Every finding on record at Heritage Home Health Services LLC

This visit was for a Federal/State complaint survey of a Home Health Provider. Survey Dates: 09-19-2024 and 09-20-2024 Complaint: IN00109649 with unrelated findings 12-month Unduplicated Skilled Admissions: 612 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State form for additional State Findings. QR by Area 3 TS on 09-25-2024.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the Governing Body failed to assume full responsibility for the parent agency and its branch, failed to evidence documentation of the relocation of the agency, and failed to address the existence of a branch office, for 1 of 1 home health agency. Findings include: 1. A review of an agency policy revised May 2022, titled 'GOVERNING BODY Policy No. 1-002.1' indicated, "… The Governing Body will assume full legal authority, responsibility, and decision-making and accountability for the overall management and operations … The Governing Body of [Entity A] will serve as the governing authority for the home care program … 20. All actions taken by the Governing Body will be documented in meeting minutes … Minutes will minimally include … summaries of agenda items and action taken, and motions documented as stated and acted upon …" 2. A review of the Governing Body's annual meeting minutes for January 2023 and January 2024 failed to evidenced discussion of the agency's relocation from Indianapolis to Greenwood, and failed to be specific regarding the agency's organization and operations to include the Martinsville branch. 3. On 09-20-2024 at 10:18 AM, the Administrator indicated the Governing Body needed to have a separate meeting for the Martinsville branch. 410 IAC 17-12-1(b)(1)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview the Administrator failed to be responsible for all day-to-day operations of the Home Health Agency (HHA), delegating administrative responsibilities to other, non-contracted entities, for 1 of 1 home health agency. Findings include: 1. A review of an agency policy revised May 2022, titled 'HOME HEALTH ADMINISTRATOR Policy no. 1-009.1' indicated, "… 3. Responsibilities of the position will include but not be limited to: A. Planning, organizing, directing and evaluating operations … B. Ensuring organizational compliance with legal, regulatory … requirements …" 2. A review of an agency policy revised May 2022, titled 'ADMINISTRATIVE QUALIFICATIONS AND RESPONSIBILITIES Policy No. 1-006.1' indicated, "… Authority and responsibility for administrative positions will include supervision of contracted services and branches of the parent organization … 3. [Entity A] position descriptions will clearly define specific responsibilities and will include at least: … D. Compliance with applicable law and regulation …" 3. A review of an untitled agency document dated 04-23-2024, from Palmetto GBA, indicated a change of information request had been approved. The letter was addressed to Corporate Person A at the agency's Greenwood address. 4. On 09-19-2024 at 9:40 AM, when queried as to the letter being addressed to Corporate Person A, the Administrator indicated they were the Corporate Compliance Officer and they handled communications with the State, etc., was not an employee of the agency, but was an employee of the 'Home Office' located in Ohio. 5. On 09-19-2024 at 1:10 PM, the Corporate Compliance person indicated they had been the one communicating with the State and attending to the State's requests for the agency's updated 855 form. Indicated they had also been the one to deal with the IRS (Internal Revenue Service) in order to obtain an updated 1575 form which would be needed to update the agency's 855 form. The Corporate Compliance person further Indicated was listed as an "authorized person" and "delegated official" through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). The Corporate Compliance person further indicated received emails from the Indiana Department of Health (IDOH) and is aware the Administrator receives these emails as well. Indicated was not an employee of the agency but was employed by Entity A and was 'support and guidance,' indicated did not normally work out the Greenwood office, and indicated had no contract. 6. On 09-20-204 at 10:00 AM, the Administrator indicated the Home Office performed OASIS submission for the agency, did not believe there was a contract for this but would verify. 7. On 09-20-2024 at 10:05 AM, the Administrator indicated Entity A provides the agency with support, for example: Corporate Person A for compliance, QA (Quality Assurance) for medical record review and OASIS submission. Indicated there were no contracts in place with Entity A for these services. 410 IAC 17-12-1( c)(1)

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the Parent office had direct oversight of the Branch office for 1 of 1 home health agencies. Findings include: 1. A review of a policy titled 'GOVERNING BODY 1-002.1' revealed, "…POLICY The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations …" 2. A review of a policy titled 'BRANCH CONTROL 1-021.1' revealed, "PURPOSE To ensure that administration, documentation, communication, coordination and retrieval of information at branch locations is treated in the same manner as that in the patent location … 7. … The parent organization will be responsible for … issues affecting the operation of a branch location. …" 3. On 09/19/2024 a visit was made to the branch office in Martinsville, IN. The office door was locked, and was not answered when knocked on. There was a sign on the door to call the main office number if assistance was needed. 4. On 09/20/2024 during a visit to the Branch office in Martinsville, IN, Administrative Staff 4 indicated they had gone to the Greenwood office on 09/19/2024 to pick up supplies, and the Administrator had asked Administrative Staff 4 to stay since surveyors were on site to assist with the survey process but is always there during business hours. 5. On 09/19/2024 when asked if the agency could separate their Martinsville Branch patients from the Parent, the Administrator indicated they would need to go through their census and figure out which ones are at the Martinsville Branch, all patients are grouped together, there are not identifiers to separate them out. 6. On 09/20/2024 the Administrator indicated they didn't realize the Branch should be open during operating hours, indicated they had asked Administrative Staff 4 to stay at the Greenwood location on 09/19/2024 to assist with the survey, and didn't realize they needed to have different identifiers for their Branch patients.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 09-19, 09-20, and 09-21-2023 Current Census: 100 At this Emergency Preparedness survey, Heritage Home Health Services, LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 3 on 09-26-2023.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 09-19, 09-20, and 09-21-2023 Partial Extended Survey Announced 09-19-2023 at 4:47 PM. 12 Month Unduplicated Skilled Admissions: 486 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR completed by Area 3 on 09-26-2023.

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 agency failed to ensure the patient’s clinical record contained a complete list of the patient’s current medications, and/or that the physician was promptly notified of any significant potential drug interactions identified, in 2 of 8 active clinical records reviewed. (Patients: #1, and 2) Findings Include: On 09-19-2023 at 12:55 PM, Patient #2’s record was reviewed. The clinical record evidenced a document titled “Patient Medication Record” dated 08-16-2023 by Registered Nurse (RN) 2. The document evidenced the medications Diltiazem HCL (sic Hydrochloride) and Metoprolol Succinate. According to WebMD, it indicated the drug interactions between the two medications were serious. The medication record failed to indicate whether the physician was not notified of the severe medication interactions. 410 IAC 17-14-1(a)(1)(B) 1. A review of a The LTM Group policy with a revision date May 2023, was provided by the Corporate Compliance staff, Corp 1, on 09-20-2023 at 3:19 PM. The “Medication Profile” policy indicated but was not limited to, “... Medication profiles are updated for each change to reflect current medications, new, and/or discontinued…A drug regimen review will be preformed at the time of admission … and with the addition of a new medication…will identify drug/food interactions, potential adverse effects and drug reactions … the physician will be notified …” 2. A home visit observation occurred on 09-20-2023 from 10:30 AM to 12:15 PM, at the residence of Patient #1’s. The Registered Nurse (RN), RN 1, was observed to initiate infusion therapy via Patient #1’s port. Patient 1 was observed completing an aerosol treatment via their nebulizer mask while RN 1 was setting up the infusion medication. RN 1 failed to review or ask Patient 1 of any medication changes or updates to Patient #1’s medications. A review of the clinical record of Patient #1 was completed on 09-20-2023, with a start of care date of 05-24-2023. Record review evidenced a document titled, “Patient Medication Record” which was signed by the Former Employee, RN 6 and dated 05-27-2023. The former employee RN 6, failed to evidence the medication reconciliation had been completed on admission date 05-24-2023. RN 1 failed to review/ask Patient #1 of any updated medications, failed to have completed an updated medication profile and med reconciliation and notify the physician, failed to have discontinued Tudorza Pressair Inhalation 100 milligrams (mg)/1 puff every 12 hours daily, and failed to add the new aerosol treatment Yupelri 175 micrograms (mcg)/3 milliliters (ml) 1 time daily at noon. During an interview on 09-20-2023 at 11:10 AM, Patient #1 indicated their physician discontinued their old Tudorza Pressair Inhalation 100 mg)1 puff every 12 hours daily, added the new aerosol treatment Yupelri 175 mcg/3 ml 1 time daily at noon to help with their shortness of breath. 3. During an interview on 09-19-2023 at 3:58 PM, the Clinical Manager, Admin 2, confirmed Patient #1’s medication profile and medication regimen was completed untimely. They also confirmed medication profiles are to be updated and reviewed with the patients every visit for changes for updates needed.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician received a complete transfer and discharge summary inclusive of goals and interventions for 2 of 3 inactive clinical records reviewed. (Patients #9 and 10) Findings Include: 1. On 09-20-2023 at 3:21 PM, the Patient Care Coordinator provided a May 2023 ACHC (Accreditation Commission for Health Care) Home Health policy titled “Discharge Planning, Policy No. 4-009.1”. The policy indicated but was not limited to, “ … 6. The organization will ensure all necessary medical information pertaining to the patient’s current course of treatment, treatment preferences, illness and post-discharge goals of care are sent to the … health care practitioner to ensure a safe and effective transition of care …” 2. On 09-20-2023 at 8:40 AM, Patient #10’s record was reviewed. The clinical record evidenced a document titled “Transfer Summary”, signed by the Clinical Manager on 05-03-2023. The document evidenced they received Skilled Nursing (SN) services, Occupational Therapy (OT), and Physical Therapy (PT) services from the agency. The summary failed to include goals and interventions. 3. On 09-20-2023 at 9:30 AM, Patient #9’s record was reviewed. The clinical record evidenced a document titled “Transfer Summary”, signed by the Clinical Manager on 08-08-2023. The document evidenced the patient received SN services from the agency. The summary failed to include goals and interventions. 4. During an interview with the Clinical Manager on 09-21-2023 at 11:33 AM, when queried regarding the contents to be included in the Transfer and Discharge summary, they indicated the summaries were to include goals and interventions.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to ensure the patient’s plan of care included all the required elements for 4 of 8 active clinical records reviewed. (Patients: #1, 2, 5 and 6) Findings Include: On 09-21-2023 at 12:55 PM, Patient #2’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 06-09-2022 and a certification period from 08-03-2023 to 10-01-2023. The plan of care listed the following diagnoses for Patient #2, Lymphedema (localized swelling in the body), Type 2 Diabetes Mellitus (a disease causing the body to be unable to regulate the blood glucose levels), Hypertension (high blood pressure), Fibromyalgia (a disorder where pain occurs throughout the body), and Spinal stenosis of the lumbar region (a conditions where the spaces in the spine narrow and put pressure on the spinal cord). The patient received Skilled Nursing services 1 time a week for 1 week and 2 times a week for 6 weeks during the certification period. The plan of care failed to evidence patient-centered goals. 410 IAC 17-14-1(a)(1)(D)(ii, xiii) 1. A review of a The LTM Group policy with a revision date May 2023, was provided by the Corporate Compliance staff, Corp 1, on 09-20-2023 at 3:15 PM. The “Care Planning Process” policy indicated but was not limited to, “...the plan of care will include … C. Reasonable, measurable, and individualized goals and outcomes…G. Equipment and supplies …” 2. A review of the clinical record for Patient #1 was completed on 09-20-2023, with a start of care date of 05-24-2023. The record contained a plan of care for the recertification period of 07-23-2023 to 09-20-2023, electronically signed by the Clinical Manager, Admin 2, and dated 07-23-2023. The plan of care indicated in the section titled, “Durable Medical Equipment (DME) & Supplies” that the DME and supplies used in the home were a cane, sterile gloves, insertion kit, dressing supplies, grab bars, oxygen, exam gloves, tub/shower bench, sharps container and alcohol pads. During a home visit on 09-20-2023 at 10:30 AM, a Patient #1’s residence Patient #1 observed Patient #1 use their pulse oximeter (a fingertip device used to measure oxygen saturation levels in the body) from their table. Patient #1 was observed to complete an aerosol breathing treatment via a nebulizer and mask during the home visit. Review of the plan of care failed to indicate a complete list of the medical equipment and supplies in the home. During an interview on 09-19-2023 at 4:40 PM, the Clinical Manger, Admin 2 confirmed that all DME & supplies should be listed on the plan of care. 2. A review of the clinical record for Patient #5 was completed on 09-19-2023, with a start of care date of 09-14-2023. The record contained a plan of care for the initial certification period of 09-14-2023 to 11-12-2023. The plan of care indicated in the section titled, “DME & Supplies” that the DME and supplies used in the home were a cane, probe covers, dressing supplies, diabetic supplies, exam gloves, walker, alcohol pads, wound care supplies provided by Entity 3, a wound care center at an acute care facility. During a phone interview with Patient #5 on 09-21-2023 at 2:13 PM, Patient #5 indicated that they test their blood sugar 1 time a day with their glucometer and administer their own insulin with their insulin pen. Review of the plan of care failed to indicate a complete list of the medical list and supplies in the home. 3. A review of the clinical record for Patient #6 was completed on 09-20-2023, with a start of care date of 09-13-2023. The record contained a plan of care for the initial certification period of 09-13-2023 to 11-11-2023. The plan of care indicated in the section titled, “DME & Supplies” that the DME and supplies used in the home were probe covers, exam gloves, alcohol pads, and an electric scooter. The section titled, “Skilled Nurse Interventions” indicated Patient #6 was to have wound care to their left buttock and to be changed 3 times a week. During a phone interview on 09-20-2023 at 3:47 PM, Patient #6 confirmed the agency nurse came 3 times a week to cleanse, pack, and apply a dressing to their wound.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all orders were followed from the referral source for 1 of 4 active records reviewed without a home visit. (Patient #7) Findings Include: 1. On 09-20-2023 at 12:35 PM, the Corporate staff member in charge of Compliance provided an undated policy titled “Wound Care Procedure and Policy for Clinicians”. The policy indicated but was not limited to, “ … Continued/Ongoing Treatment 1. Approved disciplinary team … will provide wound care per (sic according to) physician orders …” 2. On 09-20-2023 at 11:20 AM, Patient #7’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 04-21-2023 and a certification period from 08-19-2023 to 10-17-2023. The plan of care evidenced the following diagnoses Type 2 Diabetes Mellitus (a disease causing the body to be unable to regulate the blood glucose levels) with a skin ulcer (an open sore), non-pressure chronic ulcer of the right ankle with the fat layer exposed, stage 3 pressure ulcer of the right heel, Diabetic Polyneuropathy (nerve damage in the spine affecting the extremities), Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease (COPD, a condition where there was constriction of the airways causing difficulty breathing). The patient was to receive Skilled Nursing (SN) services 3 times a week for 8 weeks and 1 time a week for 1 week for wound care. The plan of care evidenced the following wound care orders, “ … SN Interventions … Cleanse wound on right lateral ankle with NS (sic Normal Saline), apply xeroform to wound bed, cover with dry gauze and football dressing, secure with tape and netting, change dressings 3 times a week. …” The clinical record evidenced an order from Patient #7’s wound care center, Entity 7, dated 8-25-2023 at 2:26 PM. The order indicated, “ … DO NOT WRAP THE PATIENT’S FEET IN DRESSING OTHER THAN WHAT IS ORDERED. (Sic Patient #7) PRESENTED TO THE WOUND CENTER 0731-2023 WITH EXTREMELY TIGHT DRESSINGS IN PLACE, SOME OF THE LAYERS OF (sic Patient #7’s) DRESSING WERE 2ND AND 3RD LAYERS FROM COMPRESSION BANDAGES. WE ARE ORDERING BULKY NON-COMPRESSIVE DRESSINGS, NOT COMPRESSION WRAPS. THE PATIENT HAS COMPROMISED BLOOD FLOW TO (sic Patient #7’s) FEET. COMPRESSION WILL ONLY MAKE (sic Patient #7’s) WOUNDS WORSE. …” 3. During an interview with the Administrator and the Clinical Manager on 09-21-2023 at 11:32 AM, they indicated the wound care orders were to be followed as ordered. 4. During an interview with Licensed Practical Nurse (LPN) 1 on 09-21-2023 at 12:10 PM, they indicated they were to follow wound care orders as ordered by the physician.

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 observation, record review, and interview, the agency failed to promptly alert the physician of changes in the patient’s condition, for 1 of 1 active clinical record reviewed with changes in condition. (Patient: #1) Findings Include: 1. A review of a The LTM Group policy with a revision date May 2023, was provided by the Corporate Compliance staff, Corp 1, on 09-21-2023 at 10:30 AM. The “Reassessment/Recertification” policy indicated but was not limited to, “...A. There is a significant change in condition, care environment and/or support system … 5. The physician will be notified of any of the above situations …” 2. A home visit observation occurred on 09-20-2023 at 10:30 AM to 12:15 PM, at the residence of Patient #1. The Registered Nurse (RN) 1, was observed to initiate infusion therapy via Patient #1’s upper right chest implanted port (a device that is placed under the skin, to administer intravenous therapy and treatment). Patient #1 was observed having a slumped posture and often hung their head down, used accessory muscles while taking breaths, had continuous thick sounding cough, short of breath when they talked, and had an unsteady gait upon ambulation. Patient #1 used their nasal cannula tubing connected to the oxygen concentrator in their mouth. RN 1 indicated to Patient #1, that their cough sounded worse this visit. A review of the clinical record for Patient #1 was completed on 09-19-2023, with a start of care date of 05-24-2023. The record evidenced a plan of care for the recertification period of 07-23-2023 to 09-20-2023. The plan of care indicated the patient’s primary diagnosis was Alpha-1- Antitrypsin deficiency (a genetic condition that causes lung and liver disease) and the secondary diagnosis of Centrilobular Emphysema (chronic lung disease affecting the upper lobes), additional diagnoses included Panlobular Emphysema (chronic lung disease affecting the lobes of the lungs), Anxiety Disorder, and Dependence on Supplemental Oxygen. During an interview on 09-20-2023 at 10:45 AM, Patient #1 indicated they needed more assistance with legal, financial, and community assistance. RN 1 indicated they would make the Clinical Manager aware. When queried about changes in patient condition and increased needs confirmed they reported to the Clinical Manager, Admin 2. 3. During an interview on 07-20-2023 at 4:10 PM, the Clinical Manager, Admin 2, confirmed that RN #1 did not notify them of Patient #1’s change in condition, or need for a MSW for community assistance. Admin 2 further confirmed RN 1 did not notify the physician of the change in condition. 410 IAC 17-13-1(a) (2)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review, and interview the agency failed to ensure the patient clinical records included information about the services the patient receives by other agencies and failed to ensure they coordinated care delivery to meet the patent’s needs for 4 of 4 active patients receiving other agency services records reviewed. (Patients: #1, 4, 6, and 7) Findings Include: On 09-20-2023 at 11:20 AM, Patient #7’s clinical record was reviewed. The clinical record evidenced wound care orders from Entity 7 and indicated the patient received wound care treatment from the entity as well. The clinical record failed to evidence coordination of care from the agency to Entity 7 regarding Patient #7’s wounds. During an interview with the Clinical Manager on 09-21-2023 at 11:32 AM, they indicated there was no coordination of care to the other providers the patient saw from the agency. 410 IAC 17-14-1(a)(1)(F) 1. A review of a The LTM Group policy with a revision date May 2023, was provided by the Patient Care Coordinator, Admin 4, on 09-21-2023 at 10:32 AM. The “Coordination Of Services With Other Providers” policy indicated but was not limited to, “… To ensure the coordination of services provided by the organization and by other service providers…other service providers will be documented in the clinical record…” During the Entrance Conference on 07-19-2023 at 9:05 AM, the Administrator confirmed the agency shares patients with other providers. The Administrator further indicated that care is coordinated and documented in the communication notes in the patient’s clinical record. 2. A review of the clinical record for Patient #1 was completed on 09-20-2023. The record contained a document titled, “Nursing Services Coordination Form” from Entity 1, an infusion company. The Entity 1 ‘s form had a section for the agency signature and date which was left blank. A review of the communication notes dated 05-24-2023 to 09-20-2023 failed to evidence documentation of coordination of care with Entity 1, the infusion company. During a home visit on 09-20-2023 at 10:30 AM, Patient #1 confirmed they received all their infusion supplies and medication from Entity 1. 3. A review of the clinical record for Patient #4 was completed on 09-19-2023. The record contained a document titled, “Patient Information.” The patient information document indicated Patient #4’s residence was at Entity 4, an assisted living facility. A review of the communication notes dated 05-19-2023 to 09-19-2023 failed to evidence documentation of coordination of care with Entity 4. A call was placed to Patient #4 for an interview on 09-19-2023 at 1:40 PM, no return call. 4. A review of the clinical records for Patient #6 was completed 09-20-2023. The clinical record contained a document titled, “Referral Form” from Entity 3, the acute care facility’s wound care center. The referral form indicated skilled wound care orders for Patient #6 for their left buttock to clean with wound cleanser, pat dry, place algidex wick in tunneled area of wound cover with a 2x2 gauze and mepilix border dressing 3 times a week. A review of the communication notes dated 09-13-2023 to 09-20-2023 failed to evidence documentation of coordination of care with Entity 2 and Entity 3. During a phone interview on 09-20-2023 at 3:47 PM, Patient #6 confirmed they go to Entity 2, an acute care facility’s dialysis center, for dialysis treatments, every Monday, Wednesday, and Friday. Patient #6 further confirmed they go to Entity 3, an acute care facility ‘s wound center for wound assessments, and they provide wound care supplies.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to ensure it prepared and/or provided all patients with an up-to-date written medication schedule, for 4 of 4 home visits observed. (Patients: #1, 2, 3, and 11) Findings Include: On 09-20-2023 at 2:33 PM, a home visit observation was conducted at Patient #2’s residence. The patient’s admission packet failed to evidence a current list of medications. The admission packet evidenced a medication list last reviewed on 02-02-2023. On 09-20-2023 at 4:06 PM, a home visit observation was conducted at Patient #3’s residence. The Skilled Nurse (SN) requested the medication list for the patient from Person 8, Patient #3’s spouse, and they indicated they had not received a medication list for the patient. The admission packet failed to evidence a current medication list for the patient. During an interview with the Administrator and the Clinical Manager on 09-21-2023 at 11:32 AM, they indicated the medication lists in the home were to reflect the current medications the patients were taking, any changes to medications, and written in layman’s terms. 1. A review of a The LTM Group policy with a revision date May 2023, was provided by the Corporate Compliance staff, Corp 1, on 09-20-2023 at 3:19 PM. The “Medication Profile” policy indicated but was not limited to, “...4. Each patient will receive appropriate written material for specific medications he/she is receiving…” 2. A home visit observation occurred on 09-20-2023 at 10:30 AM to 12:15 PM, at the residence of Patient #1. The Registered Nurse (RN), RN 1, was observed setting up the intravenous medications for Patient #1’s infusion. RN 1 indicated they had left their tablet in their vehicle with the medication list and questions to ask Patient #1. During an interview on 09-20-2023 at 11:10 AM, Patient #1 confirmed they did receive a written medication list. 3. A home visit observation occurred on 09-20-2023 at 12:26 PM, at the residence of Patient #11. The Physical Therapist (PT), PT 1, was observed completing strengthening exercises with Patient #11. A review of Patient #11’s agency folder evidenced a blank medication list. During an interview on 09-20-2023 at 12:26 PM, Patient #11 confirmed everything they received from the agency was in the agency folder.

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 the Registered Nurse (RN) practiced proper hand hygiene, gloving, infection control practices, and bag technique while providing intravenous therapy to a patient in 1 of 1 patient observed receiving intravenous therapy by the agency. (Patient #1) Findings Include: 1. A review of a The LTM Group policy with a revision date May 2023, was provided by the Corporate Compliance staff, Corp 1, on 09-20-2023 at 3:18 PM. The “Hand Hygiene” policy indicated but was not limited to, “Purpose: To prevent cross-contamination and home care-acquired infections … Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients. B. Before donning sterile gloves … C. After contact with a patient’s intact skin …” 2. A review of a The LTM Group policy with a revision date May 2023, was provided by the Corporate Compliance staff, Corp 1, on 09-20-2023 at 3:15 PM. The “Bag Technique” policy indicated but was not limited to, “… personnel will consistently implement principles to maximize efficient use of the patient care supply bag when used in caring for patients …” 3. A home visit observation occurred on 09-20-2023 at 10:30 AM to 12:15 PM, at the residence of Patient #1. The Registered Nurse (RN) 1, was observed setting up Patient #1’s infusion therapy. RN 1 obtained infusion supplies, the medication vials, infusion bag, tubing, port needle and tubing, dressings, a 50 cubic centimeter (cc) syringe with 4 needles and place them on the kitchen counter. The RN failed to place a barrier under the supplies, failed to perform hand hygiene, and failed to don gloves. The RN then withdrew the medicine from 1 vial with the 50 cc syringe and inserted the needle into the intravenous (iv) bag and failed to cleanse the iv bag port of entry prior to insertion with an alcohol pad. The RN completed the same process with the 4 vials of medication administration into the iv bag. RN #1 failed to don gloves, failed to cleanse the iv-bag port with an alcohol swab prior to inserting the needle of the syringe. The RN was then observed to obtain vital signs. The RN dropped their stethoscope on the floor cleansed the tubing but failed to cleanse the bell prior to using it on the Patient #1’s chest. RN #1 then put their blood pressure cuff, thermometer, stethoscope, and pulse oximeter back in their bag. The RN failed to clean their equipment prior to placing the equipment back in their bag. RN #1 was observed to cleanse Patient #1’s implanted port on their right upper chest. RN #1 cleansed they out skin around the port site then cleansed the port site. The RN failed to use a new swab to cleanse the port site. RN 1 grabbed the iv pole from behind Patient #1then hung the iv bag and inserting spike from the iv tubing. RN 1 failed to complete hand hygiene and don new gloves after they obtained the iv pole. During an interview on 09-20-2023 at 12:15 PM, when queried RN regarding infection control indicated they had forgotten to clean the iv bag port prior to inserting the needle into the iv bag. A review of the employee file for RN 1, on 09-21-2023, contained a document titled, “Learning Center Report” indicated RN 1 completed basic training on home care rules and regulations on 08-29-2023. 4. During an interview on 09-20-2023 at 4:10 PM, the Clinical Manger, confirmed a barrier should have been placed under the supplies, gloves should have been worn setting up the medicine for infusion, hand hygiene is to be performed after touching items and patients, and the iv bag port should have been cleaned prior to insertion of the needle from the syringe of medicine.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure wound care interventions were documented in skilled visit notes for 2 of 3 active clinical records reviewed with orders for wound care. (Patients #2 and 7) Findings Include: 1. On 09-20-2023 at 12:35 PM, the Corporate Staff member in charge of Compliance provided an undated policy titled “Wound Care Procedure and Policy for Clinicians”. The policy indicated but was not limited to, “ … Continued/Ongoing Treatment … 2. At each visit the patient’s skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. …” 2. On 09-21-2023 at 12:55 PM, Patient #2’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 06-09-2022 and a certification period from 08-03-2023 to 10-01-2023. The plan of care listed the following diagnoses for Patient #2, Lymphedema (localized swelling in the body), Type 2 Diabetes Mellitus (a disease causing the body to be unable to regulate the blood glucose levels), Hypertension (high blood pressure), Fibromyalgia (a disorder where pain occurs throughout the body), and Spinal stenosis of the lumbar region (a conditions where the spaces in the spine narrow and put pressure on the spinal cord). The patient received Skilled Nursing (SN) services 1 time a week for 1 week and 2 times a week for 6 weeks during the certification period The plan of care evidenced orders for the patient’s Lymphedema diagnosis. The orders indicated the Bilateral Lower Extremities were to be cleaned with soap and water, patted dry, skin moisturizer applied, and wrapped with Circaid (sic a compression wrap) wraps 2 times a week. The clinical record of Patient #2 evidenced documents titled “Skilled Nurse Visit”. The SN visit notes dated 08-21-2023, 09-04-2023, and 09-11-2023 by Licensed Practical Nurse (LPN) 2 indicated in the section titled “Skin”, the comments evidenced “wraps applied”. The visit notes failed to evidence the Bilateral Lower Extremities were cleansed with soap and water and skin moisturizer was applied. The SN visit notes for Patient #2 dated 09-04-2023 and 09-11-2023 failed to evidence a wound assessment was performed by LPN 2 on the patient’s Bilateral Lower Extremities During an interview with LPN 2 on 09-21-2023 at 2:37 PM, they indicated they clean, dry, and wrap Patient #2’s legs and document the interventions performed for every visit. 3. On 09-20-2023 at 11:20 AM, Patient #7’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 04-21-2023 and a certification period from 08-19-2023 to 10-17-2023. The plan of care evidenced the following diagnoses Type 2 Diabetes Mellitus (a disease causing the body to be unable to regulate the blood glucose levels) with a skin ulcer (an open sore), non-pressure chronic ulcer of the right ankle with the fat layer exposed, stage 3 pressure ulcer of the right heel, Diabetic Polyneuropathy (nerve damage in the spine affecting the extremities), Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease (COPD, a condition where there was constriction of the airways causing difficulty breathing). The patient was to receive Skilled Nursing (SN) services 3 times a week for 8 weeks and 1 time a week for 1 week for wound care. The plan of care evidenced the following wound care orders, “ … SN Interventions … Cleanse wound on right lateral ankle with NS (sic Normal Saline), apply xeroform to wound bed, cover with dry gauze and football dressing, secure with tape and netting, change dressings 3 times a week. …” The clinical record for Patient #7 evidenced SN visit notes, by LPN 1, dated 08-21-2023, 08-23-2023, 08-29-2023, and 08-31-2023 failed to evidence a wound assessment was performed. The SN visit note for Patient #7 dated 09-13-2023 by LPN 2 evidenced the right ankle wound, right lateral foot, and left lateral malleolus were open, and failed to evidence a wound description including any signs and symptoms of infection, drainage, and any pain associated with the wounds. The SN visit note for Patient #7 dated 09-14-2023 by LPN 2 evidenced the intergluteal cleft was open and failed to evidence a wound description including any signs and symptoms of infection, drainage, and any pain associated with the wound. During an interview with LPN 2 on 09-21-2023 at 12:10 PM, they indicated they were to follow wound care orders as ordered, document the assessment and descriptions, and include measurements and pictures every 2 weeks. LPN 2 indicated they were to document all interventions performed for Patient #7 in the visit notes. 4. During an interview on 09-21-2023 at 11:32 AM, the Administrator and Clinical Manager indicated wound care orders were to be performed and documented as often as the order called for them. The Administrator indicated all interventions performed were to be documented in the assessment. 410 IAC 17-14-1(a)(2)(B)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the after-hours-on-call number was operating and available to the public, patients, and employees as noted after 2 of 2 unsuccessful attempts to reach the after-hours phone number. Findings Include: 1. On 09-21-2023 at 11:18 AM, the Patient Care Coordinator provided an April 2017 Joint Commisssion Home Health policy titled “On-call/Weekend Staffing”. The policy indicated but was not limited to, “ … Policy … There will be on-call staff available after office hours Monday through Friday, and 24 hours a day on weekends and holidays … Procedure … “ Clinical staff must respond to a page within 15 minutes …” 2. On 09-19-2023 at 7:35 PM, an attempt to call the after-hours-on-call phone was made. A voicemail was left on the answering machine requesting a return call. The on-call number was listed in the admission packet as the office phone number. The agency failed to answer the on-call phone. 3. On 09-20-2023 at 7:07 PM, an attempt to call the after-hours-on-call phone was made. A voicemail was left on the answering machine requesting a return call. The agency failed to answer the on-call phone. 4. During an interview with the Administrator and Clinical Manager on 09-21-2023 at 11:32 AM, they indicated the office phone number was also the after-hours-on-call number. The Administrator indicated the call was to be transferred to one of their phones (the Administrator and Clinical Manager), and the Administrator would always be “pinged” when a call was made. The Administrator indicated they had not received a phone call on 09-19-2023 and 09-20-2023. The Administrator indicated they had updated their on-call system recently. 410 IAC 17-12-1 (c)(1)

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure that all Nurses appropriately and accurately assessed their patients according to professional standards for 1 of 2 nurse home visits completed. (Patient #1) Findings include 1. A review of a The LTM Group policy with a revision date May 2023, was provided by the Corporate Compliance staff, Corp 1, on 09-20-2023 at 3:18 PM. The “Ongoing Assessments” policy indicated but was not limited to, “...Using the standards of care … the clinician will reassess the patient for: … D. breath sounds. E. skin integrity …” 2. Constantine, L., MSN, RN, C-FNP. (2004, June 15). Overview of Nursing Health Assessment. Retrieved January 16, 2019, from rn.com " ... PULMONARY ASSESSMENT: When examining the pulmonary system … Inspect the thoracic cage, palpate the thoracic cage, Auscultate the anterior and posterior chest: Have patient breath slightly deeper than normal through their mouth, Auscultate from C-7 to approximately T-8, in a left to right comparative sequence. You should auscultate between every rib … Identify any adventitious breath sounds … " 3. Nurse.org, dated April 7, 2020, indicated: "How to Conduct a Head-to-Toe Assessment: … LENGTH OF ASSESSMENT … the duration of the exam is directly in correlation to the patient's overall health status. Health patients with limited health histories may be completed in less than 30 minutes” The Order of a Head-to-Toe Assessment: 1. GENERAL STATUS: Vital signs; … Temperature; … Pain. 2. HEAD, EARS, EYES, NOSE, THROAT … 3. NECK … 4. RESPIRATORY: Listen to lung sounds front and back; Assess respiratory expansion level; Ask about coughing; Palpate thorax. 5. CARDIAC: Palpate the carotid and temporal pulses bilaterally; Listen to heartbeat. 6. ABDOMEN: … Ask about problems with bowel or bladder. 7. PULSES: Check pulses in arms/legs/feet including, Radial, Femora, Posterior tibial, Dorsalis pedis. 8. EXTREMITIES: … Check capillary refill on fingernails/toenails. 9. SKIN: Check skin turgor; Check for lesions, abrasions, rashes; Check for tenderness, lumps, lesions; Check if patient is pale, clammy, dry, cold, hot, flushed. 10. NEUROLOGICAL: Oriented x3; Assess gait; Check coordination; Assess reflexes; Check Glasgow Coma Scale." 4. A home visit observation occurred on 09-20-2023 at 10:30 AM to 12:15 PM, at the residence of Patient #1. The Registered Nurse (RN) 1, was observed completing an assessment on Patient #1. The RN was observed to auscultate posterior lung sounds in four fields, then placed the bell of the stethoscope to auscultate the apical heart. RN 1 failed to reassess the anterior lung fields. During an interview on 09-20-2023 at 4:10 PM, the Clinical Manager, indicated confirmed the skilled nurses are to do a head-to-toe assessment and listen to all fields of the lungs during an assessment of their patients.