Every finding on record at Henry County Memorial Hospital

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 07-29, 07-30, and 07-31-2024. Active Census: 64 At this Emergency Preparedness survey, Henry County Memorial Hospital Home Care was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers at 42 CFR 484.102. QR completed by Area 3 on 8-01-2024.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 07-29, 07-30, and 07-31-2024 12-Month Unduplicated Skilled Admissions: 661 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR completed by Area 3 on 8-01-2024.

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 agency failed to ensure the plan of care was individualized and included all the durable medical equipment (DME) the patient used in the home for 2 of 9 active records reviewed. (Patients #5 and 7) Findings Include: 1. A policy titled “TITLE: 3.4 Plan of Care/Treatment” and with a reviewed of 07-2023 indicated but was not limited to, “ … Procedure … The individualized plan of care must include the following … supplies, and equipment required …” 2. A review of Patient #5’s clinical record evidenced a Plan of Care (POC) with a Start of Care (SOC) date of 06-15-2024 and an initial certification period from 06-15-2024 to 08-13-2024. The POC evidenced a diagnosis of and Encounter for adjustment and management of a Ventricular Assist Device (a pump used to assist the heart in moving blood throughout the body), Chronic Obstructive Pulmonary disease (a disease making it harder to breathe and blocking airflow), and Polyosteoarthritis (a condition where swelling or tenderness are in 5 or more joints). The POC evidenced a section titled “Supplies” and failed to include the supplies observed in the patient’s home during a home visit of Physical Therapy Assistant (PTA) 1 on 07-29-2024 at 1:30 PM. Patient #5 had a wheelchair in their home. During an interview with Patient #5 and Person 1, the patient’s caregiver, on 07-29-2024 at 1:30 PM, they indicated the patient used the wheelchair to go outside and when they went to doctor appointments. Patient #5 evidenced Person 1 was the one to wheel the patient down the ramp when they needed to leave the house. During an interview with the Administrator (Admin 1) and the Family Care Coordinator (Admin 2) on 07-30-2024 at 1:00 PM, Admin 2 confirmed any supplies in the patient’s home, whether they were using the equipment or not, should be listed in the “Supply” section on the POC. They indicated the wheelchair was supposed to be listed on the POC for Patient #5. During an interview with Registered Nurse (RN) 3 on 07-31-2024 at 11:38 AM, they confirmed Patient #5 had a wheelchair in their home and they used the wheelchair when going out of the home. 3. A review of Patient #7’s record evidenced a POC with an SOC date of 06-29-2024 and an initial certification period from 06-29-2024 to 08-27-2024. The POC evidenced a diagnosis of Type 2 Diabetes Mellitus (the body does not regulate and use sugar appropriately). The POC evidenced a section titled “Supplies” and failed to include all the supplies necessary for a diabetic patient. During an interview with Person 9, Patient #7’s relative, on 07-31-2024 at 10:10 AM, they indicated the patient had a blood glucose monitor, lancets, and test strips. Person 9 indicated they were the ones to do Patient #7’s blood sugar checks. During an interview with Admin 2 on 07-31-2024 at 10:30 AM, they indicated the POC for Patient #7 should have listed the diabetic supplies in the patient’s home. During an interview with RN 3 on 07-31-2024 at 11:38 AM, they confirmed Patient #7 had diabetic supplies in the home and should be included in the POC. 410 IAC 17-13-1(a)(D)(ii)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of changes to the patient’s care for 2 of 4 active records reviewed with no home visit. (Patients #7 and 8) Findings Include: 3. A review of the clinical record of Patient #8 evidenced a referral date of 06-21-2024 for home health skilled nursing, physical therapy, and occupational therapy. A review of Patient #8’s visit notes evidenced the first patient visit for skilled nursing occurred on 06-25-2024 and physical therapy on 07-1-2024. On 07-31-2024 at 10:45 AM the Family Care Coordinator indicated the patient’s wife requested a delayed start of care date. When queried if the physician was notified and an order written, they were unable to provide documentation of communication with Patient #8’s physician or an order to change the start of care. The Agency failed to alert the physician of the delay in the start of care. IAC 17-13-1(a)(2) 1. A policy titled “TITLE: 3.4 Plan of Care/Treatment” and with a reviewed of 07-2023 indicated but was not limited to, “ … Review of the Plan of Care … HCH Home Care must promptly alert the relevant physician … that the plan of care should be altered …” 2. A review of Patient #7’s record evidenced a Plan of Care (POC) with a Start of Care (SOC) date of 06-29-2024 and an initial certification period from 06-29-2024 to 08-27-2024. The POC evidenced the patient was to receive an assessment and evaluation for occupational therapy (OT). Patient #7’s record evidenced missed OT and Home Health Aide (HHA) visits on 07-02-2024. The clinical record failed to indicate the physician was notified of the missed visits. During an interview with the Administrator (Admin 1) on 07-30-2024 at 10:00 AM, they indicated they could not find an OT visit note in Patient #7’s clinical record. Admin 2 evidenced the patient had an order for an OT evaluation in the patient’s record but could not find a communication note or order, evidencing why Patient #7 never received the OT evaluation. During an interview with Patient #7’s relative, Person 9, on 07-31-2024 at 10:10 AM, they indicated the OT had come out to see the patient a couple of weeks ago. They evidenced they decided to continue with OT but was unsure how often they came out. During an interview with the Family Care Coordinator (Admin 2) on 07-31-2024 at 10:30 AM, they confirmed there was no order written to the physician notifying them of the OT and HHA missed visits on 07-02-2024. Admin 2 indicated an order should have been written and sent to the physician to inform them of the missed visits. During an interview with Registered Nurse (RN) 3 on 07-31-2024 at 11:38 AM, they indicated they knew Patient #7’s family personally and the family had communicated with them the patient had not wanted OT services. They explained the patient had been with the agency before, had tried OT, and had reached the maximum potential possible for Patient #7. They indicated they spoke with Person 10, Patient #7’s primary caregiver, regarding the patient only wanting skilled nursing, physical therapy, and home health aide services. RN 3 indicated they had not made a note about their conversation with Person 10 because they were anticipating RN 3 to admit the patient to the agency, but the patient was admitted by an on-call RN. RN 3 evidenced the communication with the other nurse was missed and a note should have been added to the patient’s chart.

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 and interview, the agency failed to ensure infection control practices were upheld for hand hygiene for 1 of 2 home visits with a Registered Nurse (RN) providing care. (RN 2) Findings Include: 1. A policy "Hand Hygiene Policy" with a reviewed date of 5/2024 indicated but was not limited to, " ... 3. Moments When Hand Hygiene is to be Performed ... b. Before applying and after removing gloves ..." 2. During an observation on 07-30-24 at 10:20 AM, Registered Nurse 2 (RN2) was observed performing wound care and a foley catheter change for Patient #2. RN 2 grabbed scissors, a ruler, and cotton tips, and donned gloves. RN 2 failed to perform hand hygiene before donning gloves and proceeded to remove the old wound dressing on the patient's left upper buttocks. RN 2 donned new gloves and sprayed down the wound with wound cleanser, doffed gloves, and failed to perform hand hygiene before donning new gloves. During an interview with RN 2 during the home visit at Patient #2's residence on 07-30-24 at 11:10 AM, they indicated hand hygiene was supposed to be performed whenever they felt their hands were soiled, before and after gloving, and when going in and out of their bag. During an interview with the Administrator (Admin 1) and the Family Care Coordinator (Admin 2) on 07-30-2024 at 1:00 PM, Admin 2 evidenced clinicians were to perform hand hygiene before and after gloving, when going in and out of the bag, and before providing care for the patient. 410 IAC 17-12-1 (m)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview the Agency failed to send a completed discharge summary to the health care facilities providing care after discharge from the agency in 3 of 4 discharge records reviewed. (Patients’ #10,#11, and #13) Findings include: 1. A policy titled “3.5 Discharge/Transfer/Referral of Patients” revised 08/2023 indicated but was not limited to “ A Discharge/Transfer/60 Day Summary is written immediately following a patient’s discharge/transfer/recertification and is incorporated into the clinical record . . . A copy of the Transfer Summary is sent to the acute care or extended care hospital and/or nursing home within 24 hours and/or the next working day from the time notified of admission to one of these facilities . . . .” 2. A review of the clinical record for Patient # 10 evidenced a start of care (SOC) of 06-04-2024 and a discharge date of 07-02-2024. The clinical record indicated Patient #10 a discharged to Entity 6, a skilled nursing facility, and the discharge summary was sent to the Patient’s physician. The clinical record failed to evidence a discharge summary was sent to Entity 6. 3. A review of the clinical record for Patient #11 evidenced a SOC of 01-26-2024 and a discharge date of 01-20-2024. The clinical record indicated Patient #11 was discharged to Entity 7, an unnamed hospice agency. The record evidenced the discharge summary was sent to the Patient’s physician but failed to evidence a discharge summary was to the receiving hospice agency. 4. A review of the clinical record for Patient #13 evidenced a SOC of 07-05-2024 and a discharge date of 07-08-2024. The clinical record indicated Patient #13 was discharged to Entity 7, a hospital. The record evidenced the discharge summary was sent to the Patient’s physician but failed to evidence a discharge summary was sent to Entity 7. 5. In an interview on 07-30-2024 at 1:55 PM the Administrator reported a discharge summary should be sent to the physician and the agency when the patient is discharged. They reported for Patients #10, #11, and #13 they could not locate a summary sent to the receiving agencies. IAC 17-15-1(a)(6)

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.22. Survey Date: October 12, 13; 2021 Facility Number: 157430 Provider Number: 157430 Census = 552 At this Emergency Preparedness survey, HCMH Home Care was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.22.

This visit was for a Federal Recertification and State Licensure survey. This was a partially extended survey. The administrator was notified the survey was partially extended on 10/12/21 at 3:13 PM. Survey Dates: October 12, 13; 2021 Provider number: 157430 Facility #: IN008652 Unduplicated Census: 552 These deficiencies reflect State Findings cited in accordance with 410 IAC 17.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the Registered Nurse (RN) failed to ensure the comprehensive assessment contained a complete review of the patient’s medications and medication lists were accurately maintained for 1 of 5 records reviewed (#1). A policy titled “Plan of Care/Treatment,” indicated “…The individualized plan of care must include the following … all medications and treatments … HCH [Henry County Hospital] Home Care must promptly alert the physician to any changes in the patient’s conditions or needs that suggest the outcomes are not being achieved and/or that the plan of care should be altered….” The clinical record of patient #1 was reviewed on 10/12/21 at 12:00 PM and indicated a start of care date of 9/23/21. The record contained a plan of care for the certification dates 9/23/21 to 11/21/21. The record contained a medication list, printed 10/12/21, titled “Medication Profile,” that indicated “…Start Date … 9/23/21 … Medication … clonazepam [treats anxiety and panic disorders] 1 [one] mg [milligram] oral tablet; take 1 tabs oral 3 [three] times a day … dicyclomine [treats irritable bowel syndrome] 20 [twenty] mg; take 1 tab orally 4 [four] times a day as needed for stomach pain … Zofran [treats nausea and vomiting] 4 mg oral tablet; take 1 tab orally every 8 [eight] hours as needed for nausea….” During a home visit on 10/12/21 at 1:00 PM with patient #1, the patient indicated he had visited the emergency room on 10/8/21 due to uncontrolled high blood pressure. A document dated 10/9/21, titled “Skilled Nursing Visit Note,” completed by Registered Nurse C, indicated “…Medication Profile Review … No new or changed medications….” During a home visit on 10/12/21 at 1:00 PM with patient #1, the patient indicated he was taking the medications by the lamp and on the kitchen table. Upon inspection of the areas, the patient was referencing, multiple medications from the aforementioned medication list were missing. Of note were: clonazepam, dicyclomine, and zofran, were observed by the writer. One medication, that was not listed as an order, was present: voltaren gel (treats arthritic pain). A medication list, printed 10/13/21, submitted on 10/13/21 at 3:30 PM indicated “…Start Date … 9/23/21 … Medication … clonazepam [treats anxiety and panic disorders] 1 [one] mg [milligram] oral tablet; take 1 tabs oral 3 [three] times a day … dicyclomine [treats irritable bowel syndrome] 20 [twenty] mg; take 1 tab orally 4 [four] times a day as needed for stomach pain … Zofran [treats nausea and vomiting] 4 mg oral tablet; take 1 tab orally every 8 [eight] hours as needed for nausea….” The medication list submitted did not reflect the most recent list of medications the patient was currently taking. During an interview on 10/13/21 at 3:10 PM, when asked how often a medication list needed to be updated, Administrator A indicated “with each visit.” 17-14-1(a)(1)(B)