with HHA services (Patients #1, 2, 3, 5 and 6). Findings include: 1. The agency policy “Home Health Aide Supervision”, last updated July 2018, indicated Supervision of services by a RN will be completed at least every 30 days while the client is receiving services and the aide will be present (1 of those 2 visits to be observed). 2. Patient #1’s clinical record evidenced a SOC on 6/27/24 and included a POC for the certification period 8/26/24 to 10/24/24 with orders for HHA services 1 to 2 hours a day, 4 to 5 days a week for 9 weeks. The clinical record evidenced the following discrepancies: a) A home health aide supervisory visit was completed on Saturday 7/27/24 from 3:30 to 4:00 PM by RN 1. The HHA supervisory visit form stated the HHA was present and RN 1 educated HHA 6 on safety with ADL’s and observed HHA 6 performing handwashing. The record failed to evidence a HHA visit was made by HHA 6 on 7/27/24. During an interview on 10/25/24 beginning at 11:16 AM, HHA 6 stated they do not work on Saturdays and was not present during the HHA supervisory visit on 7/27/24. During an interview on 10/25/24 beginning at 12:14 PM, RN 1 stated she thought the HHA was present and working for another agency while in Patient #1’s home. b) A home health aide supervisory visit was completed on 10/25/24 from 2:00 to 2:30 PM by RN 1. This visit note was given to Surveyor on 10/25/24 at 10:29 AM. The HHA supervisory visit form had an incorrect date and time listed on the form. During an interview on 10/25/24 beginning at 12:14 PM. RN 1 stated she dated and timed the HHA supervisory form incorrectly. She indicated the supervisory visit was completed on 10/23/24. 3. Patient #2’s clinical record evidenced a SOC on 7/05/24 and included a POC for the certification period 9/03/24 to 11/01/24 with orders for HHA services 1 hour a day, 3 to 4 days a week for 9 weeks. The clinical record evidenced the following discrepancies: a) A home health aide supervisory visit was completed on Sunday 8/04/24 from 1:00 to 1:30 PM by RN 1. The HHA supervisory visit form stated the HHA was present and RN 1 educated HHA 1 on fall prevention, safe use of assistive devices and observed HHA 1 performing handwashing. The record failed to evidence a HHA visit was made by HHA 1 on 8/04/24. b) A home health aide supervisory visit was completed on 10/03/24 from 1:00 to 1:30 PM by RN 1. The HHA supervisory visit form stated the HHA was present and RN 1 educated HHA 1 on hand hygiene and observed HHA 1 performing handwashing. The record failed to evidence a HHA visit was made by HHA 1 on 10/03/24. During an interview on 10/24/24 beginning at 1:42 PM, HHA 1 stated she had not worked on the weekend, and she was not asked to come in on her day off to do the supervisory skills observation. During an interview on 10/25/24 beginning at 12:14 PM, RN 1 states she doesn’t usually work weekends, and at 12:24 PM, RN 1 stated she thought the HHA was present and working for another agency while in Patient #2’s home. 4. Patient #3’s clinical record evidenced a SOC on 3/15/24 and included a POC for the certification period 9/11/24 to 11/09/24 with orders for HHA services 1 hour a day, 3 to 4 days a week for 9 weeks. The clinical record evidenced the following discrepancies: a) A home health aide supervisory visit was completed on 8/12/24 from 4:00 to 4:30 PM by RN 1. The HHA supervisory visit form stated the HHA was present and RN 1 educated HHA 5 on fall prevention, use of assistive devices and observed HHA 5 performing handwashing. The record failed to evidence a HHA visit was made by HHA 1 on 8/12/24. b) A home health aide supervisory visit was completed on 9/11/24 from 4:00 to 4:30 PM by RN 1. The HHA supervisory visit form stated the HHA was present and RN 1 educated HHA 5 on fall prevention and observed HHA 5 performing handwashing. The record failed to evidence a HHA visit was made by HHA 5 on 9/11/24. During an interview on 10/24/24 beginning at 1:58 PM, HHA 5 stated she did not work on her day off to do the supervisory visit. During an interview on 10/25/24 beginning at 12:33 PM, RN 1 stated the HHA was present for the HHA supervisory visits and was working for another agency while in Patient #3’s home. 5. Patient #5’s clinical record evidenced a SOC on 4/18/24 and included a POC for the certification period 10/15/24 to 12/13/24 with orders for HHA services 2 to 4 hours a day, 5 to 7 days a week for 9 weeks. The clinical record evidenced the following discrepancies: a) A home health aide supervisory visit was completed on 9/19/24 from 9:15 to 10:15 AM by RN 2. The HHA supervisory visit form stated the HHA was present, and RN 2 educated HHA 4 and observed HHA 4 performing handwashing. The record evidenced a HHA visit was performed on 9/19/24 from 6:59 to 9:03 AM. The record failed to evidence HHA 4 was present during the RN supervisory visit beginning at 9:15 AM. b) A home health aide supervisory visit was completed on 10/03/24 from 3:00 to 4:00 PM by the Clinical Manager. The HHA supervisory visit form stated the HHA was present, and the Clinical Manager observed HHA 4 performing handwashing. The record evidenced a HHA visit was performed on 10/03/24 from 7:57 to 9:57 AM. The record failed to evidence HHA 4 was present during the RN supervisory visit beginning at 3:00 PM. During an interview on 10/25/24 beginning at 12:42 PM, the Clinical Manager stated HHA 4 was present while she was in the home, however HHA 4 was working for another agency during the HHA supervisory visit. c) A home health aide supervisory visit was completed on 10/17/24 from 7:00 to 8:00 AM by RN 2. The HHA supervisory visit form stated the HHA was present, and RN 2 observed HHA 4 performing handwashing. The record evidenced a HHA visit was performed on 10/179/24 from 8:06 to 10:06 AM. The record failed to evidence HHA 4 was present during the RN supervisory visit beginning at 7:00 AM. d) During an interview on 10/28/24 beginning at 9:21 AM, RN 2 stated HHA 4 was present for the supervisory visits on 9/19/24 and 10/17/24. She relayed HHA 4 was working for another agency during the HHA supervisory visit. e) During an interview on 10/24/24 beginning at 1:52 PM, HHA 4 was unsure if she was present for the supervisory visits and if she was present, then she was probably working for another agency at that time. 6. Patient #6’s clinical record evidenced a SOC on 8/14/23 and included a POC for the certification period 10/07/24 to 12/05/24 with orders for HHA services 1 to 3 hours a day, 5 days a week for 9 weeks. The clinical record evidenced the following discrepancies: a) A home health aide supervisory visit was completed on Saturday 9/07/24 from 3:00 to 3:50 PM by RN 3. The HHA supervisory visit form stated the HHA was present, and RN 3 educated HHA 3 on range of motion and observed HHA 3 performing handwashing. The record evidenced a HHA visit was performed on 9/19/24 from 6:59 to 9:03 AM. The record failed to evidence a HHA visit was made by HHA 3 on 9/07/24. RN 3 is no longer employed by the home health agency and unavailable for an interview. During an interview on 10/24/24 beginning at 4:00 PM, Person M, family member of Patient #6, stated Patient #6 only received visits from the home health agency Monday through Friday, never on a weekend. 410 IAC 17-15-1(a)(7)

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Care Agency. Survey Dates: 1/18, 1/19, 1/20, 1/21, and 1/24/2022 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR by Area 3 on 1/31/2022

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review, interview, and observation, the agency failed to ensure the comprehensive assessment accurately reflected the patient's hearing status, psychosocial status and functional capacity within the community; impact on the delivery of services; ability to participate in their own care; and failed to ensure assessments accurately reflected the cognitive status of patients and their ability to understand, remember, and participate in the development and implementation of their plan of care in 1 (patient 3) of 3 home visits made. Findings include: Review of an agency Policy titled "Comprehensive Assessment Policy #: 2.05," stated, "A review of an agency's policy number 2.05 titled, "Comprehensive Assessment", dated 12/10/2019 revealed, "Purpose: Comprehensive assessment must be .... consistent with the client's immediate needs ... Assessment of the clients current health status include relevant past medical history as well as all active health and medical problems … Client Goal is defined as client-specific objective, adapted to each client based on the medical diagnosis, Doctor's order, comprehensive assessment, client input, and specific treatments provided by the agency." Measurable outcome is change in health status, functional status, which occurs over time in response to health care intervention. This may include: end-result functional and physical health improvement/stabilization ... Because of the nature of the change can be negative or neutral, the actual change in health status can vary from client to client, ranging from decline, no change, to improvement in client condition or functioning. The client's continuing need for care there is no limit on time the client is eligible for Home health care, therefore, the comprehensive assessment must clearly demonstrate the need, eligibility, for the home care benefit. The clients medical, nursing, rehabilitative, social, and discharge planning needs must be presented at each 60 day encounter or sooner if changes in health status." Review of an agency document titled "Case Conference," dated 1/4/2022, section titled "Notes" contained a handwritten entry, "Client called office voiced concerns about medications and knowing she is not taking them correctly. Educated client on importance of taking medications as prescribed, encouraged med set up by SN once weekly. [He/she] verbalized understanding and agreed to same. Will discharge from non-skilled and admit to Skilled care. MD aware." Review of the clinical record for patient 3 contained a plan of care with a start of care date of 11/29/2021, with a recertification period of 1/5 to 3/5/2022, with diagnoses including, but not limited to: Coronary Artery Disease (CAD - reduction of blood flow to the heart muscle due to build-up of plaque in the arteries of the heart), Diabetes Type 2 (DM - a chronic condition that affects the way the body processes blood sugar), and anxiety. Patient 3's plan of care orders included HHA (Home Health Aide) services 2 hours per day, 2 days per week for 9 weeks and Skilled Nurse visits 1 hour a day once a week for medication set-up. Review of a comprehensive assessment dated 1/5/2022, evidenced patient #3 "lives alone with no available caregiver ... [spouse] passed away August of 2021, and [patient 3] has bouts of anxiety and depression ... being treated for this with medication and reports that they do help some. [Patient 3] is alert and smiles with appropriate conversation ... adds to conversation and is engaged in what we talk about. Cognitive: [patient 3] expresses complex ideas, feelings and needs clearly and completely with no impairment ... sugars are well maintained ... checks [his/her] {blood sugar levels} weekly ... uses oral medication and diet to control sugars ... Client verbalizes that [he/she] knows [he/she] misses some of medications and does not take them as prescribed ... All diagnoses are controlled with medications and/or treatments. Strength is [patient 3] is a motivated learner and compliant with MD orders. Weakness is depression and anxiety and loss of [patient's spouse]. Client's goal for this care period is to have no falls." The clinical record failed to evidence documentation of patient #3's deficits in relation to his/her hearing and ability to effectively manage his/her medications, as evidenced by missed doses of medication, and therefore was not an accurate complete assessment. In an interview on 1/20/2022 at 2:35 PM, with the clinical manager, the clinical manager indicated believing patient 3 did not have cognitive issues, vision issues, or manual dexterity issues, and stated patient 3 had missed a few doses of ordered medications. In an interview on 1/20/2022 at 3:50 PM, with the alternate clinical manager, the alternate clinical manager indicated patient 3 had cognitive issues, and queried the surveyor, “you don’t think she has cognitive issues,?” to which the surveyor indicated based on review of the Comprehensive Assessment for the current certification period, there was insufficient documentation to establish a basis for a determination patient #3 had cognitive impairment. The alternate clinical manager indicated patient 3 was hard of hearing, and verified this was not documented in the comprehensive assessment. A home visit for patient 3 was conducted on 1/20/2022 at 9:30 AM. Although patient 3 was aware of the pending visit, upon arrival to the patient's home, the clinical manager made two attempts to contact the patient by knocking on the door and calling out for the patient by name through a screen door. The clinical manager was eventually able to reach patient 3 by telephone, who then came to the door to allow entrance into the home. Surveyor introduced self to patient 3 and thanked patient for allowing surveyor to attend the visit. Patient 3 looked directly at the surveyor, and smiled (patient squinted eyes while donning a surgical mask), patient 3 did not acknowledge formal greeting with a proper response. The surveyor and clinical manager had to raise their voices to communicate with patient 3 throughout the visit. The purpose of the skilled nurse visit was for weekly medication planner set up only and Patient 3's medications were refilled. IAC 17-114-1(a)(1)(A)

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on record review, interview, and observation, the agency failed to ensure the comprehensive assessment demonstrated the continuing need for the home health services in 1 (patient 3) in 3 patient home visit observations made. Findings include: Review of an agency Policy titled "Comprehensive Assessment Policy #: 2.05," stated "Purpose: Comprehensive assessment must be .... consistent with the client's immediate needs, ... Assessment of the clients current health status include relevant past medical history as well as all active health and medical problems ... Measurable outcome in change in health status, functional status, which occurs over time in response to health care intervention. This may include: end-result functional and physical health improvement/stabilization ... Because of the nature of the change can be negative or neutral, the actual change in health status can vary from client to client, ranging from decline, no change, to improvement in client condition or functioning. The client's continuing need for care there is no limit on time the client is eligible for Home health care, therefore, the comprehensive assessment must clearly demonstrate the need, eligibility, for the home care benefit." Review of clinical record for patient 3 contained and Oasis (Outcome and assessment information set) with a start of care date of 11/29/2021, with a recertification period of 1/5/2022 through 3/5/2022, with diagnoses including but not limited to: Coronary Artery Disease (CAD - reduction of blood flow to the heart muscle due to build-up of plaque in the arteries of the heart) Diabetes Type 2 (DM - a chronic condition that effects the way the body processes blood sugar) and anxiety. Patient 3 was to receive HHA (Home Health Aide) services 2 hours per day, 2 days per week for 9 weeks and Skilled Nurse visits 1 hour a day once a week for medication set-up. The patient, "lives alone with no available caregiver...[spouse] passed away August of 2021 and [patient 3] has bouts of anxiety and depression...being treated for this with medication and reports that they do help some. [Patient 3] is alert and smiles with appropriate conversation...adds to conservation and is engaged in what we talk about. Cognitive: [patient 3] expresses complex ideas, feelings and needs clearly and completely with no impairment...sugars are well maintained...checks [his/her] {blood sugar levels} weekly...uses oral medication and diet to control sugars...Client verbalizes that [he/she] knows [he/she] misses some of medications and does not take them as prescribed ... All diagnoses are controlled with medications and/or treatments. Strength is [patient 3] is a motivated learner and compliant with MD orders. Weakness is depression and anxiety and loss of [patient's spouse]." This documentation in the clinical record failed to evidence patient deficits that required the intervention and services of a skilled nurse for weekly Medi planner refills. An agency document titled "Case Conference" dated 1/4/2022, section titled "Notes" contained a handwritten entry, "Client called office voiced concerns about medications and knowing she is not taking them correctly. Educated client on importance of taking medications as prescribed, encouraged med set up by SN once weekly. [He/she] verbalized understanding and agreed to same. Will discharge from non-skilled and admit to Skilled care. MD aware." This document failed to evidence patient 3's deficits that required the intervention and services of a skilled nurse for weekly visits to refill the pillbox. In an interview on 1/20/2022 at 2:35 PM, the Clinical Manager indicated patient 3 does not have cognitive issues, does not have vision issues, and does not have manual dexterity issues. When queried as to patient 3's need for skilled nursing services, the Clinical Manager indicated patient 3 had missed a few doses of her medications. When queried if orders for patient medication education had been sought, the Clinical Manager stated, "No." During a home visit skilled nursing observation for patient 3 on 1/20/2022 at 9:30 AM, patient 3 was aware of the pending visit, upon arrival to the patient's home. The clinical manager made two attempts to get patient 3 to answer the door by knocking on the door and calling out for the patient by name through a screen door. The clinical manager was eventually able to reach the patient by telephone, who then came to the door to allow entrance into the home. Surveyor introduced self to patient and thanked patient for allowing surveyor to attend the visit, the patient looked directly at the surveyor, and smiled (patient squinted eyes while donning a surgical mask), patient 3 did not acknowledge the formal greeting made with a proper response. the surveyor and clinical manager had to raise their voices to communicate with patient 3 throughout the visit.

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 the plan of care was created in conjunction with the primary care physician after an assessment for 5 (patients 1, 2, 3, 4, and 5) of 5 active records reviewed in a sample of 7. Findings include: 5. A review of the clinical record of patient # 3, revealed a start of care date of 11/29/21, which contained a plan of care (485) for the certification period of 1/5/22 to 3/5/22, with orders for HHA (home health aide), 1 hour per day, 2 days per week and Skilled Nurse 1 hour per day, 1 day per week for medication set up. Review of the visit notes revealed HHA made care visits on 1/6/22, 1/10/22, 1/13/22, 1/17/22 and 1/21/22 and skilled nurse made visits 1/5/22 and 1/19/22. The clinical record failed to evidence communication with the physician and the verbal orders to establish the plan of care. In an interview on 1/20/2022 at 3:35pm with person E , nurse for doctor H’s medical group ordering physician for patient 3, when queried about whether any phone calls had been received from Heaven Sent HH, LLC. person E states there were, “no phone calls received recently and none previous to 11/24/2021, only faxes, no actual phone calls, no.” 6. A review of the clinical record of patient #1, revealed a start of care date of 5/8/19, which contained a plan of care for the certification period of 12/23/21 to 2/20/22, with orders for HHA (home health aide), 1 hour per day, 3-5 days per week. Review of visit notes evidenced the HHA made care visits on 12/23/21, 12/24/21, 12/27/21, 12/28/21, 12/29/21, 12/30/21, 12/31/21, 1/4/22, 1/5/22, 1/6/22, 1/7/22, 1/10/22, 1/11/22, 1/12/22, 1/13/22 and 1/14/22. The clinical record failed to evidence communication with the physician and the verbal orders to establish the plan of care. In an interview on 1/24/2022 at 2:35 PM, person F, with doctor I (primary care physician for patient 1) when queried as to whether agency nurse has reached out by phone to communicate with doctor or doctor’s staff concerning obtaining verbal orders for patient 1, person F stated, “not verbally usually, we get orders over the fax…I have not talked to them myself.” IAC 17-13-1(a) 1. A review of an agency's policy titled, "Physicians Plan of Treatment Policy number 2.18," revealed, "1. A physician prepares a plan of treatment and it is made available to Heaven Sent ... 3. Physician's orders are established and documented ... for those patients/clients who: a. Are being actively treated, b. Have a health care need ... c. Are home Health Aide clients of a certified home health agency ..." A review of an agency’s policy titled, “2.12 Verbal Orders,” dated 1/29/2018, revealed, “Policy: All medications, treatments, and services provided to patients must be ordered by a physician…will be signed dated and timed when received by … then faxed to physician for his/her signature…Purpose: To document verification that orders for services have been obtained from the physician. To assure accurate and complete orders are obtained and verified …” A review of an agency's policy titled, 2.37 Record Contents," dated July 2018, revealed, "...3. Physician's Orders a. A verbal or written physician order is obtained prior to starting care. A verbal order is followed by a written order signed by the physician ... " 2. A review of the clinical record of patient # 2, revealed a start of care date of 1/17/22, which contained a "Non-Oasis SOC" (non-skilled assessment rather than an Outcome and Assessment Information Set, an assessment used to collect patient information for the start of care), dated 1/17/22; for the certification period of 1/17/22 to 3/17/22, with orders for HHA (home health aide), 1 hour per day, 5 days per week. The clinical record revealed a "Plan of Care" document electronically signed and dated by the clinical nurse on 1/18/22, for the certification period of 1/17/22 to 3/17/22, which failed to evidence a physician signature. A review of the clinical visit notes revealed HHA made care visits on 1/18/22, 1/19/22, 1/20/22, and 1/21/22. The clinical record failed to evidence documentation of communication with the physician after the assessment, and prior to the furnishing care, to establish the plan of care. 3. A review of the clinical record of patient #4, revealed a start of care date of 3/8/21, which contained a "Non-Oasis Recert" dated 12/31/21, electronically signed and dated by the clinical nurse on 1/5/22; for the certification period of 1/5/22 to 3/5/22, with orders for HHA (home health aide), 1 hour per day, 5-7 days per week. The clinical record revealed a "Plan of Care" document electronically signed and dated by the clinical nurse on 1/5/22, for the certification period of 1/5/22 to 3/5/22, which failed to evidenced the physician's signature. Review of clinical visit notes evidenced the HHA furnished care visits on 1/5/22, 1/6/22, 1/7/22, 1/10/22 to 1/14/22, and 1/17/22 to 1/19/22. The clinical record failed to evidence communication with the attending physician, after the assessment, and prior to the first care visit to establish the plan of care. 4. A review of the clinical record of patient #5, revealed a start of care date of 1/13/22, which contained a "Non-Oasis SOC" for the certification period of 1/13/22 to 3/13/22, electronically signed and dated by the clinical nurse on 1/13/22; with orders for HHA 1 hour per day, 2 days a week. The clinical record revealed a "Plan of Care" document electronically signed and dated by the clinical nurse on 1/17/22 for the certification period of 1/13/22 to 3/13/22, which failed to evidence the physician's signature. T A review of visit notes evidenced the HHA furnished care visits on 1/13/22, 1/14/22, and 1/18/22. The clinical record failed to evidence documentation of communication with the attending physician,after the assessment and prior to the first care visit, to establish the plan of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided only with physician authorization/approval in 5 of 5 active clinical records reviewed in a sample of 7. (Patients #1, 2, 3, 4, and 5) Findings include: 5. A review of the clinical record of patient #3, revealed a start of care date of 11/29/21, which contained a plan of care (485) for the certification period of 1/5/22 to 3/5/22, with orders for HHA (home health aide), 1 hour per day, 2 days per week and Skilled Nurse 1 hour per day, 1 day per week for medication set up. Review of the visit notes revealed HHA made care visits on 1/6/22, 1/10/22, 1/13/22, 1/17/22 and 1/21/22 and skilled nurse made visits 1/5/22 and 1/19/22. The clinical record failed to evidence communication with the physician and the verbal orders to establish the plan of care. In an interview on 1/20/2022 at 3:35pm with person E, nurse for doctor H’s medical group (ordering physician for patient #3), when queried about whether any phone calls had been received from agency nurse to obtain orders for home health services. Person E states there were, “no phone calls received recently and none previous to 11/24/2021, only faxes, no actual phone calls, no.” 6. A review of the clinical record of patient #1, revealed a start of care date of 5/8/19, which contained a plan of care for the certification period of 12/23/21 to 2/20/22, with orders for HHA (home health aide), 1 hour per day, 3-5 days per week. Review of visit notes evidenced the HHA made care visits on 12/23/21, 12/24/21, 12/27/21, 12/28/21, 12/29/21, 12/30/21, 12/31/21, 1/4/22, 1/5/22, 1/6/22, 1/7/22, 1/10/22, 1/11/22, 1/12/22, 1/13/22 and 1/14/22. The clinical record failed to evidence communication with the physician and the verbal orders to establish the plan of care. In an interview on 1/24/2022 at 2:35 PM, person F, with doctor I (primary care physician for patient #1) when queried as to whether agency nurse has reached out by phone to communicate with doctor or doctor’s staff concerning obtaining verbal orders for home health services for patient 1, person F stated, “not verbally usually, we get orders over the fax…I have not talked to them myself.” 7. In an interview on 1/19/2022 at 2:24 PM, Clinical Manager states she does not call physician after start of care, recertification to obtain verbal orders for home health services . She states all communication is through faxes, unless there are unusual findings during the visit then she will make a phone call to the physician. IAC 17-13-1(a) 1. A review of an agency’s policy titled, “2.12 Verbal Orders,” dated 1/29/2018, revealed, “Policy: All medications, treatments, and services provided to patients must be ordered by a physician…will be signed dated and timed when received by …then faxed to physician for his/her signature…Purpose: To document verification that orders for services have been obtained from the physician. To assure accurate and complete orders are obtained and verified…” A review of an agency's policy titled, 2.37 Record Contents," dated July 2018, revealed, "...3. Physician's Orders a. A verbal or written physician order is obtained prior to starting care. A verbal order is followed by a written order signed by the physician..." 2. A review of the clinical record of patient # 2, revealed a start of care date of 1/17/22, and contained a plan of care for the certification period of 1/17/22 to 3/17/22, with orders for HHA (home health aide), 1 hour per day, 5 days per week. A review of the visit notes revealed HHA made care visits on 1/18/22, 1/19/22, 1/20/22, and 1/21/22. A review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care, had been obtained prior to furnishing the above care visits. 3. A review of the clinical record of patient #4, revealed a start of care date of 3/8/21, and contained a plan of care for the certification period of 1/5/22 to 3/5/22, with orders for HHA, 1 hour per day, 5-7 days per week. A review of visit notes evidenced the HHA made care visits on 1/5/22, 1/6/22, 1/7/22, 1/10/22 to 1/14/22, and 1/17/22 to 1/19/22. review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care, had been obtained prior to furnishing the above care visits. 4. A review of the clinical record of patient #5, revealed a start of care date of 1/13/22, and contained a plan of care (485) for the certification period of 1/13/22 to 3/13/22, with orders for HHA 1 hour per day, 2 days a week. A review of visit notes evidenced the HHA made care visits on 1/13/22, 1/14/22, and 1/18/22. review of the clinical record failed to evidence a verbal order, or a returned physician authenticated plan of care, had been obtained prior to furnishing the above care visits. 5. During a phone interview on 1/21/22 at 12:08 PM with person D, a nurse for doctor C for patient 2, stated that they hadn't received verbal order requests from Heaven Sent Home Care, they usually send a fax with their requests. During a phone interview on 1/21/22 at 10:04 AM, with person B, a nurse for doctor A for patient 5, stated they had not had phone conversations with the agency this month and queried if the agency was supposed to call for verbal orders after assessments to obtain authorization for care visits.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized plan of care was reviewed/revised by the ordering physician at the time of recertification of services in 3 (patients 1, 3, and 4) of 5 active clinical records reviewed in a sample of 7. Findings include: 5. A review of the clinical record of patient # 3, revealed a start of care date of 11/29/21, and contained a plan of care (485) for the certification period of 1/5/22 to 3/5/22, with orders for HHA (home health aide), 1 hour per day, 2 days per week and Skilled Nurse 1 hour per day, 1 day per week for medication set up. A review of the visit notes revealed HHA made care visits on 1/6/22, 1/10/22, 1/13/22, 1/17/22, 1/21/22, and the skilled nurse made visits 1/5/22 and 1/19/22. The clinical record failed to evidence documentation the attending physician had reviewed/revised the plan of care at the time of recertification of services. In an interview on 1/20/2022 at 3:35 PM, with person E, nurse for doctor H’s medical group (ordering physician for patient #3), when queried about whether any phone calls had been received from agency nurse to obtain orders to continue home health services. Person E stated, “no phone calls received recently and none previous to 11/24/2021, only faxes, no actual phone calls, no.” 6. A review of the clinical record of patient #1, revealed a start of care date of 5/8/19, and contained a plan of care for the certification period of 12/23/21 to 2/20/22, with orders for HHA (home health aide), 1 hour per day, 3-5 days per week. Review of visit notes evidenced the HHA made care visits on 12/23/21, 12/24/21, 12/27/21, 12/28/21, 12/29/21, 12/30/21, 12/31/21, 1/4/22, 1/5/22, 1/6/22, 1/7/22, 1/10/22, 1/11/22, 1/12/22, 1/13/22, and 1/14/22. The clinical record failed to evidence documentation of communication with the physician to continue furnishing agency services. In an interview on 1/24/2022 at 2:35 PM, person F, with doctor I (primary care physician for patient #1) when queried as to whether the agency nurse has reached out by phone to communicate with the doctor or doctor’s staff concerning obtaining verbal orders for home health services for patient 1, person F stated, “not verbally usually, we get orders over the fax…I have not talked to them myself.” 7. In an interview on 1/19/2022 at 2:24 PM, the Clinical Manager stated she does not call the physician the time recertification to obtain verbal orders to continue add, or remove home health services. She stated all communication was through faxes, unless there were unusual findings during the visit, then she will make a phone call to the physician IAC 17-13-1(a)(2) 1. A review of an agency’s policy titled, “2.12 Verbal Orders,” dated 1/29/2018, revealed, “Policy: All medications, treatments, and services provided to patients must be ordered by a physician…All medications and treatments, that are part of the patient's plan of care, must be ordered by the physician…Purpose: To document verification that orders for services have been obtained from the physician. To assure accurate and complete orders are obtained and verified…” 2. A review of the clinical record of patient #4, revealed a start of care date of 3/8/21, and contained a plan of care for the certification period of 1/5/22 to 3/5/22, with orders for HHA (home health aide), 1 hour per day, 5-7 days per week. A review of visit notes evidenced the HHA made care visits on 1/5/22, 1/6/22, 1/7/22, 1/10/22 to 1/14/22, and 1/17/22 to 1/19/22. A review of the clinical record failed to evidence the plan of care for the certification period of 1/5/22 to 3/5/22, had been revised/revised by the physician prior to the HHA care visit on 1/5/22.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on record review and interview, the Director of Clinical Services failed to ensure coordination of patient referrals for hospitalization and failed to document consideration of referral for patients with fall risks for 3 (Patient #1, 2, and 4) of 5 active records in a sample of 7. Findings include: 5. A review of the clinical record for patient #1 revealed a plan of care for the certification period of 12/23/21 to 2/20/22, evidenced diagnoses but not limited to Type 2 diabetes, emphysema, and unspecified abnormalities of gait and mobility and indicated the patient was at risk for falls specifying “incontinence, environmental hazards (small pet, pet toys, cluttered environment), Diagnosis (3 or more co-existing), polypharmacy (more than 4 prescriptions), prior history of falls within 3 months, and impaired functional mobility.” The plan of care indicated the patient's Functional Limitations were "endurance, incontinence, and ambulation.” The patient lived alone in their own home with no caregiver available and received home health aide services for 1 hour a day, 3-5 days a week for assist with bathing 3-5 days a week and light housekeeping. The clinical record revealed a document titled, "Non-OASIS (a comprehensive assessment supporting the patient's need for services) Recert", dated 12/20/21 revealed the patient Is a fall risk - MACH 10 score: 6 (risk). The clinical record evidenced a document titled, "Hospitalization Risk Assessment", dated 4/22/21 revealed the patient had a score of 7, indicating the patient is at high risks for hospitalization (any score above 5 was identified as high risk), indicating Therapy (Physical, Occupational, and/or Speech) and MSW (Master of Social Work), social worker referrals should be considered. The record failed to evidence documentation of communicating the specific information of the hospitalization risk assessment to the physician and failed to evidence consulting with the patient and the physician for Therapies and/or MSW referrals. 6. In an interview on 1/20/2022 at 3:50pm, alternate clinical manager (and member of Governing Body) stated she was unaware of the presence and use of the Michigan Alliance MACH 10 fall risk assessment found in patient’s paper charts. Administrator states this was a new form initiated by the clinical manager. 1. A review of an agency's policy number 2.05 titled, "Comprehensive Assessment," dated 12/10/2019 revealed, "Purpose: Comprehensive assessment must be....consistent with the client's immediate needs,...Assessment of the clients current health status include relevant past medical history as well as all active health and medical problems…” A review of an agency's policy number 2.30 titled, "Coordination of Care," dated 12/8/2019 revealed, "Purpose: To assure services are coordinated...and quality of care is being provided to clients...To provide the doctor with an ongoing assessment...and identify the clients response to services...Standard: Coordination of care...Integrate services...to assure identification of client needs and factors that could affect client safety and treatment...working with the client to recommend and make safety modifications..." A review of an agency's policy number 2.8 titled, " Hospital Risk Assessment Policy," dated 11/18/2019 revealed, "Purpose: The purpose of the policy is to establish the frequency of the assessment. Policy: The Hospital Risk Assessment has been adopted by Heaven Sent Home health Care as a screen tool to identify those patients at risk for hospitalization and thus as a guide for care planning..." 2. A review of the clinical record for patient #4 revealed a plan of care for the certification period of 1/5/22 to 3/5/22, evidenced diagnoses but not limited to chronic pain syndrome, hemiplegia (paralysis of one side of the body), history of falling, and cerebral infarction (occurs as a result of disrupted blood flow to the brain with the blood vessels that supply it), and indicated the patient was at risk for hospitalization. The plan of care indicated the patient's Functional Limitations were "endurance, contracture, ambulation, balance off due to weakness on left side,...and shuffling gait." Patient 4 lived alone in their own home and received home health aide services for 1 hour a day, 5-7 days a week, "for safety measures, keep pathways clear and well lighted, ask if any falls, assist with shower 5-7 days a week, assist with dressing, and light housekeeping". The clinical record revealed a document titled, "Non-OASIS (a comprehensive assessment supporting the patient's need for services) Recert", dated 1/5/22, which revealed the patient was a fall risk - with a MACH 10 score: Risk 6, and identified stairs and torn carpet as a Safety hazard. The clinical record evidenced a document titled, "Case Conference" dated 12/31/21, which failed to reveal the stairs and torn carpet as safety hazards were discussed, or consideration of a referral for patient 4 in relation to the identified high risk for falls. A review of the clinical record evidenced a document titled, "Hospitalization Risk Assessment," dated 3/8/21, and revealed the patient had 6 boxes checked, indicating the patient was at high risks for hospitalization, indicating Therapy (Physical, Occupational, and/or Speech) and MSW (Master of Social Work), social worker referrals should be considered. The record failed to evidence documentation of communicating the specific information of the hospitalization risk assessment to the physician, and failed to evidence consulting with the patient and the physician for Therapies and/or MSW evaluations. 3. A review of the clinical record of patient # 2, revealed a start of care date of 1/17/22, and contained a plan of care for the certification period of 1/17/22 to 3/17/22, which evidenced diagnoses but not limited to chronic pain syndrome and major depressive disorder. The patient lived alone in their own apartment and has orders for a home health aide, 1 hour per day, 5 days per week for safety measures, ask if any falls, offer fluids, assist with shower 5 days a week, observes skin for changes, assist with dressing upper and lower body after showers, lotion after showers, incontinence care as needed. The clinical record evidenced a document titled, " MAHC10-Fall Risk Assessment Tool," dated 1/17/22, which revealed the patient had a score of 6, indicating the patient was a fall risk. The clinical record evidenced a document titled, " Hospitalization Risk Assessment," dated 1/17/22, which revealed the patient had 6 boxes checked, indicating Therapy (Physical, Occupational, and/or Speech) and MSW referrals should be considered. The record failed to evidence documentation of communicating the MAHC-10 Fall Risk and Hospitalization Risk assessments to the physician, and failed to evidence consulting with the patient and the physician for Therapies and/or MSW evaluation referrals. 4. During an interview on 1/20/22 at 2 PM, with employees A (administrator)and B (alternate clinical director) regarding the "Hospitalization Risk Assessment," form that is completed upon assessments, both stated they hadn't realized the section where referrals should be considered was there.