Every finding on record at Help at Home Inc

This visit was for a Federal and State licensure complaint survey of a home health agency provider. Facility ID: 15K091 Survey Dates: 10/27/2022 and 10/28/2022 Complaint #: 71821 - Substantiated. Federal deficiencies related to the allegation were cited. Current Census: 59 QR; Area 2 11/07/22

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the continuity of home health services for 1 of 2 active patient records reviewed (Patient #1) and for 2 of 3 discharged patient records reviewed (Patient #3 and 4). Findings include: 1. An agency policy, dated 01/09/2022 and titled “Client Discharge Process,” stated “… purpose … to ensure continuity of care, treatment and services when needed … to avoid charges of abandonment at the time of discharge agency documentation will include … evidence that the decision was not made unilaterally … the client, family … participated in the decision to discharge ….” 2. Clinical record review for Patient #1, start of care date 07/31/2017, included a document titled “Home Health Certification / Recertification Plan of Care Order” for certification periods 07/04/22 to 09/01/22 and 09/02/22 to 10/31/22 with primary diagnosis of autonomic dysreflexia (symptoms due to a spinal cord injury that makes blood pressure dangerously high and heart rate low, that can lead to a stroke, seizure, or cardiac arrest) with orders for aide services 3 hours per day 7 days per week and "discharge plans … no plans to discharge ….” Review of an agency document titled “Activity Individual” signed and dated by registered nurse (RN) #2 dated 08/31/2022, indicated “… company will be issuing 15 day discharge letter due to inability to provide care for client … is quadriplegic (paralysis of all four limbs) and has no available staff when agency is not in the home ….” During a phone interview on 10/27/2022 at 10:45AM, Patient #1 indicated the agency was going to discharge him / her from service because he / she lived alone. Patient #1 indicated they had always lived alone and the agency had not mentioned this as an issue previously. At 12:47PM, when asked if patient still received home health services, Patient #1 indicated they were because found a statute that the agency could not discharge the patient under the circumstances the agency presented to the patient. 3 Clinical record review for Patient #3, start of care date 03/15/2022, included a document titled “Home Health Certification / Recertification Plan of Care Order” for certification period 09/11/2022 to 11/09/2022 with primary diagnosis cerebral palsy (disorder that affects a person's ability to move, maintain balance and posture), that indicated “… HHA to provide 2 hours a day/5 days per week … discharge plans … no plans of discharge at this time due to patient needing HHA to assist with ADLs (activities of daily living that including bathing, dressing, toileting) ….” Review of untitled agency documents of missed visits for dates 07/31/22 – 08/06/2022, 08/07/2022 – 08/13/2022, 08/14/2022 – 08/20/2022, and 08/28/2022 – 09/03/2022, indicated “… the following hours were under for the week … home health aide 10 … reason for missed hours … no staff in client’s area ….” Review of patient’s schedule indicated patient received one HHA visit between 08/01/2022 until discharge on 09/23/2022. During an interview on 10/27/2022 at 4:15PM, the alternate administrator / alternate clinical supervisor indicated the agency provided care to 6 patients whom resided in residential group home, Other 1, when the agency lost the aide in that area, the agency discharged all six patients on the same date, 9/23/22. During a phone interview on 10/28/2022 at 10:35AM, HHA #1 indicated they had requested to stop providing care to patients in Other 1 group homes and relayed they currently provide care to patients in the same town as Other 1 is located. During an interview on 10/28/2022 at 3:15PM, when asked why Patient #3 was not discharged until 09/23/2022 when the patient only received one HHA visit between 08/01/2022 to 09/23/2022, the alternate administrator / alternate clinical supervisor indicated the home health agency’s RN wanted to wait on discharge in case another HHA could cover the visits. 4. Clinical record review for Patient #4, start of care date 05/18/2022, included a document titled “Home Health Certification / Recertification Plan of Care Order” for certification period 08/30/2022 – 10/28/2022 with primary diagnosis morbid obesity that indicated “… HHA to provide 6 hours a day, 7 days a week … no plans for discharge at this time as the patient continues to require assistance with personal care ….” Review of an untitled letter addressed to Patient #4, dated 08/22/2022, indicated “… we are discontinuing your services due to lack of staff to adequately meet your needs … we will continue to try to provide staff until the last date of service ….” During a phone interview on 10/27/2022 at 3:10PM, Patient #4 indicated the agency was short on help and gave him / her many excuses as to why they couldn’t send help. Review of patient’s schedule indicated the last HHA visit took place on 05/24/2022 and a hold was entered into the schedule on 05/25/2022, and patient was discharged on 09/08/2022. During an interview on 10/28/2022 at 2:30PM, when asked why Patient #4 remained on service when no home health services were provided, the alternate administrator / alternate clinical supervisor indicated the patient asked to be placed on hold until the agency could find HHA staff.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they investigated complaints made by the patient and documented in the clinical record for 1 of 2 active patient records reviewed (Patient #1) and for 2 of 3 discharged patient records reviewed (Patient # 5). Findings include: 1. During an interview on 10/27/2022 at 4:15PM, when asked for the complaint log for 2022, the alternate administrator / alternate clinical supervisor indicated the agency has not had any complaints in 2022. 2. Review of an agency policy dated 01/04/2022 and titled “Complaints and Grievances” indicated “… a grievance will be documented by the agency and forwarded as soon as possible to the appropriate parties by administrator / designee for investigation and handling of the complaint ….” 3. Clinical record review for Patient #1, start of care date 07/31/2017, included a plan of care for the certification period 07/04/2022 to 09/01/2022, which included an agency document titled “Activity Individual” signed and dated by care supervisor on 07/08/2022, that indicated “… client stated … very upset … did not have staff over the past weekend … passed on information to … area leader ….” A. An agency document titled “Activity Individual” signed and dated by care supervisor, administrative staff [AS] #4 and dated 07/19/22, indicated “… client … called the office and is still upset about not having staff on the weekend of 7-6 (July 6th) … wanted to speak to someone in corporate … told would pass the message on ….” B. During an interview, on 10/28/2022 at 2:10 PM, when asked who they reported Patient #1's concerns, the care supervisor, AS #4, indicated they notified the area leader, Corporate staff #1. C. During an interview on 10/28/2022 at 2:30 PM, when asked about the concerns expressed by Patient #1 on 07/08/2022 and 07/19/2022, the alternate administrator / alternate clinical supervisor indicated that it was discussed with the area leader, CS #1. 4. Clinical record review for Patient #5, start of care date 12/14/2015, for certification period 05/11/2022 – 07/09/2022, included an agency document titled “Activity Individual” signed and dated by RN (registered nurse) #1 on 05/27/2022, that indicated “… client voiced concerns about … HHA #2 … made bleach water and began washing client’s walls … client told HHA #2 to stop three times and finally raised … voice ….” A. Review of an untitled document signed and dated by RN #1 on 05/28/2022, indicated “… client reports that on 05/28/2022 HHA #1 used a [sic] antiseptic wipe to clean … urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) … from vaginal opening and wiped all the way to the bag … requests that HHA #1 does not return ….” B. During an interview on 10/28/2022 at 2:30 PM, when asked if a complaint should have been created for the concerns of Patient #5, the alternate administrator / alternate clinical supervisor indicated yes, a complaint should have been created.

This visit was for a Federal and State complaint survey of a Home Health Care Provider. Survey Dates: June 9 and 10, 2022 Complaint: 62875 - Unsubstantiated. Federal and State deficiencies were not cited. An unrelated Federal deficiency was cited. Census: 197 This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on document review and interview, the agency failed to provide the contact information for the Quality Improvement Organization for Region IV, [Indiana is in Region IV] to the patients, with the potential to affect all patients for 1 of 1 agency. Findings include: Review of the agency Patient Handbook failed to identify the federally - funded and state - funded Quality Improvement Organization contact information. During an interview on 6/10/2022 at 3:28 PM, the administrator relayed that the contact information for the Quality Improvement Organization, for Indiana, was not provided to patients of the agency.

This visit was for a Federal Recertification of a home health agency. A State Re-licensure and complaint investigation survey was conducted in conjunction with the recertification survey. The federal survey was partially extended on 2/07/2022 at 1:05 PM. Complaint Number 29541 / IN00317234: Unsubstantiated: Lack of sufficient evidence Survey Dates: January 31, and February 1, 2, 7, 8, 9, 2022 QA by Area 2 supervisor

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure patients received services as ordered by the physician on the plan of care in 4 of 7 records reviewed (#1, 4, 5, and 7). Findings include: 1. During a home observation with patient #1, on 02/01/2022 at 8:44 a.m., employee G, a registered nurse, and employee M, a home health aide were present. Patient #1 was observed in the room playing with their toys; patient #1 was not wearing a helmet or head protection during the visit. A record review for Patient #1 was completed on 02/02/2022. The record included a document titled “Home Health Certification/ Recertification Plan of Care Order” for the certification period 12/04/2021 to 02/01/2022, with a diagnosis of, but not limited to, seizure disorder and included physician orders for staff to ensure the patient “… wears a helmet on waking hours.” Record review evidenced an agency document titled “Plan of Care Service Plan” for certification period 12/04/2021 to 02/01/2022, and included instructions for the home health aide to ensure the patient had “… Helmet on when awake.” During an interview on 2/8/2022 at 2:16 p.m., employee A, the administrator, confirmed the home health aide should ensure the patient wore the helmet during waking hours. 2. A record review for Patient #4 was completed on 2/4/2022. The record included a document titled “Home Health Certification/ Recertification Plan of Care Order” for the certification period 12/16/2021 to 02/13/2022 which included the diagnosis, but not limited to, fibromyalgia (a condition causing pain all over the body, sleep problems, fatigue, depression and anxiety, sleep problems, headaches, and problems with thinking, memory, and concentration). The Plan of Care included physician order for home health aide services 8 hours per day, five days a week, to provide assistance with showering, hair care, dressing, nail care, meal preparation, and light housekeeping. The record failed to evidence aide services were provided to the the patient from 12/16/2021 to 12/31/2021. During an interview on 02/8/2022 at 2:00 p.m., employee A, the administrator, confirmed the patient did not receive the services as ordered on the plan of care and relayed the assigned home health aide died and the agency was unable to provide the ordered services. 3. A record review for Patient #5 was completed on 02/07/2022, and included document titled “Home Health Certification/ Recertification Plan of Care Order” for certification period 12/17/2021 to 02/14/2022 with an order for home health aide services 5 hours a day, 3 days a week for assistance with mobility, showering, hair care, dressing, oral care, skin care, and meal preparation. Diagnosis included, but not limited to, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The record failed to evidence aide services were provided after day 1 of the certification period. Services were provided only on 12/17/2021 [day one of the certification period]. During an interview on 02/08/2022 at 1:54 p.m., Employee A, the administrator, confirmed the visits were missed due to staffing issues. 4. A record review for Patient #7 was completed on 02/07/2022. The record included document titled “Home Health Certification/ Recertification Plan of Care Order” for the recertification period 12/8/2021 to 02/05/2022 which evidenced a start of care date of 02/11/2021. The plan of care included the diagnosis of Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves, which results in nerve damage that disrupts communication between the brain and the body) and paraplegia (paralysis of the legs and lower body). The plan of care included an order for home health aide care services for 2-hour visits twice daily, 7 days a week, to aid with bathing, dressing, transferring (moving from wheelchair to bed, for example), and meal preparation. The record failed to evidence a second visit was provided on dates December 12, 19, 26, 2021 and on January 9, and 30, of 2022. During an interview on 02/08/2022 at 2:05 p.m., Employee A, the administrator, confirmed the patient did not receive the aide services as ordered and relayed the agency did not have the staff available for the missed shifts / hours. 410 IAC 17-13-1(a)

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care was accurate and reflected the most recent comprehensive assessment in 1 of 2 clinical records reviewed that received skilled nursing services (Patient #6). The findings include: Review of an agency policy dated 1/04/2022, titled “Plan of Care” indicated “… agency must promptly alert the physician of any changes in the client’s condition … that suggests … the plan of care should be altered ….” Review of document titled “Recertification / Follow-Up Assessment,” completed by Employee H, a RN (registered nurse) and dated 12/02/2021 included documentation that the patient was assessed and had one (1) unhealed pressure ulcer / injuries [injury to the skin and tissues from pressure] at a Stage 3 [a break in the top two layers of skin to the fatty tissue below]. The clinical record for patient #6 was reviewed on 02/03/2022. The record included document titled “Home Health Certification and Plan of Care” for the certification period 12/06/2021 to 02/03/2022 which included but not limited to the diagnoses of a pressure ulcer [injury to the skin and tissues from pressure] at stage 2 [a break in the top two layers of skin. The plan of care failed to evidence a revision and to include the stage 3 wound as identified and documented on the Recertification Assessment, dated 12/02/2021. During an interview on 2/07/2022 at 4:00 PM, the administrator indicated the nurse entered the incorrect staging of the pressure ulcer in the plan of care.

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 record review and interview, the skilled nurse failed to follow the plan of care for 1 of 2 clinical records reviewed receiving skilled nursing services (Patient #6). Findings include: Review of an agency policy dated 1/04/2022, titled “Plan of Care” indicated “… the plan of care/treatment shall … include all services to be provided if a skilled service is being provided ….” The clinical record of patient #6, with start of care date 02/09/2021, was reviewed on 2/07/2022. The record included a document titled “Home Health Certification and Plan of Care" for the certification period 12/06/2021 to 02/03/2022 with skilled nurse orders that included but not limited to “… RN [registered nurse] orders … 7 d/week [7 days a week] ... for VS [vital signs], full body assessment [head to toe physical exam], ADLs / IDLs [tasks of everyday life such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet] … pressure wound [injury to the skin and tissues from pressure] … SN [skilled nurse] to remove old dressing … cleanse daily … apply Drawtex [wound dressing] … cover with Superabsorber [wound dressing] … notify MD [physician] of worsening wound symptom ….” Review of an agency document titled “Recertification/Follow-Up Assessment,” completed by Employee H, a RN, dated 02/01/2022 and relayed employee H visited the patient and no wound care was completed. The documentation included but not limited to, “… wound care done during this visit … no … size (cm) [measurement of length] (L x W x D) [length and width and depth of a wound] … 1 cm x 1 cm x 3 cm … tunneling [wound that tunnels underneath the skin] … length 3 cm … surrounding skin … pink and no signs of infection … drainage/amount … small … color … clear … consistency … thin ….” The nurse visit note failed to evidence the wound care was completed as ordered on the plan care. During an interview on 2/07/2022 at 11:15 AM, employee H was asked how he / she determined the wound characteristics and measurements as documented on the Recertification Assessment as employee H documented, on same assessment, that he / she did not complete the wound care during the visit. Employee H relayed that another nurse made a visit to the patient, on that date and performed the wound care, and must have left a note for employee H with the wound characteristics. Review of agency documents titled "Skilled Nursing Visit Note," completed by Employee K, a RN, and dated 12/11/2021, 12/25/2021, 1/15/2022, 1/16/2022, 1/29/2022 and 1/30/2022 failed to evidence the patient's wound was assessed or that wound care was provided during the visits. During an interview on 2/07/2022 at 1:50 PM, the administrator indicated the nurse should have documented the assessment and care provided within the nurse visit note.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the registered nurse (RN) failed to ensure the home health aide [HHA] care plans were appropriate and specific to the needs of the patient for 1 of 6 clinical records reviewed with HHA services (Patient #2). Findings include: The agency policy dated 1/04/2022, and titled “Home Health Aide Care Service Plan” was reviewed and indicated “… a complete and appropriate Care Service Plan, identifying duties to be performed by the Home Health Aide, shall be developed by a Registered Nurse … provide a means of assigning duties to the Home Health Aide that are clear … provide documentation that the client’s care is individualized to his/her specific needs ….” Clinical record review for patient #2 was conducted on 02/01/2022. The record indicated a start of care date of 9/14/2021 and included the document Plan of Care Service Plan for the certification period 01/12/2022 to 3/12/2022. The plan of care included the home health aide tasks to be provided and included, but not limited to, medication reminder(s), patient oral care, patient nail care, laundry, and general cleaning of living areas. The plan of care failed to evidence a frequency in which the aide was to provide these services with or for the patient. During an interview on 2/07/2022 at 4:45 PM, the administrator indicated the HHA care plan should have a frequency entered for each task.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure patient records contained the current comprehensive assessment(s) for 2 of 5 active records reviewed (Patients #2 and 3) and failed to ensure patient records included the skilled nurse visit notes for 1 of 2 active records reviewed with orders for skilled nursing (Patients #6 ). Findings include: Review of an agency policy titled “Confidentiality Notices” revealed the necessity of medical information to “… be accurate, timely, complete, and available ….” Review of an agency policy titled “Medical Record Content” revealed “Clinical notes are incorporated into the clinical record within fourteen (14) days.” A record review for Patient #7 was completed on 2/7/2022, start of care date 2/11/2021, revealed a schedule with skilled nursing services on 12/21/2021 and 1/12/2022. The record failed to evidence the nursing notes in the medical record. During an interview on 12/9/2022 at 11:15 a.m., Employee A, administrator, confirmed the notes were not in the medical record. 410 IAC 17-15-1(a)(3,4) A record review for Patient #2, the start of care date 9/14/2021, was reviewed on 2/01/2022 for the certification period of 1/12/2022 - 3/12/2022. The clinical record failed to evidence the comprehensive assessment for this certification period was incorporated into the record within 14 days. During an interview on 2/02/2022 at 10:15 AM, Employee A, administrator indicated would check with the nurse to find the comprehensive assessment. At 10:25 AM, Employee H, RN [registered nurse] provided a copy of the 1/11/2022 comprehensive assessment. A record review for Patient #3, the start of care date 12/12/2016, was reviewed on 2/02/2022 for the certification period of 1/15/2022 – 3/15/2022. The clinical record failed to evidence the comprehensive assessment for this certification period was incorporated into the record within 14 days. During an interview on 2/02/2022 at 10:15 AM, the administrator indicated would check with the nurse to find the comprehensive assessment. At 10:25 AM, the administrator indicated Employee G, RN will upload the 1/10/2022 comprehensive assessment into the clinical record that day. A record review for Patient #6, the start of care date 2/09/2021, was reviewed on 2/07/2022 and contained a plan of care for the certification period of 12/06/2021 – 2/03/2022, with orders for Skilled Nurse services 3 hours daily for 7 days a week starting on 12/06.2021. Order dated 12/30/2021 indicated a change in Skilled Nurse service to 3 hours daily for 5 days a week. Order dated 1/27/2022 indicated a change in Skilled Nurse service to 3 hours daily for 7 days a week. The record failed to evidence skilled nursing visit notes for 37 days of service. During an interview on 2/07/2022 at 12:45 PM, the administrator indicated the missing skilled nurse visit notes had not been turned into the agency by the skilled nurse.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview, and agency document, the agency failed to follow their agency policy and ensure the patient records, which were of paper, were secured, for 1 of 1 agency with the potential to effect all patients. Findings include: 1. Review of the agency “Patient Admission Booklet” included but not limited to, “Section III. Patient Rights and Responsibilities,” which relayed the patient's right to “… Have a confidential clinical record … All confidential client information, whether it be paper … is stored… behind two locks.” 2. Review of the agency document titled, “Notice of Privacy Practices” included a statement that the agency was “… legally required to protect the privacy of your medical information." 3. During a tour of the agency on 1/31/2022 at 10:45 a.m., Employee A, the Administrator, opened an unlocked metal cabinet which revealed paper medical records. The cabinet was unlocked. 4. During an interview on 1/31/2022 at 10:45 a.m., Employee A, the Administrator, confirmed the paper records observed were kept in unlocked cabinets in the nursing office, which was often left unlocked when the office was unoccupied. 410 IAC 17-15-1(c)

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient's clinical records would be made available to the patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first) for all current and future patients. The findings include: Review of an agency document, dated 4/2021, and titled “Notice of Privacy Practices for Protected Health Information” included but not limited to “… right to see and get copies of your medical information … we will respond to you within 30 days after receiving your written request … we will charge you a reasonable fee as permitted ….” During an interview on 02/01/2022 at 4:00 PM, the administrator indicated that information provided to patients did not meet the regulation. 410 IAC 17-12-3(b)(3)